Aegis Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and acceptable standards of practice when staff failed to accurately complete a post (after) fall observation report for 72 hours by not obtaining current vital signs for two residents sampled (Resident #1 and #3) and failed to complete post fall observations for 72 hours for one resident (Resident #2). The facility failed to notify the physician and emergency contact when one resident (Resident #1) had a fall. The facility failed to update the residents' care plans timely after falls for two residents (Resident #1 and #3) and failed to update the care plan for one resident (Resident #2). The facility failed to document Resident #2 had a fall in the nurse progress notes. The sample was 3. The census was 62. Review of the facility's Incident and Accident policy, revised 9/1/22, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents with Post-Traumatic Stress Disorder (PTSD) in their choice of activities to meet the interests and well-being for two residents when staff failed to provide one on one (1:1) visits for two residents who preferred to stay in their room and had a history of depression and PTSD (Resident #4 and Resident #25). The sample was 14. The census was 60. Review of the facility's Activity Policy, showed: -Activities may be conducted in different ways: One-to-One (1:1) Programs. -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs; residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice, when the facility failed to clearly identify the resident's past trauma, identify triggers or individualized interventions to prevent traumatization or treat symptoms for (Resident #4), who had a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event/either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). On 4/10/25, 4/30/25 and 5/20/25 Resident #4 verbalized increase depression due to PTSD - family trauma. On 5/19/25, he/she expressed wanting to die. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for residents with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after a person has experienced or witnessed a traumatic event). The facility identified seven residents with a diagnosis of PTSD. Two residents with a diagnosis of PTSD were sampled and issues were found with one (Resident #4). This deficient practice had the potential to affect all seven residents with PTSD identified by the facility. The sample was 14. The facility's census was 60. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and organized medication cart within the facility, for two out of two carts checked. Both medication carts had several concerns which failed to ensure proper storage and labels on medications on one certified medical technician (CMT) medication cart and one registered nurse (RN) medication cart. The census was 60. Review of the facility's Medication Storage Policy, dated 2021, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturers' recommendations and sufficient to ensure proper temperature, light, ventilation, moisture control, segregation, and security; -Unused medications: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff used the incorrect insulin pen during the administration (Residents #45 and #13). Staff failed to apply personal protective equipment (PPE, equipment worn to protect individuals from various hazards) in rooms identified as requiring enhanced barrier precautions (EBP) (Residents #33 and #32). In addition, staff failed to ensure appropriate hand hygiene and glove changes during perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) (Resident #21). The sample was 14. The census was 60. Review of the facility's infection prevention and control program, showed: -Policy: to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Explanation and guidelines: [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate, as desired, eligible residents with the pneumococcal (pneumonia) and influenza (flu) vaccine for 4 out of 4 residents sampled for immunizations (Residents #40, #32, #21 and #44). The census was 60. Review of the facility's influenza vaccination policy, showed: -Policy: minimize the risk of acquiring, transmitting or experiencing complications for influenza by offering residents annual immunization against influenza; -Explanation and guidelines: -Influenza vaccinations will be routinely offered annually from October through March unless the vaccination is contraindicated or the immunization is refused; -Additionally, influenza vaccination will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) for one perineal care observation (Resident #21). The sample was 14. The census was 60. Review of the facility perineal care policy, showed: -Policy: provide perineal care to incontinent residents to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Policy explanation and compliance guidelines: -Use bath basin with warm water or disposable cleaning cloth method; -If bath basin is used, use perineal cleanser; -Perform hand hygiene and apply gloves; -Cleanse buttocks and in between the buttocks, front to back, use a separate washcloth or wipe; -Apply skin protectant as needed. [...]

