Arc at Cincinnati

Inspectors wroteBased on medical record review, staff interview, review of facility Self-Reported Incidents (SRI), review of facility email, and policy review, the facility failed to report an alleged abuse to the State Agency. This affected one (#60) of three residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, review of facility email, and policy review, the facility failed to investigate an allegation of resident abuse. This affected one (#60) of three residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on medical record review, review of the hospital records, staff interview, and policy review, the facility failed to ensure timely treatment of a left leg fracture. This resulted in Actual Harm when Resident #91 complained of a new onset of left leg pain on 12/18/25. After examination, Nurse Practitioner (NP) #235 ordered X-rays for the wrong limb. Upon realizing the error, NP #235 ordered X-rays for the correct limb on 12/19/25; however, the X-rays were not completed until 12/21/25, revealing Resident #91 had a suspected bicondylar fracture of the left distal femur. Resident #91 was sent to the hospital for evaluation and treatment on 12/22/25 where the resident required surgery for an Open Reduction and Internal Fixation (ORIF) on 12/24/25. This affected one (#91) of three residents reviewed for care post fall. The facility census was 89.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as care planned. This affected one (#74) of three residents sampled for falls. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were taken to outside appointments when scheduled. This affected one (#98) of six residents reviewed for medical appointments. The census was 92.

Inspectors wroteBased on medical record review, observation, staff and resident interview, review of facility investigation documents, and policy review, the facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff for bathing. This resulted in Actual Harm when Resident #97 was being bathed by one staff member, had a spasm in one leg, fell out of the bed, and sustained fractures in both legs. This affected one (Resident #97) of three residents reviewed for falls. Additionally, the facility failed to ensure the environment was free of accident hazards. This affected four (Residents #80, #86, #45, and #13) of 37 sampled residents. The facility census was 92. [...]

Inspectors wroteBased on medical record review, staff and resident interviews, review of the hospital record, and policy review, the facility failed to ensure ordered pain medication was available for administration. This resulted in Actual Harm, when Resident #39 missed three days of methadone (a medication to treat severe pain) a total of nine doses, had increased pain, called nine-one-one (911), and went to the emergency room. This affected one (Resident #39) of two residents reviewed for pain medication use. The facility census was 92. Findings Include:Based on medical record review, staff and resident interviews, review of the hospital record, and policy review, the facility failed to ensure ordered pain medication was available for administration. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure staff provided verbal reports to one another in a manner to protect the residents' health information. This had the potential to affect all 92 residents residing in the facility. The census was 92.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure essential kitchen equipment was maintained in safe operating condition for one of one dishwasher. This had the potential to affect all residents. The facility census was 92. A tour of the kitchen conducted on 12/15/2025 at 9:09 A.M. with [NAME] (CK) #34, revealed an area of standing water that was approximately four feet wide by 12 feet long by one inch deep was covering an area of the floor near the dishwasher. During an interview on 12/15/2025 at 9:11 A.M., CK #34 stated the dishwasher had been broken for over a year. CK #34 stated that there was a problem with the drain and every time the dishwasher drained, it flooded the whole floor. CK #34 stated that management was aware and had repeatedly informed staff that they were going to have it repaired. During an interview on 12/15/2025 at 9:13 A. [...]

Inspectors wroteBased on employee file reviews, staff interview and policy review, the facility failed to ensure two (Licensed Practical Nurse (LPN) #9, and LPN #15) of eight sampled employees received training on abuse, neglect, and exploitation during orientation and annually as required by facility policy. This had the potential to affect all residents. The facility census was 92. Findings Include:A review of employee files revealed the facility hired Licensed Practical Nurse (LPN) #9 on 02/15/2023. The employee file and in-service trainings revealed no documented evidence of abuse/neglect training within the past 12 months for LPN #9. Review of LPN #15's employee file revealed the facility hired the LPN on 06/02/2025. There was no documentation in LPN #15 ' s employee file or in-service trainings that the facility had provided abuse neglect training for the LPN. [...]

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to maintain resident equipment in good repair, specifically, a fall mat used for one (#3) of 37 sampled residents was torn and stained and a shower bench located in one (Willow Unit) of two shower rooms was observed with a worn, cracked surface. The census was 92.

