Access Mental Health

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse from Resident (R) 17 to the State Agency as required and further failed to ensure all contracted vendors or providers reported allegations of staff to resident abuse to the Administrator immediately.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents, with one reviewed for behavioral services. Based on observation, record review, and interviews, the facility failed to provide adequate behavioral health services, including resident-centered interventions to address Resident (R)15's auditory hallucinations related to his schizophrenia and bipolar disorder. On 09/23/35, R15 had exit-seeking behaviors as he heard voices telling him he was supposed to discharge from the facility. The facility staff did not report the incident, and the facility did not assess and identify possible triggers or implement interventions to address the auditory hallucinations. R15's mental provider assessed the resident on 10/07/25 but did not address this resident's recent auditory hallucinations or the associated behaviors. [...]

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for nine residents, Resident (R) 33, R2, R31, R49, R17, R42, R10, R15, and R16, related to uncomfortable, torn, and/or damaged mattresses with exposed filling on nine mattresses rendering them unsanitizable.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for three residents: Resident (R) 5, related to restraint; R1 related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid); and R2 related to dental.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 2's left shoulder limited mobility and shoulder pain and R47s oxygen, refusal of cares, and continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) use.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on interview and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 47's Electronic Medical Record (EMR) contained appropriate documentation to include physician notifications and R47's refusals to be transferred to the local hospital.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents, with one resident reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record review, and interviews, the facility failed to ensure adequate catheter care within the standards of practice was provided for Resident (R) 1 when staff failed to secure the catheter tubing to R1's leg to prevent pulling and/or dislodgement and also failed to provide catheter care using adequate infection control practices to prevent catheter related urinary tract infections (UTI).

Inspectors wroteThe facility identified a census of 42 residents. Based on observation, record review, and interviews, the facility failed to implement and maintain an effective infection control program when staff failed to provide catheter care using adequate infection control practices and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) during high contact care for Resident (R)1. Findings Included:- During an observation on 12/09/25 at 01:17 PM, Certified Nurse Aide (CNA) M emptied R1's leg bag into an empty urinal. CNA M entered the room, performed hand hygiene, and applied appropriate EBP. CNA M then emptied the urine collection bag and allowed the drain port of R1's leg bag to come in contact with the side of the urinal. [...]

Inspectors wroteThe facility reported a census of 42 residents, one central kitchen, and one dining area. Based on observation, interview, and record review, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk for food-borne illnesses.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, record review, and interview the facility failed to maintain an effective infection control program related to a sanitary environment to help prevent cross-contamination and the spread of infections in the laundry, and to ensure appropriate handling, storage, processing, and transportation of linen for the residents of the facility. This placed the residents at risk for infectious disease.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 12 residents. Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAA) that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)1, R8, R 9, R245, and R195. This placed the residents at risk for inadequate care due to unidentified care needs.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for seven residents: Resident (R) 1 and R30 related to insulin (a hormone that lowers the level of glucose in the blood); R5 related to physical restraints; R9, R8, R245, and R195 related to Wander Guard alarm (a bracelet that helps monitor residents who are at risk of wandering). This deficient practice placed the affected residents at risk for impaired care due to unidentified care needs.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 25 medication administration opportunities were observed with two insulin (a hormone that lowers the level of glucose in the blood) medication errors identified. This placed the residents who received insulin at risk for adverse medication reactions and ineffective medication regimens and resulted in a medication error rate of eight percent.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review, the facility failed to ensure that meals were prepared in a way to preserve and/or promote palatability. This placed the residents at risk for decreased enjoyment of meals and related complications.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 12 residents with five residents reviewed for psychotropic (alters mood or thoughts) medications. Based on interview, observation, and record review, the facility failed to inform Resident (R) 30 and R9 and/or their representatives regarding the risks related to psychotropic medications. These practices had the potential to lead to negative and unwarranted physical side effects.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 12 residents, and three residents were reviewed for a baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan within the required timeframe for Resident (R) 245. This deficient practice had the potential to lead to impaired care due to uncommunicated needs.

Inspectors wroteThe facility reported a census of 42 with five residents selected for review of vaccines. Based on record review and interview, the facility failed to offer the pneumococcal (type of bacterial infection) vaccine to three residents, Resident (R) 1, R11, and R9. This deficient practice placed the residents at increased risk for pneumococcal infections.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interviews the facility failed to identify and implement nutritional interventions related to Resident (R) 27's significant weight loss between 01/01/24 to 06/07/24. The facility additionally failed to implement alternative nutritional interventions for R27's ongoing significant weight loss between 08/01/24 and 01/01/25. As a result of the deficient practice, R27 had a significant unplanned weight loss of 19.52 percent (%) and 16.84 % within two three-month periods. This also placed R27 at risk for malnourishment-related complications.

