Amberwood Estates Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to use the personal funds of a resident only when authorized in writing for two of four sampled residents (Residents #64 and #63). The census was 83.1. Review of Resident #64's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/25, showed:-Diagnoses included quadriplegia (paralysis of all four limbs), contracture of right hand and both shoulders;-Moderately impaired;-Minimum depression. Review of resident's care plan, in use during the survey, showed:-Focus: Activity care plans for individuals should be personalized to their needs and interests; -Goal: Will have his/her personal preferences honored as safely allowed;-Intervention: Tailor activities to the person's interests, abilities, and needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed by failing to complete monthly resident trust fund (RTF) reconciliations, resulting in the inability to accurately account for money held in the RTF account. In addition, the facility failed to provide quarterly statements to residents and their representatives. This affected 41 residents whose funds were handled by the facility. The census was 83. Review of the facility's Resident Trust policy, dated 2/2022, showed:-Policy: To maintain a complete and accurate accounting for resident monies. The Administrator is responsible for the establishment and accurate maintenance of the RTF and the related resident trust petty cash account including the handling of the funds according to corporate policies as well as state and federal regulations;-Procedures: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents had a homelike environment by failing to maintain a comfortable sound level throughout the facility, failed to maintain adequate hot water temperatures for three residents (Resident #67, #5 and #6) and failed to thoroughly clean one resident's room (Resident #42). The sample was 22. The census was 83. Review of the facility's Environment of Care policy, dated 4/1/22, showed: -The facility staff will provide a safe, clean, comfortable and homelike environment; -The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; -The facility will provide for the maintenance of comfortable sound levels. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a grievance official responsible for overseeing the grievance process. In addition, the facility failed to post signage informing residents of the location of grievance forms or the process for filing grievances orally, in writing or anonymously. This deficient practice had the potential to affect all residents in the facility. The census was 83. Review of the facility's grievance policy, dated 4/1/2022, showed:-Policy: Of this facility to provide residents, resident representatives, family and visitors with methods of sharing grievances and/or concerns with the facility;-Procedure: -The facility will have Grievance Forms available 24 hours per day , 7 days per week in an unsecured common area. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or resident representatives a bed hold policy at the time of transfer or as soon as practicable when residents were transferred to the hospital. In addition, the facility failed to send a copy of discharge notices to the representative of the Office of State Long Term Care (LTC) Ombudsman. The census was 83. Review of the facility's Transfer and Discharge policy, dated 4/1/22, showed:-30-day facility-initiated discharge (notice requirements before transfer/discharge):--The facility must send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman;-Planned discharges and transfer to the hospital: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL) care received at least two showers weekly for three of 22 sampled residents (Residents #80, #6, and #67). The census was 83. Review of the facility's Showering/Bathing policy, dated 4/1/22, showed:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician or designee responded to the pharmacy recommendations timely for three out of five residents sampled for medication review (Resident #11, #5, and #9). The sample was 22. The census was 83. During an interview on 2/4/26 at 8:55 A.M., the pharmacy review policy was requested. As of 4:00 P.M. on 2/4/26 no policy was received. 1. Review of Resident #11's medical record showed, a diagnosis of schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations, delusions, disorganized speech) with a mood disorder (major depression or bipolar mania/depression). Review of the care plan, in use at the time of survey, showed:-Focus: Resident used psychotropic medications;-Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a palatable, safe and appetizing temperature during tray service by failing to maintain the temperature of hot foods to at least 120 degrees Fahrenheit (F). This deficient practice affected all residents who ate at the facility, including (Residents #19, #67, #6 and #74). The sample size was 22. The census was 83. Review of the facility's Final Cooking Temperatures policy, revised 10/1/23, showed:-Policy: Food is to be cooked to specified temperatures and times to mitigate the presence of dangerous microorganisms. The danger zone for food temperatures is above 41 degrees Fahrenheit (F) and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings were documented as attended and consisted of the required committee members when the Administrator, Infection Preventionist Nurse (IP) and the Medical Director failed to attend the facility's QAPI meetings. The census was 83. Review of the facility's Quality Assessment