Arbors at Marietta

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident assessment was completed that accurately reflected the resident's status at the time of the assessment. This affected one resident (#102) of three sampled for Minimum Data Set (MDS) accuracy. The facility census was 122.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a person centered care plan that met the resident's medical and physical care needs related to contractures and failed to implement the Activities of Daily Living (ADL) care plan as it was written when providing care to the resident. this affected on e resident (#102) of three sampled for care planning. The facility census was 122.

Inspectors wroteBased on review of the facility's cycle menus, observation, interview, and policy review, the facility failed to ensure meals were provided as per the menu and all substitutions of the meal that deviated from the planned menu were recorded and kept on record as required. This had the potential to affect all but 11 residents (#25, #26, #54, #55, #57, #58, #65, #66, #68, #119, and #127), who the facility identified as being on nothing by mouth (NPO) diets, and did not receive meals from the kitchen. The facility's census was 127.

Inspectors wroteBased on record review, review of a facility investigation, staff interview, and policy review, the facility failed to ensure a possible situation of neglect was reported to the State survey agency, as required, when a resident choked during a meal resulting in the resident's death. This affected one resident (#128) of two residents reviewed for death.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure resident safety during facility provided transportation to prevent injury. In addition, the facility failed to ensure fall interventions were in place for residents at risk for falls. This affected two residents (#1 and #15) of three residents reviewed for falls. The facility census was 117. Actual Harm occurred on 10/27/25 when Resident #1, a resident dependent on staff for transportation, was on her way back to the facility from an appointment at a local hospital when Transport Aide (TA) #118 failed to ensure the wheel straps on the left side of Resident #1's wheelchair were secured appropriately. This resulted in Resident #1 being dislodged from her wheelchair as the bus turned, falling and hitting her head. [...]

Inspectors wroteBased on interview, observations and policy review, the facility failed to maintain the shower room and resident rooms in a clean and sanitary manner. This affected one (#43) of two residents reviewed for physical environment. The facility census was 124.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure minimum data set (MDS) assessments were completed accurately for falls, dental status, catheter and continence status. This affected three (#86, #104, and #178) of four residents reviewed for accurate assessments. The facility census was 124.

Inspectors wrote3. Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, tracheostomy status, and severe protein-calorie malnutrition. Interview and observation on 04/21/25 at 1:28 P.M. with Resident #104 revealed the resident had broken and missing teeth due to history of drug use. Review of Resident #104's current plan of care did not address oral/dental status. Interview on 04/22/25 at 2:33 P.M. with Certified Nursing Assistant (CNA) #592 confirmed staff provide oral care for Resident #104 and the resident has several missing and broken teeth but does not complain of pain during care. Interview on 04/22/25 at 2:38 P.M. [...]

Inspectors wroteBased on observations, interviews, medical record review and missing items log review, the facility failed to ensure missing hearing aides were reported to the appropriate staff and failed to ensure hearing aides were worn as directed to aide in communication. This affected one (Resident #32) of one resident reviewed for vision/hearing. The census was 124. Findings Include: Record review revealed Resident #32 admitted to the facility 09/04/23 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, hyperlipidemia, diastolic heart failure, congestive heart failure, hearing loss. Review of Resident #32 care plan completed 08/16/23 and revised 02/10/24 revealed Resident is at risk for impaired communication related to being hard of hearing. Goals include Resident#32 will understand others when communicating through next review. [...]

Inspectors wroteBased on observation, interview, medical record review and facility policy review the facility failed to provide a comprehensive treatment plan for altered skin integrity to Resident #48. This affected one resident (Resident #48) of two residents reviewed for non pressure skin conditions. The facility census was 124.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received comprehensive and resident centered care related to indwelling urinary catheters. This affected two residents (#28 and #178) of three sampled for catheters. The facility census was 124.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure nursing staff planned to administer the appropriate dose of medication, without resident intervention, to prevent a potential overdose. This affected one resident (Resident #104) of one residents reviewed for a medication error. The census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications. This affected one resident (#104) of one residents reviewed for a medication error. The facility census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): [...]

