Alderwood Post Acute & Rehabilitation

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide sufficient qualified staff to provide care and services for 15 of 24 sampled residents (Residents 8, 16, 19,24, 25, 28, 31, 42, 45, 46, 58, 61, 73, 94 and 99) and 1 of 3 family members that had concerns related to staffing. The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily livings (ADLs) including bathing/meal assistance, supervision to prevent accidents and altercations and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, clean, comfortable environment on 2 of 2 floors. Failure to ensure resident rooms and spaces received routine cleaning placed residents at risk for decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 5 medication carts was locked (Blue Medication Cart), failed to ensure proper storage and labeling of medications for 5 of 7 residents (Residents 8, 42, 61, 71 and 100), and failed to dispose and replace expired medications and equipment in 2 of 2 crash carts. These failures placed residents at risk for having access to medications not prescribed to them, missing medications, and receiving compromised or ineffective medication/equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 10 and 16) reviewed for Pre-admission Screening and Resident Review (PASRR - a federal requirement which identifies individual with Serious Mental Illness (SMI) or intellectual or developmental disabilities (I/DD) to provide appropriate services), received the required screening for necessary services. This failure placed the residents at risk for unidentified mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistants received the required 12 hours of in-service education per year, and the in-service education included abuse, dementia and infection prevention related training for 3 of 5 staff reviewed (Staff E, X and Y). Failing to ensure nursing assistants received the required in-service education had the potential to result in staff failing to meet their licensing requirements and decreased staff competency to provide safe and compassionate resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff followed transmission-based precautions (TBP) for 1 of 2 units (Second floor) reviewed for infection control procedures. This failure placed other residents and staff at risk for transmission of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plans accurately to reflect the resident's needs for 3 of 4 residents (Residents 1, 2 and 3), reviewed for care planning revision. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received restorative services (movement of joints to maintain range of motion and/or splint brace assistance) to maintain and/or prevent declines in mobility and contracture for 2 of 2 sampled resident (Residents 1 and 2) reviewed for range of motion (ROM)/mobility. This failure placed residents at risk for development of contractures (joints become fixed in place), further decline in ROM, decreased mobility and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure preparations were made for a safe discharge for 1 of 3 residents (Resident 1) reviewed for discharges. The facility failed to provide instructions upon discharge, provide wound care training and ensure medications and wound care supplies were provided at discharge. This failure placed residents at risk of an unsafe discharge and risk for medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received scheduled hemodialysis (HD- a form of dialysis - an artificial filtration of waste products and excess fluid of the body from the blood using a machine with a special filter) treatment as ordered for 1 of 2 residents (Resident 1) reviewed for HD. Resident 1 experienced harm when they had volume overload (a condition where the body holds too much fluid) requiring hospitalization to intensive care unit due to missed HD treatments. This failure placed other residents that required HD at risk for unmet care needs, decline in medical condition and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure preparations were made for a safe discharge for 1 of 2 residents (Resident 1) reviewed for discharges. The facility failed to provide instructions upon discharge, evaluate the need for home health support or equipment needs and ensure resident had medications upon discharge. This failure placed residents at risk of an unsafe discharge and risk for medical complications.

Inspectors wroteBased on interview and record review, the facility failed to designate and ensure a full-time Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. This failure could negatively impact the care and services to the residents that could result in potential harm and unmet care needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from abuse for 1 of 1 sampled resident (Resident 1) reviewed for allegation of abuse and neglect. The facility failed to ensure resident protection by allowing alleged staff to continue to work with vulnerable residents, failed to report and investigate an injury of unknown source in a vulnerable area and implement interventions to prevent mental and physical abuse. This failure placed residents at risk for psychosocial harm and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report to the state survey agency allegations of injury of unknown origin in a vulnerable area for 1 of 1 sampled resident (Resident 1) reviewed for abuse. This failure placed residents at risk of undiscovered and potential, continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of sexual assault to rule out abuse/neglect, protect residents, and prevent further incidents of abuse for 1 of 1 sampled resident (Resident 1) reviewed for abuse. These failures placed residents at risk for continued abuse, increased risk of harm, having allegations of abuse not being responded to and thoroughly investigated, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of range of motion (ROM) for 1 of 4 sampled residents (Resident 4) reviewed for ROM. Resident 4 experienced harm as evidenced by moderate pain and decreased functional ability due to the formation of a hand contracture (joint becomes fixed in place) which was not present on admit. The failure to not provide appropriate services/interventions for ROM placed other residents at risk of developing new contractures and/or worsening of existing contractures.