and Assurance (QAA) policy and procedure, revised 10/1/123, showed:-Policy: It will be the policy of the facility to hold a QAA committee meeting at least quarterly;-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable infection control standards and failed to follow Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact care activities as recommended by Center for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Service (CMS)), when staff failed to wear a gown while providing high contact care for four out of five residents observed for care (Resident #79, #81, #72, and #9). [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist (IP) for the facility's infection control and prevention program (IPCP). The census was 83. Review of the facility's Infection Prevention and Control Program policy, revised 11/28/22, showed, the facility will designate one or more individual(s) as the infection preventionist(s) who is responsible for the facility's IPCP. The IP will have completed specialized training in infection prevention and control. During an interview on 1/29/26 at 8:57 A.M., the Administrator said the IP worked part time, and the Assistant Director of Nursing (ADON) was currently in the process of obtaining her specialized training. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year. The facility failed to document the length of time the in-services were provided for each individual CNA's training hours. The census was 83. A policy related to CNA 12-hour training was not provided by the facility. Review of the facility's In-Service Training Report sheets, dated from 3/19/25 through 1/5/26 and provided as training records for CNA B, CNA J, CNA K. CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R, showed the heading consisted of facility name, date, subject, time start and end, type of in-service, and instructor. Time start and end lines were all blank. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for one resident (Resident #6) who was dependent on staff for bathing/showering by failing to ensure the resident received showers or bed baths, in accordance with the resident's preferences. The sample size was 22. The census was 83. Review of the facility's Resident Rights, Dignity and Visitation Rights policy, issued 4/1/22, showed:-Policy: It will be the policy of this facility that employees shall treat residents with kindness, respect and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers in the exercise of these rights. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting of residents who expired, for one of one sampled resident who expired and had money left in their resident trust account (Resident #9). The census was 83. Review of Resident Trust policy dated 2/2022, showed no funds are released until a final audit of the account is completed. Such funds are to be provided within 30 days of the death of the resident. Reference state regulations for further guidelines. Review of Resident #9's resident trust fund account, showed:-Resident expired on [DATE];-A balance of $5,175.22;-A TPL had not be completed and money remained in the resident trust fund account. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make accessible for examination, the results of the most recent survey, certifications and complaint investigations of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility available to residents, visitors and resident representatives. The sample size was 22. The census was 83. Review of the facility's Resident Rights policy, showed the policy did not address residents' rights to examine the results of the most recent federal or state survey and any plan of correction in effect for the facility. [...]

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 services and Notice of Medicare Non-Coverage (NOMNC-form CMS-10123, a notice that indicates when care is set to end from a skilled nursing facility) for three sampled residents upon discharge from Medicare Part A services. Two residents (Residents #3 and #82) remained in the facility. One resident (Resident #95) discharged to the community. The census was 83. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive policies and procedures to prevent potential sexual abuse for two residents who were identified by staff as being in a sexual relationship (Residents #86 and #80). The census was 83. Review of the facility's Abuse, Neglect and Exploitation policy, revised on 3/3/22, showed:-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;-Definition of sexual abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one resident when staff documented a resident's weight loss medication as unavailable when the medication was available and did not administer the medication as ordered (Resident #19). The census was 83. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure double portions and a divided plate and sack lunch were provided for one resident (Resident #74) per the physician's and Registered Dietician's (RD) orders. The facility failed to ensure the RD assessed residents upon admission, quarterly, annually, and as needed for three sampled residents (Resident #74, #19, and #5). In addition, the facility failed to notify the physician or RD of fluctuations in resident's weights for two residents (Residents #19 and #5). The sample size was 22. The census was 83. Review of the facility's undated Nutritional Assessment and Diet History Policy, showed:-A nutritional assessment and diet history will be completed for each resident according to State and Federal requirements. The assessment/history form should be initiated within 72 hours; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice for one resident with an enteral tube feeding (TF, delivers liquid nutrition directly into the stomach or small intestine via a tube for patients unable to meet their nutritional needs by mouth). The facility identified one resident as having a tube feeding (Resident #9), and issues were identified. Staff failed to follow the TF flush infusion rate and duration as ordered by the physician. In addition, staff failed to stop or hold the infusion while providing personal care while the resident's head of bed was lowered, increasing the risk of aspiration of the tube feeding formula. The census was 83. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services and appropriate person-centered care to meet his/her highest practicable psychosocial well-being for one resident (Resident #93), who recently admitted to the facility. The sample size was 22. The census was 83. Review of the facility's Social Services policy, issued 4/1/22, showed:-Policy: It will be the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident to assure that sufficient and appropriate social services are provided to meet resident's needs;-Examples of medically related social services include; -Making arrangements for obtaining items such as clothing and personal items; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified two medication rooms, two nurse carts, two Certified Medication Technician (CMT) carts, and one treatment cart. Both medication rooms, two CMT carts, and one nurse cart were checked for medication storage. Issues were found in all three medication carts and one medication room. Staff failed to double-lock the refrigerated controlled medications. In addition, staff failed to dispose of expired over-the-counter (OTC) medications. Furthermore, staff placed an unlabeled capsule in the drawer of a medication cart. The census was 83. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and offer nourishing snacks at bed time. This affected all residents who ate at the facility. The census was 83. Review of the facility's undated Between Meal Snack/Bedtime Nourishments policy, showed:-Policy: Between meal snacks and bedtime nourishments are to be offered to all residents unless contraindicated by the physician diet order;-Procedure:--The bedtime nourishment must consist of foods that are nourishing. These include milk, 100% fruit juice, cookies, crackers, fruit;--Dietary should develop a snack nourishment stock level for each nursing stations;--According to regulation, nursing is to pass snacks and nourishments from room to room. It is not acceptable to announce that snacks are being served from the nursing station. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, homelike environment for the residents. This includes the failure to maintain adequate pest control in resident rooms with one room having multiple ants on the floor, in his/her sink, and on his/her wall by the sink. Also, the facility failed to notice an air conditioning unit leak through the wall in the same resident's room, which caused a discoloration spot on the wall (Resident # 4). The facility failed to clean up droppings left by pests in another room and multiple brown droppings on the floor by the resident's bed (Resident #5). The sample was 12. The census was 79. Review of the Facility's Floor Care Policy and Procedures, undated, included Step-by-Step for Cleaning Vinyl Plank Flooring:-Sweep or Vacuum: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from the potential of abuse when staff failed to follow their policy and did not remove Certified Nurse Aide (CNA) A after an allegation of abuse was made. On 7/31/25 at approximately 10:30 P.M., Resident #3 notified staff both verbally and in a written statement that CNA A roughed him/her up. CNA A was removed from the resident's hall but continued to have direct contact and provide care for residents until the end of his/her shift at approximately 7:00 A.M. on 8/1/25. In addition, staff failed to immediately notify the Administrator and/or Director of Nursing (DON). The census was 84. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the services provided met acceptable professional standards of care when staff failed to ensure ordered Tramadol (narcotic used to treat pain) 50 milligram (mg) was processed timely by the pharmacy. When the medication was not delivered timely, staff failed to promptly contact the physician for medication order processing. As a result, the resident did not receive the ordered Tramadol for a total of 6 missed doses (Resident #1). The sample was 7. The census was 76. Review of the physician order policy, dated 1/1/22 showed: -Policy: -Electronic orders: (Direct into any clinical record): -Physicians may be given access to any one of the systems of the clinical record for use to provide orders; -Orders will be directly entered into the system and automatically become a part of the clinical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment by not maintaining appropriate water temperatures throughout the facility, which included three of the residents' hallway shower rooms. The sample size was 16. The census was 88. Review of the facility's Water Temperature Policy, revised 12/2019, showed: -Policy Statement: -Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. -Policy Interpretation and implementation: -Water heaters that service the resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than (blank) Fahrenheit (F) (blank) Celsius (C), or the maximum allowable temperature per