Inspectors wroteBased on review of facility alternative dispute resolution agreements, interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected three of three residents reviewed for arbitration agreements (Residents #31, #89, and #178). The facility census was 124.

Inspectors wroteBased on observation, interview and record review the facility failed to complete appropriate hand hygiene during medication administration and to maintain contact isolation precautions while in a resident's room with clostridium difficile. This affected two residents (#104 and #178) of five sampled for infection control. The facility census was 124.

Inspectors wroteBased on review of employee personnel files, review of the background check monitoring log, staff interview, and policy review, the facility failed to implement their criminal background check policy for one employee. This had the potential to affect all 124 residents.

Inspectors wroteBased on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents was free from physical and sexual abuse. This affected two residents (#57, #61) of four residents reviewed for abuse. The facility in-house census was 110.

Inspectors wroteBased on observation, medical record review, interviews, policy review, mechanical lift user manual review, and review of fall assessments, the facility failed to provide adequate assistance, supervision and/or interventions to prevent resident falls. The facility also failed to develop and implement adequate safety interventions for resident smoking to prevent accidents/injury. This affected five residents (#24, #42, #47, #70, and #80) of five residents reviewed for accidents. Actual psychosocial and physical harm occurred on 12/27/23 during a staff assisted transfer using a mechanical lift for Resident #47 resulting in a fall. During the transfer facility staff failed to provide a safe, clear, environment resulting in the lift becoming stuck under the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to ensure food preparation equipment was clean. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility also failed to ensure two residents (#32 and #62)'s personal refrigerators were kept clean and at an appropriate temperature and failed to ensure four residents (#10, #33, #62, and #81)'s personal refrigerator temperatures were logged for safety. The facility census was 97.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 97 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident showing signs of Covid-19 was promptly identified, tested, and placed in transmission based precautions (TBP's) for Covid-19 when symptoms originated, failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a room of another resident who was on TBP's for being positive for Covid-19, failed to timely identify and place a third resident in TBP's who had a multi-drug resistant organism in his urine, and failed to ensure sharps (syringes and vacutainers needles) were properly disposed of inside of sharps containers so the needles could not be easily retrieved. [...]

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure the noise levels were not too loud for Resident #82 and failed to ensure the walls were in good repair for Resident #46, #60, and #192. This affected four residents (Resident #82, #46, #60, #192) of five residents reviewed for environment. The facility census was 97.

Inspectors wroteBased on record review, review of medication error reports, review of staff education reports, resident interview, and staff interview, the facility failed to ensure residents only received medications ordered and intended for them, medications were administered in accordance with professional standards, and medications were administered within appropriate time frames set forth by the physician's orders. This affected 11 residents (#12, #17, #38, #46, #54, #60, #63, #64, #70, #191, and #192) who were identified from a review of one medication error report.

Inspectors wroteBased on facility documentation review, interview, and facility policy review, the facility failed to provide evidence all food was temperature checked prior to serving to confirm food had reached a safe cooking temperature. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility census was 97.

Inspectors wroteBased on review of the facility's week at a glance menu, menus posted in the dining areas, review of the facility's daily newsletter, resident interview, and staff interview, the facility failed to ensure residents were informed of all alternate meals that were made available to them to allow them to make informed choices about the food they wanted to eat with each meal. This had the potential to affect all but six residents (Resident #1, #23, #28, #29, #39, and #198) who the facility identified as receiving nothing by mouth (NPO) and did not receive any food from the kitchen.

Inspectors wroteBased on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#7) of two residents reviewed for advance directives.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was afforded the right to choose how often they bathed and received the type of bathing activity they preferred. This affected one resident (#83) of two residents reviewed for choices.

Inspectors wroteBased on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#59). The facility handled the funds for 62 residents. The facility census was 97.