Inspectors wroteBased on medical record review, staff interview, facility document review, facility policy review, and review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices and Ohio Secretary of State Certification, the facility failed to ensure intravenous (IV) therapy was administered in accordance with professional standards of practice and Ohio state requirements, as evidenced by failure to ensure criteria to determine medical necessity for the provision of IV hydration with micronutrients was established, monitored, and documented and failure to ensure the contracted ancillary provider (IV Therapy Company #1) had the appropriate State of Ohio-required credentials for the provision of such services for three (#82, #39, and #1) of three residents reviewed for IV therapy provided by IV Therapy Company #1. [...]

Inspectors wroteBased on medical record review, staff interview, and facility document review, the facility failed to develop intravenous (IV) therapy procedures that were compliant with state requirements and accepted standards of practice for three (Residents #82, #39, and #1) of three residents reviewed for IV medications provided by IV Therapy Company #1. Based on a review of all residents' physician orders, the failed practice had the potential to affect 21 current residents and three discharged residents including but not limited to Resident #14, Resident #26, Resident #56, Resident #64, and Resident #94 received services from IV Therapy Company #1. The facility census was 92.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure expired medications were discarded. In addition, the facility failed to ensure a thermometer was available to monitor the temperatures of one of two medication refrigerators and the facility failed to ensure staff monitored the temperatures of two of two medication refrigerators daily. This had the potential to affect all residents residing on the [NAME] and Elm units. The facility was census was 92. An observation of the [NAME] Unit medication room on 12/16/2025 at 10:40 A.M. revealed 25 expired heparin lock flush solutions 50 United States Pharmacopoeia (USP) per 5 milliliters (ml); 12 had expiration dates of 07/2022, nine had expiration dates of 04/2023, and four had expiration dates of 03/2023. All items were unopened but available for use during the observation. [...]

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure staff did not discard used towels on the shower room floor or designate bath/shower items for individual resident use in one (Willow Unit) of two shower rooms observed. In addition, the facility failed to store respiratory equipment properly when not in use. This affected two (Resident #06 and #37) of four residents reviewed for respiratory care. The facility census was 92. Findings Included:1. During an observation of the [NAME] Unit shower room on 12/19/25 at 9:12 A.M., multiple dirty towels were observed on the floor, and large bottles of shower supplies and brushes were not designated for individual resident use. During an interview on 12/19/25 at 10:32 A.M., Housekeeper #05 stated the Certified Nursing Assistants (CNAs) were responsible for cleaning the shower rooms between residents; [...]

Inspectors wroteBased on medical record review, resident responsible party interview, staff interview, and facility policy review, the facility failed to ensure a resident's responsible party was notified and approved of a change in treatment, specifically a change in the tube feeding rate for one (#6) of two residents reviewed for a change of condition/treatment. The census was 92.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to provide activities of daily living (ADL) assistance for dependent residents. This affected one (#56) of four residents reviewed for ADLs. The census was 92.

Inspectors wroteBased on medical record review, observation, staff interview, resident representative interview, and policy review, the facility failed to ensure a residents tube feeding was administered according to physician orders. This affected one (Resident #06) of one resident reviewed for tube feedings. The facility census was 92. Findings Included:Review of the medical record revealed the facility admitted Resident #06 on 10/28/22 and readmitted the resident on 04/11/23. Diagnoses included persistent vegetative state, unspecified severe protein-calorie malnutrition, and gastrostomy status. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #06 was in a persistent vegetative state with no discernible consciousness. [...]

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to provide respiratory care in accordance with physician's orders for one (Resident #35) of four residents reviewed for respiratory care. The facility census was 92. Review of the medical record for Resident #35 revealed an admission date of 12/20/2020. Diagnoses inlcuded chronic respiratory failure with hypercapnia (abnormally elevated carbon dioxide levels in the blood); chronic diastolic (congestive) heart failure; chronic obstructive pulmonary disease (COPD), unspecified; shortness of breath; and morbid (severe) obesity with alveolar hypoventilation. [...]