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility environment was maintained in a clean, comfortable, homelike and safe environment, for one of two floors (2nd floor), 1 of 1 resident reviewed for missing property (Resident 26), and 2 of 2 residents reviewed for noise complaints (Residents 4 and 102). Failure to ensure the facility maintained comfortable noise levels, ensured security of resident property, maintained flooring and controlled odors placed residents at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer bed holds and provide a written transfer notice upon transfer to the hospital and notify the Office of the State Long Term Care Ombudsman (LTCO) for 5 of 5 residents (10, 12, 82, 108 & 109) who were reviewed for hospitalization. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for lack of advocacy, not having an opportunity to make informed decisions about their transfer/discharge rights and possible unidentified or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 6 residents (Residents 3, 4, 33 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 5 sampled residents (1,11, 22, 81, and 98) reviewed for PASRR. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 101) for dialysis management, 1 of 4 resident (Resident 26) for pain management, 1 of 3 resident (Resident 4) for mobility, 2 of 6 resident (Residents 1 and 22) for mood and behaviors, and 3 of 6 residents (Residents 3, 22, and 81) for nutrition. This failure placed residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise quarterly care plans accurately to reflect the resident's needs for 2 of 7 residents (Residents 12 and 72), reviewed for care planning. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 5 of 5 sampled dependent residents (Residents 1, 33, 81, 98, and 99) reviewed for ADLs. The facility failed to provide showers/bathing assistance to residents (Residents 1, 33, 81, and 98), who were dependent on staff for bathing, and failed to ensure Resident 99, who was dependent for splint placement was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the failed to ensure that 3 of 3 residents (Residents 12, 40 and 81) reviewed for pressure ulcers (PU), were provided interventions that were required for the prevention of a PU. This failure to implement pressure reducing interventions in accordance with physician's orders placed residents at risk for PU development, prolonged wound healing, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 6 medication carts (Yellow, Blue and Pink Carts) and 1 of 2 medication rooms (second floor medication room) had unexpired medications and/or biologicals, reviewed for medication storage. These failures placed residents at risk of receiving compromised or ineffective medications and biologicals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were provided for 6 of 6 Medicaid residents (Residents 3, 12, 79, 81, 85, and 101) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to wear ill-fitting dentures. These failures placed residents at risk of difficulty chewing, oral pain, decreased self-image and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store food for residents in accordance with professional standards in 1 of 2 nourishment refrigerators (second floor) reviewed for food service safety. The failure to maintain safe refrigerator temperatures placed residents at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system in which residents' records were complete, accurate, and accessible for 2 of 2 residents (Residents 9 and 85) reviewed for physician visits, 1 of 5 residents (Resident 72) reviewed for unnecessary medications, and 1 of 3 residents (Resident 82) for hospitalizations. The facility failed to ensure the residents' medical records were complete and accurate which placed the residents at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 5 residents (Resident's 2, 12 and 116) reviewed for transmission-based precautions (TBP), 2 of 2 staff (Staff AA, Nursing Assistant Certified - NAC and Staff CC, NAC) reviewed for environmental disinfection of equipment, 2 of 2 drainage bags (Resident's 82 and 96) were secured off the floor and 1 of 1 facility water management plan. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriately disinfecting reusable resident equipment, and failed to ensure an appropriate placement of urinary drainage tubing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD-a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 4 of 21 sampled residents (Residents 3, 4, 22 and 82), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 5 residents (Resident's 22 and 81) were reviewed for unnecessary medications (a drug that affects brain activities associated with mental processes and behavior). The facility failed to provide a valid diagnosis for the use of psychotropic medications, ensure a consent was obtained, attempt non-pharmacological interventions, and monitor hours of sleep which placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendation of the Level ll Preadmission Screen and Resident Review (PASRR - a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]) evaluation was submitted after a hospital exemption was no longer valid for 1 of 5 residents (Resident 72) reviewed for PASRR. This failure placed residents at risk of behavioral health needs not being met and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an environment that was free from accident hazards over which the facility had control for 1 of 3 residents (Resident 5) reviewed for falls. Failure to identify hazards and implement safety interventions in the facility therapy courtyard, resulted in Resident 5 experiencing a fall and placed residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 6 sampled resident's (Residents 3 and 81) reviewed for nutrition, received adequate weight monitoring, and implemented effective interventions to maintain adequate nutrition and hydration. This failure placed residents at risk of ongoing weight loss, poor nutrition, and potential harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 101) reviewed for dialysis services received accurate, specific care and monitoring and received coordinated communication and collaboration with the dialysis facility. These failures had the potential to cause unmet care needs and unrecognized medical complications.