Inspectors wroteThe facility identified a census of 45 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 45 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure dietary staff safely thawed meat to prevent bacterial growth. This placed residents at risk for food-borne illnesses.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination Resident (R) 5, R16, R19, and R30. The facility also failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for R5, R16, R27, and R30. This placed the residents at an increased risk for influenza, pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure staff had documented when, where, and why Resident (R) 39 was transferred to an acute hospital. This placed R39 at risk of risk for uninformed care choices.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notification of transfer to Resident (R)39 and R20 for their facility-initiated transfers. This deficient practice placed R39 and R20 at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Resident (R) 28 who lacked the need of specialized services, and R39 to include the diagnosis of post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the residents at risk for inappropriate comprehensive care.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 30 and R39 which included individualized person-centered interventions for their trauma-based care. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 with 12 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R) 3's Care Plan to reflect his identified care needs related to his incontinence, activities of daily living (ADLs), and behaviors. This deficient practice placed R3 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with one resident reviewed for increase and prevent decrease in mobility or range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement a ROM program to help maintain and prevent a potential decrease in ROM/mobility for Resident (R) 16. This deficient practice placed R16 at risk of loss of ability to perform activities of daily living (ADLs) and worsening or development of contractures (abnormal permanent fixation of a joint or muscle).

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 with two reviewed for bowel and bladder incontinence. Based on record review, observations, and interviews, the facility failed to implement individualized toileting interventions to improve/maintain Resident (R) 3's bowel and bladder incontinence based on his incontinence evaluations. This deficient practice placed R3 at risk for complications related to incontinence.

Inspectors wrote- R39's Electronic Medical Record (EMR) documented diagnosis of posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), major depressive disorder (major mood disorder that causes persistent feelings of sadness), suicidal ideations (the thought process of having ideas, or ruminations about the possibility of completing suicide), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and borderline personality disorder (a disorder characterized by disturbed and unstable interpersonal relationships and self-image along with impulsive, reckless, and often self-destructive behavior). [...]

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 with five residents reviewed for behavioral services. Based on record review, observations, and interviews, the facility failed to implement individualized behavioral care intervention for Residents (R)3, R30, and R39. This deficient practice placed the residents at risk for continued behavioral episodes and unmet care needs.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 5 and R19's physician ordered diclofenac (a non-steroidal anti-inflammatory medication used to treat pain and inflammation) lacked a specified dosage. The CP further failed to identify and report when R19's pulse was outside the physician-ordered parameters. This placed the R5 and R19 at risk for unnecessary medications and related complications.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician order was followed for Resident (R) 19's laboratory tests to monitor for high-risk medications and that the physician was notified of values outside the physician-ordered parameters. The facility also failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for R16 and R5. These deficient practices placed these residents at risk for unnecessary medication use and physical complications for the affected resident.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the as needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 30's and R16's PRN psychotropic medications. This deficient practice placed these residents at risk for unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations for Resident (R) 30 and R5. This deficient practice placed these residents at increased risk for COVID-19.

Inspectors wroteThe facility reported a census of 43 residents, with six residents sampled and one resident reviewed for the right to be free from physical restraints. Based on interview and record review, the facility failed to ensure Resident (R) 3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. The facility failed to identify the resident's medical/behavioral symptoms that warranted the use of chemical restraint, physical restraint of five to six staff, and the use of a bedsheet to further restrain the resident. [...]

Inspectors wroteThe facility reported a census of 43 residents, with six residents sampled and one resident reviewed for treatment and services for mental/psychosocial concerns. Based on interview and record review, the facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses. The resident made statements such as I will kill my guardian and comments regarding killing himself on 09/18/24 at 05:07 PM. The resident became loud, insisted he had nothing to live for and wanted to kill himself. R3 became very belligerent and combative. R3 stated he just wanted to die and then started to hit his head with his fist, banged his head on the wall, hit himself in his own face with his knee, and five staff assisted in restraining the resident from hurting himself. [...]

Inspectors wroteThe facility reported a census of 45 residents. The six sampled residents included three reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of Resident (R)1, who remained on 30-minutes checks from a prior elopement, eloped again from the facility on 01/28/24 at 04:36 PM, with staff present. The facility staff did not realize R1 was missing until another staff member saw R1 walk past a window outside the building, on 01/28/24 at 05:30 PM. almost an hour after the resident eloped. [...]

Inspectors wroteThe facility reported a census of 45 residents and identified six residents at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to provide sufficient staff with the appropriate competencies and skills sets to meet the behavioral health needs one Resident (R)1, who had known elopement behaviors and a history of an elopement, to prevent an additional elopement from the facility.

Inspectors wroteThe facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to provide administrative services in a manner to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being, when the administrator failed to follow-up on plans for correction from a resident's elopement from the facility to prevent another elopement. The had the potential to affect all 45 residents that resided in the facility.

Inspectors wroteThe facility reported a census of 45 residents. Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified resident care issues to enhance the residents' quality of life, failed to implement appropriate and effective action plans for mitigation of identified elopement risk of Resident (R) 1, who had known elopement behaviors and a history of an elopement, to prevent an additional elopement from the facility.

Inspectors wroteThe facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure the reporting of incidents of sexual assault and harassment to local law enforcement, as required. The facility failed to provide adequate supervision and care planned interventions to prevent R2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab another resident's breast with no interventions in place. [...]

Inspectors wroteThe facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to protect residents from incidents of sexual assault and harassment the failure to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. [...]

Inspectors wroteThe facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy.

Inspectors wroteThe facility reported a census of 45 residents, with one resident sampled for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision, identify likely avenues of exit (including windows), and failed to ensure the windows were secured after Resident (R)1 broke the window out in his room, to prevent elopement. On 01/05/24, R1, who suffers from delusions/hallucinations and wandering, broke the window out in his room and reported he was scared and wanted to leave. Certified Nurse Aid (CNA) D did not provide the supervision of R1, as directed by Licensed Nurse (LN) C. [...]