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to ensure there was ongoing communication with dialysis providers. This affected two (Resident #05 and #68) of two residents reviewed for dialysis. The facility census was 92. Findings Include:1. Review of the medical record revealed Resident #05 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, and end stage renal disease (ESRD). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/25, revealed Resident #05 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident received dialysis while they were a resident at the facility. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to ensure medications were administered as ordered, resulting in significant medication errors. This affected three (#56, #100, and #101) of six residents reviewed for medications. The census was 92.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide routine dental services for one (Resident #45) of one resident reviewed for dental services. The facility census was 92. Review of the admission record revealed that the facility admitted Resident #45 on 07/30/2024. According to the admission record, Resident #45 had a medical history that included traumatic subdural hemorrhage with loss of consciousness, cerebral infarction (stroke) due to unspecified occlusion or stenosis of an unspecified cerebral artery, and aphasia (a language disorder from brain damage that impairs speaking understanding, reading, or writing). Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2025 revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #45 had moderate cognitive impairment. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for one (Resident #39) of 37 sample residents. The facility census was 92. Review of an admission Record indicated the facility admitted Resident #39 on 03/14/2025. According to the admission Record, the resident had a medical history that included unspecified pain, low back pain, and chronic pain syndrome with opioid dependence. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to maintain a current hospice plan of care for one (Resident #03) of one resident reviewed for hospice services. The facility census was 92. Review of the admission Record indicated the facility admitted Resident #03 on 01/20/2022. According to the admission Record, the resident had a medical history that included metabolic encephalopathy, type II diabetes mellitus, emphysema, and non-pressure chronic ulcer of the right lower leg. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2025, indicated Resident #03 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #03 received hospice services. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to conduct post-fall investigations. The affected one (Resident #3) of three residents reviewed for falls. The facility census was 91 residents.

Inspectors wroteBased on medical record review and staff interview the facility failed to properly notify residents/resident representatives of room changes. This affected one (Residents #194) of three residents reviewed for room changes. The facility census was 94 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to appropriately monitor resident blood pressures. This affected one (Resident #10) of 15 residents reviewed for blood pressures. The facility census was 94 residents.

Inspectors wroteBased on medical record review, staff interview, observations, review of facility policy, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP) website, the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. [...]

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure the resident's electronic medical records (EMR) which contained private and confidential health information were secured and kept confidential. This affected one (#17) of the four residents reviewed for privacy of medical records. The facility census was 92.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure controlled substances were accounted for and signed out after administration. This affected one (#80) of four residents reviewed for medication administration. The facility census was 92.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure medication error rate was less than five percent. This affected one (#80) of four residents reviewed for medication administration. The facility census was 92.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure infection control practices were followed during medication administration and failed to ensure Enhanced Barrier Precautions (EBP) were followed during a resident's dressing change. This affected three (#11, #17, and #80) residents of the four reviewed for infection control practices. The facility census was 92.

Inspectors wroteBased on closed record review, staff interview and review of facility policy, the facility failed to ensure they discharged a resident in a safe and orderly manner. This affected one (#90) resident of the five residents reviewed for discharge. The facility census was 87.

Inspectors wroteBased on record review, observation, staff and resident interviews, review of facility policy and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the phone system was maintained in a safe and functional manner. This had the potential to affect all 84 residents residing in the facility. The facility census was 84.

Inspectors wroteBased on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two Residents (#32 and #75) who did not receive food from the facility's kitchen. The facility census was 84.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected 23 (#03, #07, #10, #11, #12, #22, #23 #26, #28, #31, #37, #39, #40, #46, #52, #54, #55, #61, #64, #69, #76, #78 and #84) residents residing in the Fountains Nursing Unit. The facility census was 84.

Inspectors wroteBased on record review, staff interviews, review of facilities Self-Reported Incidents (SRIs), and facility policy review, the facility failed to ensure their policy regarding injuries of unknown origins was implemented when a resident was found with injuries. This affected one (#11) of the two residents reviewed for abuse. The facility census was 84.

Inspectors wroteBased on record review, staff interviews, review of facilities Self-Reported Incidents (SRIs), and facility policy review, the facility failed to timely report an injury of unknown origin to the state agency. This affected one (#11) of the two residents reviewed for abuse and injury of unknown origin. The facility census was 84.

Inspectors wroteBased on record review, review of the facility incident log, review of facility Self-reported Incidents (SRI's), staff interview, and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown source. This affected one (#11) of the two residents reviewed for abuse and injury of unknown origin. The facility census was 84.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure a resident's medications were ordered timely upon admission. This affected one Resident (#8601) of three residents reviewed for admissions. The facility census was 84.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a incident report, review of a facility investigation, review of personnel files, observations, resident and staff interviews, and facility policy review, the facility failed to ensure a resident was free from a physical restraint. This affected one (#01) of three residents reviewed for physical restraints. The census was 85.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure a resident's fall care plan was updated with current interventions. This affected one (#01) of three residents reviewed for falls. The census was 85.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility investigation review, observations, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision during a mechanical lift transfer resulting in a mechanical lift (Hoyer) tipping during a transfer. This affected one (#86) of three residents reviewed for accidents. The census was 83.