Inspectors wroteBased on Interview and record review, the facility failed to provide nonpharmacological interventions prior to the use of as needed pain medications for 1 of 1 sampled residents (Resident 26) reviewed for pain medication use. The facility failed to provide nonpharmacological interventions These failures placed residents at risk for receiving unneeded mediations, related side effects of medications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 44) remained free of significant medication errors during medication administration. This failure of administrating expired insulin injection placed residents at risk for unnecessary medication-related complications and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of 1 of 3 residents (Resident 33) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and review of lab results. This failure had potential for risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food services met the individual food plans, nutritional needs and preferences for 1 of 2 sampled residents (Resident 102) reviewed for nutrition and preferences. The failure placed residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 2 residents (Resident 1), reviewed for rehabilitation services. This failure placed the residents at risk for the decline in function, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to provide timely medication administration, provide care without residents having to wait a long time and licensed nursing staff were able to adequately monitor resident's conditions and supervise nursing assistants to ensure care was provided timely for 2 of 2 units (first floor, second floor) reviewed for sufficient staffing. Failures to ensure sufficient nursing staff resulted in delays in nursing staff response to residents' call lights, delays in administering medications, and placed residents at risk for unmet care needs, complications of medical condition and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a patient-centered discharge planning by the interdisciplinary team, involved resident and/or representative in the discharge planning, direct communication with the resident and/or representative about discharge process, and document required discharge information for 2 of 4 sample residents (Resident 5 and 6) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent. 8 medication errors were identified out of 29 opportunities due to the failure of 2 of 2 nurses (Staff B and D) provided medications outside of the scheduled administration time. This resulted in a medication error rate of 27 percent. This failure placed residents at risk of reduced medication effectiveness, worsening of symptoms, and/or complications of medical condition.

Inspectors wroteBased on record review and interview, the facility failed to maintain a completed state reporting log for 2 of 3 (April and May 2025) months reviewed. The facility failed to ensure incidents were logged within 5 days of incident discovery. This failure placed residents at risk of unidentified patterns of alleged violations, which could include neglect, abuse and/or exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a qualified Infection Preventionist (IP, responsible for the facility's infection control program that includes early detection, analysis of evidence-based surveillance of infection, implementation, and management of healthcare associated infections by ensuring sources of infections were tracked/managed to isolate/prevent the spread of infection) designated for the facility. The facility was currently in a viral respiratory disease outbreak and this failure placed the residents and staff at risk for transmission of an infectious disease and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party for 1 of 3 residents (Resident 1) reviewed for hospitalization. Failure to notify the resident representative of transfer to a hospital placed the resident at risk for not having their representative involved in their health care decision-making with timely care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled staff (Staff B) had an active professional license. Failure to ensure the Director of Nursing had an active license placed all residents at risk of substandard quality of care as the Director of Nursing was responsible for all residents in the center.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a background check prior to employment for 1 of 5 sampled staff (Staff B) reviewed for staff qualifications. This failure placed residents at risk from interactions with staff who were not qualified to work with vulnerable adults and created the potential for abuse, neglect and exploitation.

Inspectors wroteBased on interview and record review the facility's governing body failed to ensure that the facility's abuse policy was followed by ensuring the Director of Nursing (DNS) had a completed background check and failed to ensure the DNS had an active professional license prior to employment. This failure placed residents at risk of substandard quality care and placed residents at risk of abuse, neglect and/or exploitation.