Inspectors wroteBased on resident record review, interview, and facility policy review, the facility failed to ensure a resident's advanced directives were clear and consistent. This affected one resident (#25) of two residents reviewed for advanced directives. The facility census was 97.

Inspectors wroteBased on record review, review of self-reported incident (SRI), review of grievance/concern log, interviews, and policy review the facility failed to resolve a resident's grievances. This affected one resident (#65) of two residents reviewed for personal property.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident or their representative was provided with a written summary of the baseline care plan. This affected one residents (#88) of 27 sampled residents. The facility census was 97.

Inspectors wroteBased on medical record review, review of the concern log, review of invoice, observation, and interview the facility failed to ensure a resident had a comprehensive plan of care for vision. This affected one resident (#70) of two residents reviewed for sensory needs.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to revise comprehensive care plans and failed to have quarterly care conferences. This affected three residents (#18, #65, and #70) of four residents reviewed for care planning. The facility census was 97.

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the care plan, and resident choice, in the areas of orthopedic follow up services, hospice services, and specialty physician consult services. This affected three residents (#26, #80, and #191) of 27 sampled residents. The facility census was 97.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to arrange an audiology consult per physician's orders for a resident who was hard of hearing. This affected one resident (#30) of two residents reviewed for communication. The facility census was 97.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure pressure ulcer treatments were administered as ordered. This affected one resident (#65) of two reviewed for pressure ulcers. The facility census was 97.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure suprapubic catheter treatments and antibiotics were administered per order. This affected one resident (#65) of one resident reviewed for urinary catheter/urinary tract infection.

Inspectors wroteBased on observations, medical record review, policy review, and staff interview, the facility failed to evaluate a resident's decline in intake to ensure the resident maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#80) of four residents reviewed for nutritional status. The facility census was 97.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure a resident received timely respiratory care. This affected one resident (#73) of three residents reviewed for respiratory care. The facility census was 97.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to schedule a pain management appointment for a resident per physician orders. This affected one resident (#65) of one resident reviewed for pain.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#197) of one resident reviewed for dialysis. The facility census was 97.

Inspectors wroteBased on interview, resident record review, and facility policy review, the facility failed to ensure medication regimen review irregularities were reviewed by the physician and Director of Nursing (DON). This affected one resident (#47) of five residents reviewed for unnecessary medications. The facility census was 97.

Inspectors wroteBased on medical record review and interview the facility failed to ensure resident medications were monitored per orders. This affected two residents (#65, #70) of five residents reviewed for medication review.

Inspectors wroteBased on record review, review of medication error report, review of drug administration information sheet, staff education sheet, interview, and policy reviews the facility failed to ensure residents were free of significant medication errors. This affected one resident (#191) of one resident reviewed for psychotropic medication review.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure laboratory tests were obtained per orders. This affected one resident (#191) of one resident reviewed for change of condition.

Inspectors wroteBased on record review, review of the facility's infection control tracking logs, staff interview, and policy review, the facility failed to ensure a resident was not treated with an antibiotic, unless they met criteria for the treatment of an infection. They also failed to ensure a resident treated for a urinary tract infection caused by a multi-drug resistant organism received the appropriate antibiotic the identified organisms were sensitive to. This affected one resident (#21) of two residents reviewed for urinary tract infections (UTI) and one resident (#47) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, policy review, and staff interview, the facility failed to ensure residents were offered a pneumococcal immunization as appropriate. This affected three of five residents reviewed for immunizations (Residents #80, #21, and #82). The facility census was 97.

Inspectors wroteBased on medical record review, policy review, and staff interview, the facility failed to offer COVID-19 vaccines to residents. This affected two residents (#46 and #26) of five residents reviewed for immunizations. The facility census was 97.