Inspectors wroteBased on medical record review, staff interview, physician interview, and review of the hospital records, the facility failed to monitor a resident's lack of bowel movements, implement interventions to prevent a fecal impaction, and assess a resident with signs of fecal impaction. This resulted in Actual Harm when Resident #16 had no bowel movements for four days, no assessment of the resident was completed, no interventions were provided, physician ordered as needed laxatives were not administered, and the physician was not notified. Subsequently, Resident #16 experienced abdominal pain, vomiting, and was admitted to the hospital with a large fecal impaction which required treatment with medications, enemas, and a nasogastric tube. This affected one (#16) of two residents reviewed for hospitalization. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, review of the facility's policy, and review of the resident council minutes, the facility failed to ensure there was enough staff in dietary to provide dining room services to the residents and maintain a clean and sanitary kitchen. This affected two residents (#17 and #71) and had the potential to affect 88 of 90 residents who received food from the kitchen. Two residents (#13 and #58) did not receive food from the kitchen.

Inspectors wroteBased on observations, record review, review of the facility's policy, and staff interviews, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 88 residents who received meals in the facility. The facility identified two residents (#13 and #58) as receiving no food from the kitchen. The facility census was 90.

Inspectors wroteBased on review of facility document and staff interview, the facility failed to have a Legionella prevention program in place. This had the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, staff and resident interview, review of the resident council minutes, and policy review the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#17, #57, and #71) out of three residents reviewed for dignity and respect during the annual survey. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, review of the cut letters, and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the facility failed to ensure the resident notice letter was accurately completed. This affected three residents (#41, #79, and #488) out of three residents reviewed for Beneficiary Notification. The facility census was 90. 1. Review of the medical record for Resident #41 revealed an admission date of 03/10/22. Diagnoses included acute kidney failure, muscle weakness, type 2 diabetes mellitus, hyperlipidemia, dementia, major depressive disorder, and generalized anxiety disorder. Review of the cut letter for Resident #41 dated 04/09/22 revealed it was signed on 04/05/22 by the resident. The SNFABN for the Resident was dated 04/09/22 and consent was given by the resident verbally. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure resident rooms were clean. This affected two residents (#54 and #61) out of 25 residents in the initial pool. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, observation, and policy review, the facility failed to ensure residents or resident representative were notified of a transfer from the nursing facility. This affected two residents (#16 and #69) out of three residents reviewed for transfer notice. The facility census was 90.

Inspectors wroteBased on medical record review, staff and resident interviews, observations, and policy revivew, the facility failed to provide written bed hold notices to residents or their representatives prior to transfers. This affected two residents (#16 and #69) of three reviewed for hospitalizations. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual the facility failed ensure a Significant Change in Status Assessment (SCSA) was completed when a resident was admitted to hospice services. This affected one resident (#436) of three residents reviewed for hospice services. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, hospice staff interview, observation, and policy review, the facility failed to ensure accuracy of the minimum data set (MDS) assessments to reflect the resident current health status. This affected two residents (#36 and #65) of two residents reviewed for accurate MDS's. The facility census was 90.

Inspectors wroteBased on medical record review and staff interview the facility failed to complete baseline care plans for residents. This affected three residents (#08, #16, and #41) of 19 reviewed in the sample. The census was 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a comprehensive plan of care to include the delegation of hospice services and facility staff services for the hospice resident. This affected one resident (#65) of one reviewed for the development of the comprehensive care plan. The facility census was 90.

Inspectors wroteBased on medical record review and staff and resident interview the facility failed to ensure resident care conferences were held. This affected one resident (#54) out of five reviewed for care planning of 19 sampled. In addition, the facility failed to update the plan of care. This affected two residents (#08 and #70) out of five reviewed for care planning of 19 sampled. The census was 90. 1. Review of Resident #54's medical record revealed an admission date of 02/01/18. Diagnoses included hypertension, obstructive sleep apnea, atrial fibrillation, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Review of Resident #54's medical record revealed no documentation of a care conference being held in the last year. During an interview on 05/23/22 at 10:11 A.M. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a physician ordered splint was in place. This affected one resident (#36) of one resident reviewed for range of motion of 19 sampled during the annual survey. The census was 90.