Inspectors wroteBased on interview and record review, the facility failed to administer services effectively and efficiently to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. The facility failed to ensure all allegations had a complete and thorough investigation and failed to maintain systems to prevent repeat citations throughout the last year. In addition, the facility failed to recognize and/or correct repeated concerns that had been documented on the Resident Council meeting minutes for long call light wait times. The administrator should have been aware of these issues and did not put corrective action into place to sustain these systems. These failures placed residents at risk for the potential for continued abuse, unmet care needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the governing body failed to provide adequate active and engaged oversight and monitoring of the facility's appointed Administrator. The governing body failed to ensure the Administrator had clinical systems in place and that were followed related to Abuse/Neglect, Resident Rights, Grievances, Pressure Ulcers, Infection Control and Prevention, Social Services, Nutrition, Care Planning, Accidents and Supervision, Transfer and Discharge, Staffing, Medication Safety, Range of Motion program, and Infection Control Practices, failed to identify and correct their own identified deficiencies to ensure sustainability with compliance for state/federal regulations and previous deficiencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to act, respond, and resolve the organized resident group's concerns for 1 of 1 Resident Council groups. The facility administration's failure to respond to the organized group's concerns resulted in an extended period where reported resident care needs went uninvestigated, unidentified and unmet due to the facility's systemic failure to investigate the concerns reported during the Resident Council meetings from May, June, July and August 2024. Additional failed practice included the facility failure to maintain complete and accurate Resident Council meeting minutes that included all concerns and grievances voiced during Resident Council meetings, and failures to log, report, investigate, and resolve concerns voiced by the Resident Council. [...]

Inspectors wroteBased on interview and record review the facility failed to recognize, record and promptly resolve grievances for 5 of 5 residents (Residents 2, 37, 45, 98 and 255) reviewed for grievances. Failure to implement their grievance process placed the residents at risk for anxiety, undue stress, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse and neglect due the facility failure to respond to and resolve nursing care, staffing and food services grievances voiced by 1 of 1 organized resident groups over a four-month period from May to August 2024. Facility administration chose to address only select grievances and opted not to address reported nursing staffing and food service concerns. The facility administration's systematic failure to investigate and act on residents' reported concerns deprived an unknown number of residents necessary nursing care and food service support, the extent of which could not be ascertained due to a gross lack of documentation and overt failures in the facility's Resident Council/Grievance procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure systems were in place for staff following and implementing abuse and neglect policies & procedures for reporting, investigation, and protection for 3 of 11 residents (Residents 15, 50, and 84), reviewed for abuse and neglect. The failure to identify potential abuse, timely report allegations of potential abuse, complete timely and thorough investigations of the potential abuse, assess and monitor the residents for physical and psychosocial harm, notify responsible parties and providers, and to document the allegations and revise resident care plans placed residents at risk for injury, fearfulness, frustration, humiliation, and further potential abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a thorough investigation for 17 of 20 resident investigations (6, 15, 46, 78, 84, 454, 58, 2, 80, 31, 11, 56, 19, 66, 62, 46, 12) and 1 of 1 organized resident group (the Resident Council) reviewed for accidents and allegations of potential abuse and/or neglect . The facility failed to identify the root cause, and all contributing factors related to allegations of abuse and/or neglect placed residents at risk for injury, and additional abuse/neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 4 residents (Resident14, 43, 88 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 8 residents (Resident 24, 43, and 98) reviewed for comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the residents highest practicable well-being placed the residents' at risk of not receiving services that would meet their desires or wants and a decreased quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow professional standards of practice for 4 of 29 residents (Resident 2, 5, 58, and 78) reviewed for medication administration. Failure to transcribe orders accurately upon admission and pre-signing medications in the Medication Administration Record (MAR) ahead of adminsitration placed residents at risk for medication errors and acute medical problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and provide necessary treatment and services consistent with professional standards of practice for 3 of 4 residents (Resident 14, 43, and 98) reviewed for Pressure Ulcers. This failure placed the resident at risk for increased pressure ulcers, pain, discomfort and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment and services for 4 of 4 residents (Residents 2, 41, 46, 88) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function.