Inspectors wroteBased on closed record review, review of a facility self-reported incident (SRI) and the facility related investigation, review of controlled drug record/disposition forms and staff interview the facility failed to ensure Resident #86 was provided an adequate and effective pain management program, including the administration of as needed (PRN) narcotic pain medication as requested and to meet the resident's pain and total care needs. Actual Harm occurred beginning on 10/11/22 when Resident #86 requested the ordered narcotic pain medication (Percocet) but was administered Colace (a stool softener) in place of the medication resulting in the resident having increased bowel movements during the night, increased pain and an inability to sleep. [...]

Inspectors wrote3. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, chronic obstructive pulmonary disease, major depressive disorder, pseudobulbar affect (PBA), generalized anxiety disorder, difficulty walking, and muscle weakness. A review of Resident #92's Minimum Data Set (MDS) 3.0 assessments revealed she had an admission MDS assessment completed on 02/18/22. Quarterly MDS assessments had been completed on 04/06/22, 07/01/22 and 10/01/22. The quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment noted the resident was able to make herself understood and was able to understand others. No behaviors were noted. [...]

Inspectors wroteBased on record review, review of facility self-reported incidents and related investigations, facility policy and procedure review and interview the facility failed to ensure all allegations of abuse and misappropriation were thoroughly investigated. This affected eight residents (Resident #7, #10, #23, #50, #71, #72, #101, and #102) reviewed in 10 facility self-reported incidents. The facility census was 100.

Inspectors wroteBased on record review, facility self-reported incident review and related investigation, facility policy and procedure review, review of Controlled Drug Receipt/ Record/Disposition Forms, review of narcotic shift count sheets and interview the facility failed to ensure routine medications were provided to residents as ordered and failed to provide adequate pharmaceutical services to meet the needs of each resident. The facility failed to ensure controlled narcotic pain medication was timely/appropriately documented when administered to residents and proper shift to shift reconciliation counts of controlled medication were completed to identify any discrepancies in the counts. The facility also failed to ensure medications were available for administration from their contracted pharmacy. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure pharmacy recommendation were addressed timely. This affected four residents (#2, #21, #39 and #71) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure and interview the facility failed to provide timely dental services. This affected five residents (Resident #38, #50, #54, #81, and #92) of six residents reviewed for dental services.

Inspectors wroteBased on observation, facility policy and procedure review and interview the facility failed to ensure pureed foods were prepared in a sanitary manner to prevent potential contamination and/or food borne illness. This had the potential to affect 10 residents (#1, #33, #51, #59, #62, #71, #73, #76, #106 and #310) of 10 residents identified by the facility to receive pureed foods. The facility census was 100.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38's advance directives/code status was consistent between the paper (hard) chart and the electronic health record (EHR). This affected one resident (#38) of 32 residents reviewed for advanced directive.

Inspectors wroteBased on record review, review of a beneficiary protection notification review form and interview the facility failed to ensure Resident #41 was provided an appropriate liability notice when discontinued/cut from Medicare Part-A services with days remaining. This affected one resident (#41) of two residents reviewed for liability notices who remained in the facility.

Inspectors wroteBased on record review, review of a facility self-reported incident, facility policy and procedure review and interview the facility failed to ensure Resident #50 was not forced to receive care against her wishes resulting in an allegation of rough care and the resident sustaining minor skin alterations. This affected one resident (#50) of three residents reviewed for physical abuse.

