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Inspectors wroteBased on observation, interview, facility policy review, and Food and Drug Administration (FDA) guidelines review, the facility failed to ensure food was stored and served in a sanitary manner. Specifically, the facility failed to ensure that kitchen equipment was kept clean, prepared food stored in the walk-in cooler was labeled and dated, and staff wore effective hair restraints in the kitchen. This failed practice had the potential to affect all 91 of 92 residents who received meals from the kitchen.

Inspectors wroteBased on record review, review of the admission Agreement, and interview, the facility failed to ensure completion of an admission Agreement for three (#6, #95, and #99) of four sampled residents reviewed for admission agreements.

Inspectors wroteBased on closed medical record review, hospital record review, review of information from the Cleveland Clinic regarding hypotension, and interviews, the facility failed to ensure staff identified a change in condition for Resident #22 when the resident experienced hypotension (low blood pressure) and diaphoresis (sweating especially to an unusual degree as a symptom of disease) and failed to notify the physician of the resident's hypotension and diaphoresis resulting in a delay in care and treatment. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on 08/03/24 at 3:15 P.M. when Resident #22, who had a history of hypertension (high blood pressure), had a blood pressure of 93/51 millimeters of mercury (mm/Hg) which was not reported to the physician and no treatment was provided. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of abuse. This affected one resident (#44) of one resident reviewed for abuse. The facility census was 88.

Inspectors wroteBased on review of the medical record, review of hospital records, and care plan review, observations, and interviews, the facility failed to provide adequate assistance with care resulting in a fall and failed to ensure fall interventions were in place. This affected two residents (#22 and #29) of four residents reviewed for falls. The facility census was 88.

Inspectors wroteBased on review of the posted COVID-19 signage regarding personal protective equipment (PPE), observations, review of the facility policies and procedures, staff interviews, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to implement effective and recommended infection control practices including a system to ensure the availabilty and appropriate use of PPE by staff, a system to ensure staff were donning and doffing PPE when required, and ensuring staff were practicing proper hand hygiene to prevent the spread of COVID-19 in the building. [...]

Inspectors wroteBased on medical record review, staff interviews, resident interview, review of the facility's fall investigation, and policy review, the facility failed to provide adequate staff assistance to prevent accidents. This resulted in actual harm when Resident #73 was receiving care by one staff, fell out of bed and fractured her left femur. Additionally, the facility failed to ensure Resident #2 received adequate staff assistance during care that resulted in an avoidable fall which resulted in no actual harm with the potential for more than minimal harm. This affected two (#2 and #73) out of four residents reviewed for falls. The facility census was 91.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Review of Payroll Based Journal , facility documents, and interview with staff, the facility failed to submit the Payroll Based Journal report in first quarter of 2023. The facility censu was 91.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility documents for residents rights, the facility failed to honor the choice to not be gotten out of bed to be weighed prior to getting up for the day for one resident (#47) out of 21 residents reviewed for choices. The facility census was 91. Findings Include: Review of medical record for Resident #47 revealed an admission date 01/17/23. Diagnosis included Alzheimer's disease, myocardial infarction, chronic obstructive pulmonary disease, cardiac pacemaker, and atherosclerotic heart disease. Review of the Minimum Data Set assessment, dated 10/15/23, revealed Resident #47 was cognitively intact. Resident #47 required two-person physical assist for transfers. [...]

Inspectors wroteBased on review of the medical record, interviews, and policy review, the facility failed to complete a comprehensive care plan. This affected three (#15, #20, and #84) out of 21 residents reviewed for care plans. The facility census was 91.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences for two residents (#6, #39) and failed to update the care plan for one (#84) of 21 residents reviewed for care conferences. The facility census was 91.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure dependent residents received assistance with bathing. This affected two (#78 and #84) out of three residents reviewed for activities of daily living. The facility census was 91.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure weights were obtained per physician order for one resident (#84) and failed to follow physician orders to notify the physician of weight changes within prescribed parameters for one (#47) resident. This affected two (#47 and #84) out of 21 residents reviewed for physician orders. The facility census was 91.

Inspectors wroteBased on medical record review, observations, and staff interviews, the facility failed to properly date oxygen tubing according to physician orders. This affected one (#20) out of 19 residents reviewed for oxygen therapy. The facility census was 91.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure a resident's medications were administered without error. This affected one resident (#43) of five reviewed for unnecessary medications. The facility census was 91.

Inspectors wroteBased on staff interview, review of the posted staffing and the staffing schedule the facility failed to have a Registered Nurse (RN) for at least eight hours daily. This had the potential to affect all the residents who resided in the facility. The in-house census was 79.

Inspectors wroteBased on record review and staff interview, the facility failed to develop care plans addressing behaviors and the use of an enclosed walker (Merry Walker). This affected one Resident (#20) of 18 sampled residents. The facility census was 79 residents.

Inspectors wroteBased on record review, observations, interview, and policy review the facility failed to complete ongoing assessments for the use of side rails. This affected one Resident (#65) of one reviewed for side rail use. The facility census was 79.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure that one resident's drug regimen was free of anti-psychotic medications administered in excess of the dose ordered by the physician. This involved one resident (#22) of seven residents reviewed for Unnecessary Medications. The facility census was 79.