Inspectors wrote<RESIDENT 54> Resident 54 admitted to the facility on [DATE]. According to the admission MDS assessment, dated 07/17/2024, the resident had no cognitive impairment. Review of Resident 54's weight history showed weights to include: 07/11/2024 no documented weight found (day of admit) 07/14/2024 - 182.0 lbs. 08/08/2024 - 157.2 lbs. This was significant weight loss of 13.6% in less than 30 days. There was no documented re-weight found in the electronic health record. 08/16/2024 - 154.2 lbs. 11/07/2024 - 150.4 lbs. Review of a hospital Discharge summary, dated [DATE], showed Resident 54's weight was 186 lbs. 11 ounces on discharge from the hospital. Review of a nursing progress note, dated 10/09/2024, showed staff documented the resident had no significant weight changes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient numbers of adequately supervised nursing staff to provide care and services for 5 of 9 residents (Residents 5, 2, 43, 36, 15) and 1 of 1 organized resident groups (Resident Council) reviewed for nursing staffing and nursing care and services. Failures to ensure sufficient nursing staff and nursing staff supervision resulted in delays in nursing staff response to resident call lights, failures in administering nutritional supplements as ordered by physicians, missed bathing, cold food and not-accurate medical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent (%), there were 29 opportunities for error observed and resulted in 68.97% medication error rate. Failure to administer the right dose of medication for 1 of 8 residents (Resident 43), failure to administer medication by the correct route for 1 of 8 residents (Resident 78), and failure to administer medications at the right time for 7 of 8 residents (Resident 2, 5, 34, 43, 58, 75, 78) placed residents at risk for adverse side effects, medical complications and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 7 of 10 residents (Residents 5, 2, 58, 78, 24, 98, 453) remained free of significant medication errors when administering and documenting medication administration. The failure to administer medications within the required time frame of one hour before/after the scheduled time resulted in countless timing and/or documentation errors including breakfast and lunch insulin administrations given within minutes of each other. The facility's failed medication management practices placed residents at risk for adverse medication-related complications, diminished quality of life, and for having inadequate medical records being used to make medical decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured for 4 of 4 residents (Resident 47, 78, 453 and 454) observed with medications at bedside. Further, the facility failed to discard expired in three of four medication carts reviewed. This failure placed the residents at risk for receiving compromised or ineffective medications This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and were palatable for 6 of 7 residents (Resident 75, 81, 84, 95, 98 and 454) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' menus and individual food plans met the nutritional needs and preferences of 5 of 9 residents (Residents 2, 19, 50, 5, 81) and 1 of 1 organized resident groups (Resident Council) reviewed for food services. The failure to ensure residents received foods that met their nutritional needs, and their individual preferences placed residents at risk for weight loss, dissatisfaction with their food and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently offer and/or provide a nutritional snack when ordered or requested for 4 of 6 (Resident 2, 24, 84, and 50) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 5 of 5 residents (Resident 6, 14, 46, 54, and 81) observed during cares. Failure to wear personal protective equipment (PPE) prior to entering a precaution room(first floor) and failure to do hand hygiene between glove changes during wound care and peri care placed residents and staff at risk for potential infections.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were consistently operational and functioning appropriately on 2 of 2 floors, including 6 residents (Residents 24, 50, 53, 78, 98,and 454 ) and potentially any of the residents who used a call light throughout the facility. The failed practice placed residents at risk of not having their needs met and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility staff were educated on all required topics that were identified on the facility assessment for 5 of 5 sampled staff (Staff DD, CC, EE, K, X) reviewed for education and training. Failure to ensure staff received required trainings placed residents at risk of not receiving competent care, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated 2 of 2 residents (Residents 84 and 98) in a dignified and respectful manner. This failure placed the residents at risk for experiencing a high level of frustration, embarrassment, and the need to constantly advocate for their care.

Inspectors wroteBased on interview and record review, the facility failed to honor a residents' representative's request to schedule a care meeting for 1 of 3 residents' (Resident 5) representative. The failure to honor the resident's representative's request to schedule a care meeting placed the resident at risk for unmet needs and for the resident's representative being unable to advocate for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (Resident 46) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's right to be free from involuntary seclusion for 1 of 1 resident (Resident 253). Failure to prevent involuntary seclusion placed the resident at risk for psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 14 and 78) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer or within 24 hours of transfer to the hospital, for 1 of 2 residents (Resident 78), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR)(a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings) was completed as required and that Level two comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 2 of 5 (Resident 43 and 74) residents reviewed for PASRR services. This failure placed residents at risk for not receiving necessary mental health care and services in the most integrated setting appropriate to their needs