Inspectors wroteBased on record review, review of facility Self-Reported Incidents (SRIs) and related investigation, review of controlled drug records/disposition forms, review of an employee personnel file, facility policy and procedure review and staff interview the facility failed to ensure residents were free from misappropriation of controlled (narcotic) medications. This affected two residents (#86 and #110) of three residents reviewed for misappropriation of medication.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure residents and/or their representatives were provided with a transfer notice as required and failed to ensure the State Ombudsman was notified of facility initiated transfers/discharges. This affected three resident (#75, #52 and #109) of four residents reviewed for hospitalization and discharge.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #109 was provided a bed hold notice upon transfer to the hospital. This affected one resident (#109) of three residents reviewed for hospitalization.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documentation was accurate to reflect the resident's cumulative diagnoses and updated following a change in mental health diagnoses. This affected one resident (#77) of two residents reviewed for PASARR.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for Resident #39 prior to admission. This affected one resident (#39) of two residents reviewed for PASARR.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure comprehensive and individualized care plans were developed and implemented for all residents. This affected three residents (#38, #54, and #77) of 36 sampled residents reviewed for care planning.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive, person-centered care plans were accurate to reflect the resident's current status and/or revised to include current interventions for Resident #28 related to pressure ulcers and for Resident #41 related to falls/accident hazards. This affected two residents (#28 and #41) of 36 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #39 received the necessary care and weight monitoring as ordered related to a diagnosis of congestive heart failure and failed to ensure Resident #2 had appropriate indication of use of an anti-fungal medication and monitoring. This affected one resident (#2) of one resident reviewed for non-pressure related skin impairment and one resident (#39) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents received optometry services timely when needed. This affected two residents (#50 and #92) of four residents reviewed for vision/hearing.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure a thorough and complete pressure ulcer assessment was completed for Resident #28 following a re-admission to the facility and failed to ensure wound treatments were provided as ordered by the physician. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #28 received appropriate services to maintain range of motion/mobility and failed to ensure Resident #38 received restorative services. This affected two residents (#28 and #38) of five residents reviewed for position/range of motion and mobility.

Inspectors wroteBased on observation, record review, review of facility fall investigations, facility policy and procedure review and interview the facility failed to ensure Resident #92 received the appropriate level of assistance during a transfer and had proper footwear on at the time of the transfer to prevent an avoidable fall. The facility also failed to develop a comprehensive and individualized fall prevention program for Resident #41 and failed to ensure comprehensive fall investigations were completed to identify the root cause of falls so appropriate interventions could be initiated to prevent additional falls from occurring for the resident. This affected two residents (#41 and #92) of four residents reviewed for falls and/or accident hazards.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #79 received adequate and proper care during incontinence care to decrease the resident's risk of developing a urinary tract infection. In addition, the facility failed to timely obtain a urinalysis with reflex culture for Resident #28, who had symptoms of a urinary tract infection, as ordered by the physician. This affected two residents (#28 and #79) of nine residents reviewed for unnecessary medication use or urinary tract infection.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to accurately document Resident #78's enteral (tube) feeding intake to ensure the resident's overall nutritional status was monitored. This affected one resident (#78) of two residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure oxygen was delivered at the flow rate ordered by the physician for Resident #38. This affected one resident (#38) of four residents reviewed for respiratory therapy.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #78 had an appropriate diagnosis for the use of the anti-psychotic medication, Seroquel. This affected one resident (#78) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected one resident (#98) of three residents observed for medication administration.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38 received timely diagnostic services. This affected one resident (#38) of two residents reviewed for nutrition.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to implement an effective infection control program including the timely implementation of contact isolation for Resident #92 who was diagnosed with a urinary tract infection that was positive for Methicillin Resistant Staphylococcus Aureus to prevent the spread of infection. This affected one resident (#92) of nine residents reviewed for unnecessary medication use or urinary tract infections.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to develop and implement an effective antibiotic stewardship program as part of their infection control program to ensure the appropriate use of antibiotic treatment for infections. This affected three residents (#2, #79 and #77) of nine residents reviewed for unnecessary antibiotic use or urinary tract infections.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #52's call signal device was in proper working order. This affected one resident (#52) of six residents reviewed for physical environment.

Inspectors wroteBased on record review, review of an employment list for the social service department, review of quality assessment and process improvement committee minutes, review of the facility assessment, review of facility job descriptions and interview the facility failed to provide a qualified social service worker, on a full time basis as required. This had the potential to affect all 100 residents residing in the facility. The facility capacity was 150 beds.