state regulation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor water temperatures throughout the facility which resulted in water temperatures in two resident rooms being above the required temperature range (105 and 120 degrees Fahrenheit (F)). The facility also failed to ensure a complete and thorough investigation was performed and documented after each resident fall for one resident (Resident #2) out of 16 sampled residents. The census was 88. Review of the facility's Water temperature policy, revised 12/2019 showed: -Policy Statement: -Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. -Policy Interpretation and implementation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain privacy and confidentiality of medical information for one resident (Resident #20) by having identifying information exposed and sticking out of a shred bin that was unlocked in an area that was accessible to all residents and the public. In addition, staff used a personal device to take a photo of Resident #20's medication prescription (script) and then used a personal email address to email the resident's script to the pharmacy. The sample size was 14. The census was 78. Review of the facility's Resident Rights Policy, dated 2021, showed: -Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records; -a. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse for one of 14 sampled residents (Resident #4). The census was 88. Review of the facility's Abuse Investigation and Reporting Policy, dated May 2019, showed: -Policy: --It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law in any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or maybe adversely affected by abuse or neglect caused by another person; --The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect, or misappropriation property, and provide notification and release of information to the proper authorities, in accordance with federal and state regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of property involving narcotics. The facility also failed to thoroughly investigate an allegation of resident to resident physical abuse for two residents (Resident #4 and Resident #5) out of 16 sampled residents. The census was 88. Review of the facility's Abuse Investigation and Reporting Policy, dated May 2019, showed: -Policy: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law in any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or maybe adversely affected by abuse or neglect caused by another person; -Definition: -Misappropriation of properties/financial abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly wound assessments and ordered treatments were performed per order, resulting in one resident (Resident #3) found by staff with small, white, legless, worm-like organisms in his/her brief and wound; and failed to ensure the facility had wound care policies and procedures in place and available to staff. This has the potential to affect all residents with wounds. The sample was 16. The census was 88. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences. The facility also failed to provide showers/baths per resident preferences. This affected one of 21 sampled residents and members of the resident council (Resident #71). The census was 87. Review of the facility's Resident Rights policy, reviewed/revised 9/1/22, showed: -The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; -Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a functional bathroom toilet for one resident (Resident #50). The resident's bathroom toilet did not function for 4 out of 5 days of the survey. The resident had to use the shower room down the hallway. The facility also failed to ensure functional resident bathroom lights for two residents (Residents #71 and #72) and call light for one resident (Resident #36) on the 500 hallway as well as a comfortable water sink temperature and pressure. The census was 87. Review of the Environmental Quality Policy, revised 9/1/21 showed: -Policy: the facility shall be equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents; -Explanation and compliance guidelines: -Maintain all essential mechanical, electrical and patient care equipment in safe operating condition; [...]

Inspectors wroteBased on observation, interview and record review, the facility filed to ensure residents who required assistance with activities of daily living (ADL) care received showers in accordance with their personal needs for eight (Residents #19, #17, #15, #51, #35, #78, #39 and #50) of 21 sampled residents. The census was 87. Review of the facility's 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 Guidelines; -Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety; -Partial baths may be given between regular showers as per facility policy. 