Inspectors wroteBased on observation, interview and record review, the facility failed to implement, review and revise care plans for 1 of 14 residents (Resident 46) reviewed for care planning. These failures placed residents at risk for unmet care needs, adverse health effects and diminished quality of life. <RESIDENT 46> Resident 46 admitted to the facility on [DATE]. Diagnosis to include Multiple Sclerosis (a disease that causes the breakdown of the protective covering of the nerves). According to the Minimum Date Set (MDS - an assessment tool) assessment, dated 10/17/2024 Resident 46 showed severe cognitive impairment. Resident was able to verbalize needs and responded appropriately when questions were asked. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and requires total assist with care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary activities of daily living care and services for 2 of 4 residents (Residents 5, and 54) reviewed for bathing. The failure to bathe residents per their bathing care plans placed residents at risk for hygiene issues and for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for 1 of 3 residents reviewed for non-pressure skin conditions (Resident 2), 1 of 2 residents reviewed for falls (Resident 37) and 2 of 4 residents reviewed for medication management (Residents 24 and 88) The failure to provide monitoring and assessment related to wounds, medication management, fluid restrictions and fall prevention placed residents at risk for adverse outcomes and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen (O2) tubing was appropriately maintained, changed regularly, and dated consistently according to with professional standards of practice for 1 of 1 sampled resident (Resident 43) reviewed for O2 tubing. Additionally, the facility failed to ensure 1 of 1 sample resident (Resident 43) physician's orders were followed related to O2. These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 43) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 Residents (Resident 74) reviewed for unnecessary medications were free from unnecessary psychotropic medications. Failure to provide complete and accurate informed consent for medications and identify/monitor target behaviors for as needed antipsychotic medication placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 1-unit refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, the maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . <WALK IN REFRIGERATOR> During an observation 11/04/2024 at 9:48 AM the main refrigerator located in the kitchen had a temperature log on the front door showed no logged temperatures for the PM for 10/28/2024, 10/29/2024, 10/30/2024 and AM and PM for 10/31/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for 4 of 4 residents (Residents 41,5,14 and 253) reviewed for care and services. The failure to ensure thorough and consistent documentation of care and services placed residents at risk for unmet needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the skills and competencies to perform an ordered procedure on 1 of 1 sampled resident (Resident 1) reviewed for care of a chest tube (tubing that inserted into lining of lung to drain fluids). This failure placed the resident at risk of excess fluid collecting around the lung which could compromise breathing and respiratory function.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and/or failed to follow the resident's care plan to prevent accidents/falls for 2 of 3 residents (Resident 1 and 2) reviewed for injuries and accident hazards. Resident 1 experience harm when they received care while in bed without two staff assistance which resulted in a fall and the resident sustained a pelvic fracture, and Resident 2 experienced harm when they exited the facility unsupervised, was subsequently found by an Emergency Medical Technician (EMT) lying on the sidewalk next to the road and sustained a significant injury requiring a hospital admission. This failed practice placed residents at risk for elopement, falls, and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of an allegation of abuse for 1 of 2 allegations reviewed for abuse. The facility failed to report a resident-to-resident altercation (Resident 3 and 4) to the facility's abuse coordinator and the State Agency and failed to initiate a timely abuse investigation. This failure placed the resident at risk for further altercations and lack of protection, and exposed additional residents at risk for potential of abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the discharge summary was completed that included a recapitulation (overview) of the residents' stay, a final summary of the resident's status, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) and a post-discharge plan of care for 3 of 3 sampled residents (Residents 1, 3 and 4) reviewed for discharge planning. This failure put the residents at risk of complications and delayed treatment of medical conditions by not having the necessary information to ensure continuity of care when discharged to the community.