Inspectors wroteSee deficiency cited at event ID 4PUY12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 4/9/24. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 47 opportunities observed, 7 errors occurred resulting in a 14.89% error rate (Resident #1, #9, and #503). The census was 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were comprehensive, person-centered and were developed based on the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) care area assessment summary (CAAS), for four of 14 sampled residents (Residents #33, #23, #188, and #187). The census was 41. Review of the facility's Comprehensive Care Plans policy, dated 9/1/21, showed: -It is the policy of this facility to develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for quality of care for two residents (Residents #337 and #20). Resident #337's peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart) line dressing had not been changed in accordance with the facility policy and physician orders. Staff had not documented Resident #20's skin assessment since February 2024. The resident had a wound to the left heel. The sample was 14. The census was 41. 1. Review of the facility's PICC/MIDLINE/central venous access device (CVAD) dressing change policy, dated 9/1/21, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for 4 of 4 sampled Certified Nursing Assistants (CNAs) sampled. The facility identified four CNAs employed for more than a year. The census was 41. Review of the Facility Assessment Tool, updated 3/24/24, completed by the facility, showed: -Total number needed or average: 5-10 Nurse aides; -Staff training/education and competencies: Staff training/education is conducted by in-services; -1 on 1 training education packets with post-tests; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable accurate reconciliation. The facility failed to ensure accuracy and monitoring for controlled substances for 2 of 2 narcotic count books reviewed. The census was 41. Review of the facility's Controlled Substance Administration & Accountability policy, dated 9/1/21, showed: -It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure; -Policy Explanation and Compliance Guidelines: Inventory Verification: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 38 opportunities observed, 11 errors occurred resulting in a 28.94% error rate (Residents #27, #6 and #28). The census was 41. Review of the facility's Medical Provider Orders policy, dated 9/1/21, showed: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of the facility's Medication Administration policy, dated 9/1/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications are stored in accordance with currently accepted professional principles when the medication room refrigerator temperature was out of range and staff were not checking the temperature per policy, medications were not labeled with resident names, medication carts were left unlocked and not supervised, and schedule II medications were not stored behind two locks for one of one medication room and three of three medication carts reviewed. The facility had one medication room and four medication carts. The census was 41. Review of the facility's Medication Storage policy, dated 9/1/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with a variety of food, in an appropriate quantity, to meet the needs for 2 of 14 sampled residents (Residents #9 and #19). The facility also failed to have enough food to provide for residents who asked for seconds and failed to provide an alternate upon request. The facility also failed to ensure residents had access to a menu prior to meal service. The census was 41. Review of the facility's Nursing Home Residents' Rights, provided upon admission to the residents showed: -Right to a dignified existence: -Be treated with consideration, respect, and dignity, recognizing each resident's individuality; -Quality of life is maintained or improved; -Exercise rights without interference, coercion, discrimination, or reprisal; -Right to self-determination: [...]

Inspectors wroteBased on observation, interview, and record review, the facility dietary staff failed to follow proper hand hygiene while preparing food for the steam table when staff did not remove his/her gloves after he/she touched/rubbed/adjusted his/her clothing, touched their face mask, and the inside of the kitchen door frame using both gloved hands, and wiped off counter tops with a stained wet dish rag. Additionally, the facility dietary staff failed to maintain cold fruit at a temperature of 41 degrees Fahrenheit (F) or less on two separate days of observation, to prevent foodborne illness, prior to it being served to the residents in the facility. The sample size was 14. The census was 41. Review of the facility's Hand Hygiene Policy, dated 9/1/21, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff hung medication through a single lumen (internal channel) peripherally inserted central catheter (PICC, intravenous (IV) access site) without cleaning the cap of the lumen, for one resident (Resident #337). Staff failed to ensure proper placement of indwelling urinary catheter (tube inserted into the bladder to drain urine) drainage bags when the bags lay directly on the floor and a catheter bag was not positioned to prevent reflux of urine. The facility identified four residents as having indwelling urinary catheters. Of those four, three were included in the sample and issues were identified with two (Residents #337 and #18). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents' antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 41. On 4/9/24 at 2:10 P.M., the facility's Antibiotic Stewardship policy was requested from the Director of Nursing (DON) who is the facility's Infection Preventionist. The policy was never provided. Review of the facility's Infection Prevention and Control Program policy, revised 9/1/23, included the following: Antibiotic Stewardship: Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents allowed to self-administer medications had been assessed by the interdisciplinary team to ensure the residents were knowledgeable and safe to self-administer medications and ensure there was a physician order for medication self-administration for two residents observed with medications left at the bedside (Residents #4 and #7). The census was 41. Review of the facility's undated Self-Administration of Medications policy, showed: -To maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if they facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment was accurately coded for one of three closed resident records reviewed for accuracy of resident assessments (Resident #35). The census was 41. Review of Resident #35's medical record, showed: -discharged [DATE]; -A nursing note, dated 3/18/24 at 6:57 A.M., non-emergent transport was called to arrange transportation to the hospital. Review of the resident's discharge MDS, dated [DATE], showed: -admitted [DATE]; -discharged [DATE]; -Discharge status: Inpatient Rehabilitation Facility (IRF, free standing facility or unit). During an interview on 4/5/24 at 1:41 P.M., the MDS Coordinator said she was aware that the resident was sent to the hospital and she anticipated a return. She did select the incorrect coding for the resident's discharge.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident who is incontinent of bowel and bladder received appropriate treatment and services after an incontinent episode. One resident was left by a staff member in the middle of providing personal care. The resident was left saturated with urine (Resident #23). Later that morning, the same resident had an incontinent bladder and bowel episode. The resident requested personal care and a staff member told the resident to wait until after lunch service to have personal care provided. The resident waited over 30 minutes for the second time that morning while soiled. The resident had stool stuck to his/her skin as a result, as well as a reddened area to his/her buttocks. The staff did not apply cream to the area after staff provided personal care. The sample size was 14. The census was 41. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management is provided to residents who require such services when staff failed to inform the nurse one resident experienced symptoms of pain. The resident was admitted to the facility with a femur (bone that goes from the hip to the knee) fracture that required surgical repair and a cervical spinal cord compression. The resident also wore a cervical collar (c-collar, a medical device used to support and immobilize a person's neck) related to the spinal cord compression. The resident did not receive pain medication for over two hours after requesting pain medication (Resident #23). The sample size was 14. The census was 41. Review of the facility's Pain Management policy, revised 9/1/21, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address a suspected eating disorder after it was reported the resident was binge eating and vomiting (Resident #13). In addition, staff comments addressing the suspected eating disorder were not only denied by the resident, but left the resident self-conscious about what he/she ate and whom he/she ate in front of. The sample was 14. The census was 41. Review of the facility's Behavior Management policy, revised 9/1/22, showed: -Residents who exhibit behavioral concerns may require a behavior management care plan to ensure they are receiving appropriate services and interventions to meet their needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors when one resident was administered the wrong dose of insulin and one resident had an for a medication patch to be applied for longer than recommended per acceptable standards of practice (Residents #27 and #6). The census was 41. Review of the facility's Medical Provider Orders policy, dated 9/1/21, showed: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a timely Magnetic Resonance Imagine (MRI, diagnostic test that can create detailed images inside the body) and notify the physician when the MRI was delayed for one resident (Resident #18), who showed a lesion on his/her right humerus (upper arm). The facility also failed to obtain an appointment for a swallow test timely after concerns of him/her coughing during meals (Resident #19). The sample was 14. The census was 41. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/15/23, showed: -Severe cognitive impairment; -Diagnoses included heart failure, pneumonia, aphasia (language disorder), stroke, quadriplegia (paralysis of all four limbs) and seizure disorder; -Dependent with toileting hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appealing options of similar nutritive value to residents who choose not to eat food that was initially served or who requested a different meal choice, when alternate meals were not provided. This had the potential to affect all residents who could not eat or did not want what was being served (Residents #187, #8 and #29). The sample was 14. The census was 41. Review of the facility's Menu Alternates policy, revised 5/31/21, showed: -Policy: Nutritionally comparable menu items shall be available to accommodate resident food preferences; -Procedure: Alternate menu items are planned during the menu planning process for protein source, grains, fruits, and vegetables; -Alternate menu items may be included on the cycle menu and/or included with the always available menu; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to meet the needs of the residents. On [DATE] from approximately 8:17 P.M. until [DATE] at approximately 5:27 A.M., only one staff person, the Director of Nurses (DON), was present and working in the facility. The DON contacted the Acting Administrator (Administrator #1) and Administrator in Training (AIT) for assistance. The AIT called sister facilities for assistance with staffing. Administrator #1 and the AIT did not come into the facility. One of the facilities could not provide any staff, and the other two did not respond. The census on [DATE] was 50 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five residents (Residents #9, #8, #7, #11 and #10) had a code status in their medical record and had a code status recorded in the code status book, which staff would refer to in the event their heart stopped. Residents #9 and #8, both alert and oriented residents, did not want Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest) administered in the event of cardiac arrest, however staff said they would perform CPR on them in accordance with the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, for one resident (Resident #25) who received a kidney transplant, when staff failed to obtain labs and administer anti-rejection medication as ordered by the physician. The resident was admitted to the facility on [DATE] and taken to the emergency room by family on [DATE] when the resident's blood work taken on the date of discharge showed critical. The resident was admitted to the hospital on [DATE] and passed away on [DATE]. The facility also failed to administer medication to one resident as ordered by his/her physician who was diagnosed with depression (Resident #27). The facility also failed to complete wound treatment as ordered by the resident's physician (Resident #21). The sample size was 28. The census was 51. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered, failed to document the reason the residents missed doses and failed to document the measures they took to obtain the medication, for four of 28 sampled residents (Residents #6, #27, #21 and #1). Resident #6 experienced pain resulting in the resident crying out and rocking back and forth and calling family members crying. Resident #27 was unable to get out of bed because he/she was in so much pain he/she could not sit up in his/her wheelchair. Resident #21 described their pain as excruciating. The facility also failed to administer pain medications to Resident #1 prior to completing wound care. The resident described their pain as an eight out of ten, aching and steady to the areas where he/she had wounds. The census was 51. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatments and services to promote healthy healing by failing to follow orders for antibiotics for one resident (Resident #1). Additionally, the facility failed to complete wound treatments, failed to complete skin assessments upon admission, re-admission and weekly and failed to complete weekly wound assessments for two residents (Residents #1 and #26). The sample size was three. The census was 51. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The daily staffing posting was reviewed from 10/1/23 through 11/6/23 and no RN was scheduled for 18 out of 37 days. The census was 51. 1. Review of the facility's Facility Assessment Tool, last reviewed on 8/17/23, showed: -Number of residents licensed to provide care for: 66; -Average daily census: 35; -Number (enter average or range) of persons admitted : -Weekday: 1-3; -Weekend: 1-3; -Number (enter average or range) of persons discharged : -Weekday: 1-5; -Weekend: 1-3; -Acuity: -Special treatments and conditions: number/average or range of residents: -IV medications: 0; -Injections: 12; -TPN: not listed; -Tube feedings: not listed; -Assistance with activities of daily living (ADL): -Transfer: -Independent: 6; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a nourishing snack for all residents between dinner and breakfast. The sample size was 28. The census was 51. Review of the facility's Offering/Serving Bedtime Snacks policy, dated 11/17, showed: -It is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis; -The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and requests on a daily basis; -All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the resident's name and room number; -Dietary services staff delivers bedtime snacks to each nurse's station. The charge nurse is made aware of the delivery of the snacks; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was administered in a manner that allowed residents to attain or maintain their highest practicable physical well-being. The Registered Nurse who was the Director of Nurses (DON) from 10/2/23 to 11/24/23 was not physically present in the facility. The administrator at the facility from 7/10/23 through 10/7/23 and from 10/31 through 11/9/23 failed to ensure the facility's maintenance needs were met in a timely manner, including replacement of sprinkler heads and repairs to the call light system damaged in June 2023. Administration failed to ensure sufficient nursing staff were on duty to provide care to residents, sufficient housekeeping staff and oversight of housekeeping services, and ensuring the dietary department had adequate supplies to meet menus and residents needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment. Facility staff failed to sweep and mop residents' rooms and failed to empty trash cans. The shower room was littered with dirty linen, trash and used razors. The hallway floors were dirty and littered with trash. The census was 51. Review of the facility's Routine Cleaning and Disinfection policy, updated 7/19, showed: -It is the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible; -Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms and at time of discharge; *Cleaning considerations include, but are not limited to, the following: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective process for residents to voice grievances and failed to promptly make efforts to resolve grievances (Residents #6, #23 and #21). The facility failed to follow the policy by not making the information regarding how to file a grievance or a complaint visible and available to all residents residing in the facility (Residents #25 and #22). The facility also failed to maintain the results of grievances filed for a minimum of three years. The census was 51. Review of the facility's Nursing Home Residents' Rights form posted on the walls, throughout the facility, showed: -Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had physician orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) and assessment/monitoring of dialysis access sites for three of three sampled residents (Residents #26, #21 and #5). In addition, the facility failed to maintain ongoing communication with dialysis centers for residents receiving dialysis treatment. The census was 51. Review of the facility's Hemodialysis policy, revised 2/23, showed: -Policy: The facility will provide the necessarily care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis; -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with a variety of food, in an appropriate quantity, to meet the needs for three of 26 sampled residents (Residents #5, #22 and #28). The facility also failed to have enough food to provide for residents who asked for seconds. The census was 51. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/25/23, showed: -Understood, understands, clear comprehension; -Cognitively intact. Observation and interview on 11/1/23 at 8:35 A.M., showed staff served the resident two boiled eggs, two pieces of toast with no butter or jelly and a glass of juice. The resident said he/she does not like boiled eggs. He/She is a diabetic and needs protein. They never serve him/her meat at breakfast. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize recipes approved by a Registered Dietician (RD) for the residents' dietary needs and preferences and failed to obtain RD approval to ensure the menu is of equal nutritive value after substituting food items on the menu. The sample size was 28. The census was 51. 1. Observation of the Menu Substitution Log, posted on the wall in the kitchen on 11/2/23 at 11:30 A.M., showed: -Date: 10/9 Meal: Lunch. Planned Menu Item: Vegetable Blend. Substitute Item: Broccoli. Reason for Sub: Out of Stock. Initials: Dietary Manager. RD initials: Left blank; -Date: 10/11 Meal: Lunch. Planned Menu Item: Carrots. Substitute Item: Spinach. Reason for Sub: Out of Stock. Initials: Cook. RD initials. Left blank; -Date: 10/12 Meal: Lunch. Planned Menu Item: Steamed Tomatoes. Substitute Item: Zucchini. Reason for Sub: Out of Stock. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system on the 300 hall was adequately equipped to allow residents to call for staff assistance through a communication system, which relayed the call directly to a staff member or to a centralized staff work area. The call light system on the 300 hall was disabled in [DATE] after being damaged by lightening. The room light indicators lit upon activation but the alarms did not sound. The room light indicators, located above the room doors, were not visible from the nurse's station. Three of eight sampled residents on the 300 hall were not provided with an alternative means to request staff assistance for care with their needs or in an emergency (Residents #26, #23 and #27). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate discharge for one of three sampled residents who transferred to the hospital. Resident #15 was transported to the hospital for a psychiatric evaluation. The facility issued an emergency discharge notice to the resident the next day. An appeal was filed, however, the facility did not reevaluate the resident's status to determine if they were able to meet the residents needs after treatment, and refused to readmit him/her back to the facility pending the appeal hearing. The hearing notice for the resident was sent to the facility, however, he/she was no longer at the facility to receive it. The census was 51. Review of the facility's Transfer and Discharge policy, revised 3/3/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents who required assistance with activities of daily living (ADLs) received showers in accordance with their needs and preferences (Residents #6, #16 and #21). The sample was 28. The census was 51. Review of the Resident Showers policy, dated 9/1/21, showed: -Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice; -Policy Explanation and Compliance Guideline: -Residents will be provided showers as per request or as per facility protocols and based upon resident safety; -Assist the resident to the shower room and bring all necessary supplies; -Assist the resident with showering as needed. Encourage the resident to participate as much as possible. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety when staff staff failed to label and date opened/stored food and allow dishes to completely air dry. Furthermore, the facility failed to employ sufficient staff to ensure kitchen equipment remained clean, floors were free of dust, grease and grime, and walls, vents and ceilings remained free from dust and stains. Staff also failed to keep food stored off the floor during three of three days of observation. The census was 40. Review of the facility's Date Marking for Food Safety policy, dated 9/1/21, included: -Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food; -Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents could safely administer their own medications for four of 12 residents observed with medications left at bedside (Residents #7, #26, #132 and #134). The census was 40. Review of the facility's resident self-administration of medication policy, revised 4/7/22, showed: -Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: -The medications appropriate and safe for self-administration; -The resident's physical capacity to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to facilitate resident self-determination through support of resident choice and ensure the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. The facility implemented a policy that removed the resident choice for communal dining in the main dining room, requiring residents to eat in their room. In addition, the facility removed a drink cart from use due to staff failure to place lids back on the drinks, which prevent residents from making choices about what to drink at the time of meal service. Residents were required to choose their drinks for the day in the morning and staff said if residents said they wanted something else to drink, they did not always go back to the kitchen to get the residents choice of drinks. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that before the facility transfers or discharges a resident, they notified the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing, ensure the notice of transfer or discharge was made by the facility at least 30 days before the resident is transferred or discharged , and that the discharge or transfer notice included the reason for transfer or discharge, effective date, location in which the resident will be discharged , and residents right to appeal for three of five residents investigated for discharge (Residents #39, #49 and #183). The facility said for residents discontinuing skilled services, the facility did not issue a discharge notice, just the notice that skilled services was ending. The census was 40. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for four of 12 sampled residents who were recently transferred to a hospital for various medical reasons (Residents #37, #182, #1 and #18). The census was 40. Review of the facility's bed hold notice upon transfer policy, dated 9/1/21, showed: -Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed; -Bed hold: the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on the residents' assessment, to support residents in their choice of activities and to meet the needs of the residents. The facility failed to have organized activities on the evenings and weekends and failed to have group activities outside of the resident's rooms or halls. The resident counsel representatives reported activities to be insufficient and childlike. In addition, residents interviewed reported concerns with the activity program, for three of four resident's investigated for activities (Residents #14, #2 and #132). The census was 40. 1. Review of the facility's Statement of Resident Rights, provided to residents upon admission, showed: -Under federal and state laws, you have the following rights and responsibilities. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record keeping for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of six medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 40. Review of the facility's Controlled Substance Administration and Accountability policy, revised 4/7/22, showed: -It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure; -Storage and Security: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days and failed to ensure residents who receive psychotropic medications have a related diagnosis documented in the medical record. Five residents were selected for medication regimen review and problems were found with four of the five residents (Residents #9, #28, #26 and #1). The census was 40. Review of the facility's Use of Psychotropic Medication policy, dated 9/1/21, included: -Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals are labeled in accordance with currently accepted practices. The facility also failed to discard expired dressings. These practices affected four of six medication carts reviewed. The census was 40. Review of the facility's mediation storage policy, revised [DATE], showed: -It is policy of this facility to ensure all mediations housed on our premises will be stored in the pharmacy and/or mediation rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilations, moisture control, segregation and security; -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing label. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and make available personal funds on an ongoing basis for all residents for which the facility held funds. The census was 40. Review of the facility's Statement of Resident Rights, provided to residents upon admission, showed: -Under federal and state laws, you have the following rights and responsibilities. We will not engage in interference, coercion, discrimination, ore reprisal when you exercise your rights and responsibilities. We will inform you of your rights during your stay in our facility, and we will notify you of any changes made to these rights; -You have the right to exercise your rights as a resident of the facility and as a citizen or resident of the United States; -You have the right to manage your financial affairs. [...]

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for three of five residents investigated for discharge and personal property (Residents #39, #400 and #40). The census was 40. 1. Review of the facility's Statement of Resident Rights, provided to residents upon admission, showed: -Under federal and state laws, you have the following rights and responsibilities. We will not engage in interference, coercion, discrimination, or reprisal when you exercise your rights and responsibilities. We will inform you of your rights during your stay in our facility, and we will notify you of any changes made to these rights; -You have the right to exercise your rights as a resident of the facility and as a citizen or resident of the United States; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the name and contact information in their grievance policy, and failed to follow the policy by not making the information on how to file a grievance or complaint visible and available to all residents residing in the facility. The facility also failed to maintain the results of grievances filed for a minimum of 3 years by not being able to provide requested grievance logs for May and June 2021. The census was 40. 1. Review of the facility's Resident and Family Grievances policy, dated 9/1/21, showed: -It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate discharge plan for one of two sampled residents who transferred to the hospital (Resident #49). Resident #49 was transported to the hospital and the facility refused to readmit him/her back to the facility. The census was 40. Review of the facility's Transfer and Discharge policy, revised 3/3/22, showed: -It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Notice of transfer of discharge at the time of discharge, shall be provided to the resident and/or resident representative in a manner they understand. The notice should contain required information and documentation of transfer in the medical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the use of a urinary catheter for one resident (Resident #132) and the nutritional needs of one resident (Resident #1). The facility also failed to update the care plan once the use of a urinary catheter was no longer in use for a third resident (Resident #22). The census was 40. Review of the facility's Comprehensive Care Plans policy, revised 6/2/22, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy when staff failed to perform post fall assessments and neurological assessments 72 hours following a resident's unwitnessed fall (Residents #22, #182 and #34). The facility also failed to call the physician when Resident #183's blood sugars were high. The sample was 12. The census was 40. Review of the facility's fall prevention program policy, undated, showed: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of fall. -Definitions: -A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as result of an overwhelming external force (resident pushes another resident). [...]