1. Review of Resident #19's care plan, revised 3/28/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a bed rail assessment and fall assessments with new interventions were completed for one resident and failed to follow the facility's bed maintenance and inspection policy (Resident #71). The facility also failed to ensure safe Hoyer (mechanical lift) transfers for three of three Hoyer transfer observations (Residents #7, #35 and #15). The facility failed to ensure smoking assessments were completed for two sampled residents (Residents #11 and #4). In addition, staff failed to respond timely to an exit door alarm sounding. The sample was 21. The census was 87. Review of the incident and accident policy, revised 9/1/22, showed: -Policy: staff to report, investigate and review any accidents or incidents that occur or allegedly occur on the facility property and may involve or allegedly involve a resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate and competent staffing to adequately provide resident care and meet resident needs, including the Residents #71, #39, #50 and #19. This had the potential to affect all residents who resided at the facility. The sample was 21. The census was 87. Review of the facility's Nursing Services and Sufficient Staff Policy, dated 9/1/21, showed: -Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified eight medication/treatment carts and two medication rooms. Four of the eight carts and two medication rooms were checked for medication storage. Issues were found in one medication room, three medication carts and one treatment cart. Multiple bottles of over the counter (OTC) medications, and ointment tubes were opened, undated and expired. The refrigerator in one medication room that stored unopened insulin pens was placed on top of another refrigerator, unsteady and leaned sideways. The thermometer was stuck in the freezer and no temperature log sheet was observed. The census was 87. Review of the facility's Medication Storage Policy, revised 9/1/21, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain dignity and provide personal privacy for Resident #71, when staff did not place a cover over the resident's half full catheter drainage bag that was visible from the hallway through the resident's open room door. The sample was 21. The census was 87. Review of the facility's Resident Rights policy, revised 9/1/22, showed: -Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -Respect and dignity. The resident has a right to be treated with respect and dignity; -Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated when residents were involved in a physical resident to resident altercation (Residents #3 and #76), resulting in one of the involved residents (Resident #3) being struck in the face, causing an injury. The sample size was 21. The census was 87. Review of the facility's Abuse, Neglect and Exploitation policy, revised 8/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was a risk to develop skin injury, did not develop skin impairment (Resident #41). The staff failed to report the skin impairment to the nurse when discovered. On 4/18/24, the facility wound nurse assessed the areas and implemented wound care treatments to the skin impairments. The sample was 21. The census was 87. Review of the wound treatment management policy, revised 9/1/22, showed: -Policy: promote wound healing of various types of wounds; -Guidelines: -Wound treatments will be provided in accordance with physician orders, including the cleansing methods, type of dressing and frequency of dressing change; -In the absence of treatment orders, the nurse will notify the physician to obtain treatment orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited mobility received appropriate services, equipment and assistance to maintain or improve mobility for two of 21 sampled residents (Residents #19 and #35). The sample was 21. The census was 87. Review of the facility's Restorative Nursing Program, revised 9/1/21, showed: -Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level; -Definition: -Restorative Nursing Program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focused on achieving and maintaining optimal physical, mental and psychosocial functioning; -Policy Explanation and Compliance Guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who received routine dialysis treatment had physician orders in place and consistent communication with the dialysis provider. This affected one of three residents sampled for dialysis review (Resident #50). The census was 87. Review of the hemodialysis (a treatment given to filter waste products from the kidneys) policy, revised 9/1/22, showed: -Policy: the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders and the care plan for those receiving dialysis; -Purpose: the facility will assure each resident receives care and services for the provision of hemodialysis including: -On-going assessment of the resident's condition and monitoring for complications before and after dialysis treatments; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the attending physician about the pharmacy medication regimen review recommendation and the action taken or not taken to address the recommendations (Resident #71). The sample was 21. The census was 87. Review of the facility's Medication Reconciliation policy, dated 9/1/21, showed: -Policy: This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent; -Policy Explanation and Compliance Guidelines: -Monthly Processes: -Provide pharmacy consultant access to all medication reason and records for completion of pharmacy services activities; -Respond to any medication irregularities reported by pharmacy consultant within relevant time frames. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a gradual dose reduction was attempted or documented as contraindicated for two of 21 sampled residents who received psychotropic medications (Resident #19 and #17). The census was 87. Review of the facility's Medical Provider Orders policy, revised 4/7/22, showed: -Policy: This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Policy Explanation and Compliance Guidelines; -Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider on the next visit to the facility; -Documentation of Medication and/or Treatment Orders; -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented administration of a medication for one resident (Resident #38), when the medication was not available. The census was 87. Review of the facility's Medication Administration Policy, reviewed/revised 9/1/22, showed: -Policy: Medications are administered by licensed nursed or other staff who are legally authorized to do so in this state, as ordered by the physician in accordance with the professional standards of practice, in a manner to prevent contamination or infection; -Review Medication Administration Record (MAR) to identify medication to administered; -Administer medication as ordered in accordance with manufacture specifications; -Sign MAR after administered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable infection control practices during personal care for one of one resident observed to receive personal care prior to insertion of a Foley (a hollow tube inserted into the bladder to drain urine) catheter (Resident #41) and failed to sanitize their hands during medication administration and handled medications with bare hands (Resident #23). The sample was 21. The census was 87. Review of the hand hygiene policy, implemented 9/1/21, showed: -Policy: staff will perform proper hand hygiene procedures to prevent the spread of infection to other residents, this applies to all staff; -Definitions: -Hand hygiene: cleaning the hands by hand washing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); -Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a working call light system for one resident (Resident #36), allowing him/her to call for staff assistance. The sample was 21. The census was 87. Review of the facility's Resident Environmental Quality policy, reviewed/revised 9/1/21, showed: -Policy: It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -The facility shall: -Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition; -The facility must provide each resident with: -A nurse call system in the resident's room and toilet/bathing facilities, which relays the call directly to a staff member or to a centralized staff work areas; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the Nurse Staffing Information on a daily basis to include the total number and the actual hours worked for both licensed and unlicensed staff, per shift and the total facility census. The census was 87. Review of the facility's Nurse Staffing Posting Information, implemented on 9/1/21, showed: -Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time; -The Daily Staffing Sheet will be posted on a daily basis and will contain the following information: -Facility name; -The current date; -Facility's current resident census; -The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift; -Registered Nurses; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete each portion of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) to reflect the resident's status as of the Assessment Reference Date for one resident (Resident #1). The sample size was three. The census was 96. Review of Resident #1's discharge MDS dated [DATE], showed: -admitted on [DATE]; -discharged on 2/1/24; -Discharge Status: Short-Term General Hospital. During an interview on 2/9/24 at 12:46 P.M., the Administrator said: -The resident left the faciity on leave of absence on 2/1/24; -The resident told the Administrator he/she would return that same evening before midnight; -The resident never returned to the facility; -The facility staff did not know with whom the resident left with or where the resident went to on his/her leave of absence; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for one resident. The facility failed to immediately report and investigate when Resident #1 did not return to the facility and they did not know his/her whereabouts. On 2/1/24 at approximately 5:45 P.M., the resident left on a leave of absence stating he/she would return before midnight that same day. The facility staff was unaware the resident was not in the building until the next morning between 7:30 A.M. and 8:00 A.M. When a Code Pink (missing resident) was announced on 2/2/24, approximately eight hours later, staff failed to report the missing resident to the physician, local authorities to assist in the search and to the Department of Health and Senior Services (DHSS), in accordance with the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The census was 90. Review of the facility's staffing sheets for the weekend of 11/19/23 and 11/20/23, showed the facility staffed Licensed Practical Nurses (LPNs). There was not an RN on staff either day. Review of the facility's staffing sheet for the weekend of 11/25/23 and 11/26/23, showed the facility staffed LPNs. There was not an RN on staff either day. Review of the facility's staffing sheet on Sunday 12/3/23, showed the facility staffed an LPN. There was not an RN on staff that day. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party after the development of pressure ulcer for one resident (Resident #1). The sample was six. The census was 90. Review of the facility's policy on Pressure Injury Prevention and Management, updated 1/23/23, showed the following: -Policy: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -Policy: 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions and modifying the interventions as appropriate; 3. A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident was free from physical abuse (Resident #2). On 11/30/23, Resident #3 stabbed Resident #2 in the face with a fork. The sample was 6. The census was 90. The Administrator was notified on 1/3/24 of the past non-compliance. The facility immediately intervened and separated the residents, arranged for ongoing medical care for both residents, updated the care plans of both residents and provided training for all staff regarding the facility's abuse prevention policy. Review of the facility's Abuse Prevention Policy, updated 10/21/22, showed the following: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food under sanitary conditions by not ensuring food was properly closed and sealed from air. In addition, the facility failed to ensure that kitchen equipment was kept clean and in proper working condition during four of four days of observation. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 80. 1. Observations on 9/6/22 at 9:20 A.M., 9/7/22 at 4:22 P.M., and 9/8/22 at 6:28 A.M., of the walk-in freezer, showed the following: -A plastic bag contained biscuits, sat inside of a big box, opened and exposed to air; -A big bag of ice opened and the end of the bag exposed to air. Observations on 9/7/22 at 4:22 P.M. and 9/8/22 at 6:28 A.M., of the walk-in freezer, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for three residents (Residents #84, #43 and #71). The sample was 18. The census was 80. 1. Review of Resident #84's hospice election form, showed the resident enrolled in hospice as of 3/23/22. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/22, showed: -Hospice services not indicated as received while a resident; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No. During an interview on 9/6/22 at 4:52 P.M., the administrator said a resident on hospice should have this indicated on their MDS assessment and it should indicate a life expectancy of less than 6 months. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for two of 18 sampled residents and one discharged resident (Residents #14, #85 and #67). The census was 80. Review of the facilities' Care Plan Policy, revised on 6/2/22, 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, professional standards of practice, medical provider orders, and resident's goals and preferences, that includes measurable objectives and timeframes to meet a resident's special medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy was provided during personal care for one of three residents observed to receive incontinence care (Resident #66). The census was 80. Review of the facility's Perineal Care (cleansing of the body area to include the genitals, groin, buttocks and rectal areas) policy, dated 9/1/21, showed: -It is the practice of this facility to provide perineal care to incontinent residents during routine baths and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Provide privacy by pulling the curtain or closing the room door if a private room. Review of the facility's Resident Handbook, provided to residents upon admission to the facility, showed: -Under federal law, you have the following rights and responsibilities; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote healing of existing pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device), reduce or remove underlying risk factors, modify interventions as appropriate and modify the care plan as needed for one resident with pressure ulcers (Resident #4). The facility identified 10 residents as having pressures. The census was 80. Review of the facility pressure injury prevent and management policy, dated 3/3/22, showed: -Facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate fall interventions were put in place to prevent accidents, for a resident who was bed bound and had falls from bed (Resident #71). The sample was 18. The census was 80. Review of the facility's fall prevention program policy, revised 3/3/22, 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 falls; -A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the facility's policy regarding gastrostomy tube (g-tube, a small rubber tube surgically inserted through the abdomen into the stomach to administer nutrition, fluids and medications) feedings by not changing the tube feeding bag every 24 hours to prevent bacteria growth in the bag, not accurately labeling the bag with the initials of staff who hung the bag. In addition, the facility failed to ensure the enteral feeding pump was providing water flushes at the correct rate. The facility identified five residents who received g-tube feedings. Of those five, three were chosen for the sample of 18 and problems were found with one resident (Residents #3). The census was 80. Review of the facility's Care and Treatment of Feeding Tubes Policy, dated [DATE] showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, two errors occurred resulting in a 7.69% error rate (Residents #78 and #46). The census was 80. Review of the facility's Medication Administration Policy, revised on [DATE], showed: -Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Policy Explanation and Compliance Guidelines: -Obtain and record vital signs, when applicable or per medical provider orders. When applicable, hold medication for those vital signs outside the medical provider's prescribed parameters; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to residents to prevent the spread of infection and to provide a safe and sanitary environment for two residents (Residents #14 and #66) of three residents observed during incontinence care. The census was 80. Review of the facility's Hand Hygiene policy, dated 8/16/21, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub; -Staff will perform hand hygiene when indicted, using proper techniques consistent with accepted standards of practice; [...]