Inspectors wroteBased on interview, and record review, the facility failed to conduct safe and orderly discharges for 2 of 3 sampled residents (Residents 3 and 4) reviewed for discharges. The failure: 1) to provide necessary post-discharge instructions regarding wound treatments, 2) to coordinate for and/or provide necessary post-discharge medications, 3) to provide discharge instructions to a resident's representative for a cognitively impaired resident, 4) to provide information regarding a resident's post-discharge follow-up physician appointment, 5) to document medications prescriptions provided to residents, 6) to follow the discharge plan for the time of day for a resident to be discharged , and 7) to document medications/quantities of medications sent with a resident on discharge placed residents at risk for unmet care needs and for Resident 3 it resulted in missed medications after discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer (PU) (bedsore)/pressure injury (PI), (localized damage to the skin and underlying soft tissue usually over a bony prominence) for 2 of 2 sampled residents (Resident 28 and 74) reviewed for PU's. The facility did not consistently complete comprehensive and accurate assessments, develop/update and implement person centered care plans to address the residents' risk factors for developing and deteriorating PUs, or monitor to ensure the implementation of care plan interventions. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to provide sufficient qualified staff to provide care and services for 20 of 48 sampled residents (Residents 1, 7, 9, 10, 21, 30, 36, 37, 45, 48, 49, 59, 60, 61, 74, 77, 78, 120, 138, and 143), 3 of 4 family members (Residents 59, 138, and 141), and 2 of 2 anonymous complaints that had concerns related to staffing on 2 of 2 floors (Floor 1 and 2). Failure to timely respond to resident call lights and to provide adequate nursing supervision and oversight to the Nursing Assistants resulted in residents with diminished quality of life and unmet needs including having toileting accidents and soiling themselves when staff did not respond to their call lights timely and they were unable to hold it any longer.

Inspectors wroteBased on interview and record review, the facility failed to ensure their facility assessment (a required document that comprehensively assessed levels and types of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff accurately reflected the risks and resources necessary for the facility's infection prevention and control program. This failure placed the facility at risk for lack of ability to manage day to day infection control and prevention and to respond appropriately in the event of an infectious disease outbreak in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective system to obtain and use information from staff, residents, and resident representatives to identify problem areas within the facility through a Quality Assurance and Performance Improvement (QAPI) program. This failed practice placed residents at risk of receiving lower quality services and for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide timely and accurate Medicare notices to 3 of 4 sampled residents (Residents 290, 61 and 289) reviewed for required liability notices. This failure placed residents or their representatives at risk for not being informed of their appeal rights prior to the end of their health plan company (managed Medicare insurance) ended and not being fully informed of the cost of continued services after skilled services ended.

Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigations for 4 of 5 residents (Residents 143, 3, 59, and 74) whose investigations were reviewed. The failure to conduct thorough investigations placed residents at risk for repeat incidents, unmet care needs, and for frustration with unresolved care issues.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 7 sampled residents (40, 11, 19, 28 and 27) reviewed for unnecessary medications. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability.

Inspectors wroteBased on interview and record review, the facility failed to provide 3 of 3 residents (Residents 143, 147, and 85) and/or their representatives with a written summary of their baseline care plans (minimum healthcare information necessary to properly care for a new resident). This failure resulted in residents not being informed of their initial plan for delivery of care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide assistance with activities of daily living (ADLs) for 3 of 3 sampled residents (Residents 59, 28, and 49) reviewed for ADL's. The facility failed to provide the necessary assistance with grooming (oral care) and assist with hearing needs placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services according to professional standards of practice for 6 of 10 residents (Residents 138, 143, 1, 3, 40, and 61) reviewed. The failure to perform resident weights as ordered, to push fluids as ordered, and to hold medications when indicated per physician ordered parameters placed residents at risk for unidentified weight loss/gain, dehydration, and for medication-related complications, and for not reaching their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order with a prescribed oxygen (O2) flow rate (the amount of supplemental oxygen flowing over a certain length of time), indication for use was completed, and failure to ensure O2 tubing was regularly changed and dated for 1 of 3 sampled residents (Resident 27). Additionally, the facility failed to provide routine cleaning for a C-Pap (continuous positive airway pressure device used for breathing issues during sleep) and Bi-Pap (Bi Level Positive Airway Pressure) machine for 3 of 3 sampled residents (Residents 5, 27, and 49) reviewed for respiratory care. This failure placed residents at risk for respiratory distress, respiratory infection, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Nurses and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 3 of 4 staff (Staff K, L and M) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for three of four employees (D, E, and GG) files reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 5 residents (138, 40, 11, 36) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). The failure to monitor residents for adverse side effects and appropriate target behaviors (any behavior that has been chosen or targeted for change) and to provide/obtain informed consent for treatment with psychotropic drugs placed residents at risk for receiving unnecessary psychotropic drugs and for not being fully informed of the risks/benefits/alternatives of treatment with psychotropic drugs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to timely administer 19 of 28 medications for 3 of 5 residents (47, 69, and 78) observed during medication pass audit resulted in a medication error rate of 67.86%. The failure to administer medications on time placed residents at risk for side effects and/or altered medication effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications timely for 5 of 6 residents (3, 238, 144, 28, 151) reviewed for medication timeliness. The failure to administer medications timely resulted in these residents having multiple significant medication errors and placed them at risk for medication-related complications and for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (first floor and second floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Additionally, the facility failed to ensure medications were secured for two of two residents (19, 61) observed with medications at bedside. This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines (IPC) and standards of practice for 1 of 2 units (2nd floor) reviewed for IPC procedures. The facility failed to follow processes to prevent cross contamination during meal delivery in resident halls and to follow standards of practice related to hand hygiene and disinfection of multi-use equipment. These failures placed residents at risk for food borne illness and/or other infectious diseases.