Inspectors wroteBased on interview and record review, the facility failed ensure a safe resident discharge to the community by failing to ensure a discharge planning process was in place which addressed each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate. One resident with an order to discharge home with home health was discharged without the proper planning or assessment and without home health set up as ordered. The facility failed to provide the required 30 day notice to ensure the resident had time to appeal the decision. When the resident was discharged , staff failed to assist the resident to their car or ensure clear discharge directions were provided. When the resident arrived home, he/she had to crawl into the house and could not access a bed due to the failed discharge process. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure when the facility anticipates discharge, a resident must have a discharge summary that includes reconciliation of all pre-discharge medications with the post-discharge medications and a post-discharge plan of care that is developed with the participation of the resident and/or representative for one of five residents investigated for discharge (Resident #39). The census was 40. Review of the facility's Transfer and Discharge policy, revised 3/3/22, showed: -It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and follow the fluid restriction and diet restriction ordered by the registered dietician (RD) for one resident (Resident #1). The facility also failed to implement interventions as recommended by the registered dietician. The sample was 12. The census was 40. Review of Resident #1's admission Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/23/22, showed: -Cognitively intact; -Required supervision with eating; -Care area assessment tool triggered for nutritional status; -Diagnoses include anemia (the blood doesn't have enough healthy red blood cells), end stage renal disease (ESRD), diabetes, arthritis and depression. Review of the RD progress note, dated 7/28/22 at 10:22 A.M., showed: -Diet Order: Regular/Diabetic precautions; -Height: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy by not completing pre and post dialysis assessments for 1 out of 1 sampled dialysis resident (Resident #1). The census was 40. Review of the facility's hemodialysis policy, revised 3/3/22, included: -This facility will provide the necessary care and treatment, consistent with professional standards of practice, medical provider orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis; -The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly drug regimen review (DRR) recommendations were followed timely. The requirements associated with the medication regimen review (MRR) apply to all residents, whether short or long stay. The facility failed to complete the timelines and responsibilities for the MMR by the consultant pharmacist when they failed to address MRR irregularities for two of five residents investigated for the MMR (Residents #7 and #9). The facility census was 40. Review of the facility's MMR policy, dated 9/1/22, showed: -The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart; -Thorough evaluation of the medication regimen of a resident; the requirements associated with the MRR apply to all residents, whether short or long stay; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent flies in the kitchen, where resident food was prepared and served. The census was 40. Review of the facility's Pest Control Program, last revised on 5/4/22, showed it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Observations of the kitchen, showed: -On 8/2/22 at 11: 05 A.M., several flies flew around the steam table while food was left uncovered; -On 8/2/22 at 2:33 P.M., several flies observed in the dishwasher area near the pot sinks and on the walls while staff ran the dishwasher; -On 8/2/22 at 2:36 P.M., food on the hot cart left open while several flies flew over and and around the food; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post all pertinent State agencies and advocacy groups such as adult protective services and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of resident property in a form and manner accessible and understandable to residents. The census was 40. Review of the facility's Statement of Resident Rights, provided to residents upon admission, showed: -Under federal and state laws, you have the following rights and responsibilities. We will not engage in interference, coercion, discrimination, or reprisal when you exercise your rights and responsibilities. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two out of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #10 and #23). The facility census was 40. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]