Inspectors wroteBased on record review and interview, the facility failed to develop, implement and maintain an in-service training program for 3 of 4 Nursing Assistant's (D, E and GG) reviewed for the required 12 hours of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 3 of 5 residents (Residents 3, 1, and 61) reviewed for resident rights. The facility failed to ensure staff interacted with residents in a dignified manner which placed residents at potential risk to experience emotional distress, humiliation, embarrassment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide information and/or resources to residents to assist with the development of an Advanced Directive (AD) for 2 of 4 sampled residents (Residents 59 and 61) reviewed for AD. This failure denied residents the opportunity to appoint someone to make choices regarding finances and/or healthcare decisions if the residents became unable to make their own decisions.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation regarding a grievance for 1 of 2 residents (Resident 49) reviewed for grievances. This failed practice placed the resident at risk for not having their grievance resolved and for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse policy by not ensuring reference checks were conducted prior to hire for 2 of 5 employees (Staff J and T) reviewed for reference checks. These failures placed residents at risk for abuse, neglect, or mistreatment by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 2 of 5 sampled residents (Residents 19 and 59) reviewed for Minimum Data Set (MDS - a required assessment used to identify resident's care needs) accuracy. Failure to ensure accurate assessments regarding dental/oral status and behavioral health indicators placed residents at risk for unidentified and/or unmet care needs, and inaccurate or incomplete care plans.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 residents (Residents 1 and 61) in the areas of pacemaker and dialysis. This failure placed residents who had a pacemaker and were on dialysis at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a resident's request to change their code status (level of intervention a resident wishes to have started if their heart or breathing stops) for 1 of 1 resident (Resident 85) reviewed for Cardiopulmonary Resuscitation (CPR - staff performing chest compressions and providing breaths to mimic heartbeat and breathing). This failure placed residents at risk to have CPR initiated when they had requested to change their status to No CPR.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 1 of 1 residents (Resident 11) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two residents (47 and 61) reviewed for dialysis, received consistent ongoing communication and collaboration with the dialysis center. The facility further failed to document before and after-dialysis assessments of resident's condition, which placed the residents at risk for unmet care needs and dialysis related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) license completed a Nursing Assistant Certified (NAC) class and passed the state license exam within four months of hire for 1 of 2 NAR's (Staff J) reviewed for staff licenses. This failure placed residents at risk to receive care from unlicensed staff.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, and administering of all drugs) to meet the needs of each resident for two of two residents (40 and 147). Failure to ensure timely receipt and administration of ordered medications placed Residents 40 and 147 at risk for discomfort, pain and a decline in their physical health.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents (138, 27) remained free of unnecessary drugs. The failure to monitor for adverse side effects of medications and to provide non-pharmacological pain interventions placed the residents at risk for medication-related complications and for receiving unnecessary pain medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information postings were current, accurate, and posted in prominent locations. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information.

Inspectors wroteBased on interview and record review, the facility failed to follow standards of practice for completing physician orders upon admission and medication administration for 1 of 1 residents (Resident1) reviewed for medication orders. Failure to transcribe orders accurately upon admission, failure to document when new orders were obtained and why, and failure to administer medications per orders placed residents at risk of exacerbation of acute medical problems.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate management of diabetes for 1 of 1 residents (Resident 1) reviewed for diabetes management. Failure to educate resident and/or resident representative on diabetes management such as diet, monitoring blood glucose (BG), use of glucometer (device to test blood glucose), and side effects of diabetes medications placed residents at risk of complications.