Inspectors wroteBased on observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents were safely smoking. This affected three (#32, #51, and #182) of four residents reviewed for smoking. The facility identified there were nine residents who were smokers. The facility census was 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely implement nutritional recommendations when a resident has severe 12.7% weight loss in one month. This affected one (Resident #70) of three residents reviewed for weight loss. The facility identified one resident with unplanned significant weight loss.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to have clean and sanitary respiratory supply items for a resident. This affected one (Resident #54) of three residents reviewed for respiratory care. The facility identified eight residents who receive respiratory care. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of the facility's policy, the facility failed to routinely assess and document the pain for Resident #63 to monitor the effectiveness of the pain medications. This affected one (Resident #63) of three residents reviewed for pain management. The facility identified 33 residents on a pain management program. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as physician ordered. This affected two (#65 and #435) of three residents reviewed for medication administration. The facility census was 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure gradual dose reductions were attempted for residents receiving psychotropic medications. This affected one (Resident #65) of three residents reviewed for unnecessary psychotropic medications. The facility identified 62 residents receiving psychoactive medications. The facility census was 90.

Inspectors wroteBased on medical record review, review of the facility's policy, observation, and resident and staff interview, the facility failed to properly store the resident's medications. This affected one (Resident #57) of 19 residents observed in the final sample and two medication carts of three medication carts observed for drug storage. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, hospice staff interview, and review of the hospice contract, the facility failed to collaborate with hospice on a resident's comprehensive plan of care. Additionally, the facility failed to designate a staff member who was responsible for working with hospice to coordinate care provided to the resident by hospice and facility staff. This affected one (Resident #65) of one resident reviewed for hospice services. The facility identified one resident receiving hospice services. The facility census was 90.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, the facility failed to have a bed in good condition for a resident. This affected one (Resident #61) of 25 residents observed in the initial pool. The facility census was 90.

Inspectors wroteBased on medical record review, resident interview, family interview, and staff interview, the facility failed to notify residents and/or their responsible parties in writing of the purpose of the resident's transfer out of the facility. This affected four (#4, #18, #28, and #79) of four residents reviewed for discharge. The census was 125.

Inspectors wroteBased on medical record reviews, staff interviews, family interviews, staff interviews and review of facility policy, the facility failed to provide written bed hold information upon transfer to the hospital for four (#4, #18, #28, and #79) out of four residents reviewed for bed hold notices. The census was 125.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, the facility failed to provide personal care for dependent residents. This affected four (#28, #37, #46, #113) residents of five reviewed for activities of daily living. The facility census was 125.

Inspectors wroteBased on observation, facility policy reviews, resident and staff interviews, the facility failed to ensure measures were taking to secure sharps containers from un authorized access. This had the potential to affect three ( #17, #72 and #97) of three residents who were confused and independently mobile in the area. The facility failed to ensure residents were following establish smoking policy. This affected two (#600 and #374) random residents observed smoking. The facility failed to ensure staff was available for residents in the dining room who required supervision while eating. This had the potential to affect 19 (#17, #27, #30, #33, #36, #37, #40, #43, #44, #56, #69, #95, #97, #101, #102, #108, #135, #147, #264) residents who ate in the dining room and required supervision with eating. The facility census was 125.

Inspectors wroteBased on observation, review of the facility policy and staff interview, the facility failed to secure resident medications. This had the potential to affect three (#17, #72 and #97) of three residents who were confused and independently mobile in the area. The facility census was 125.

Inspectors wroteBased on observations, review of facility policy and staff interviews, the facility failed to fail to store food in a safe manner. This had the potential to affect 39 residents (#2, #5, #6, #7, #9, #10, #14, #16, #23, #26, #27, #30, #31, #32, #33, #41, #44, #45, #49, #54, #56, #57, #60, #68, #69, #71, #80, #84, #88, #90, #94, #96, #98, #99, #101, #102, #108, #112, and #266) who resided on the Elm and [NAME] hall. The facility census was 125.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to maintain the dignity of a resident with a urinary catheter and of a resident who lacked clothing. This affected two (#28, #88) of two residents reviewed for urinary catheters. The facility census was 125.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to follow their policy to report an allegation of abuse to the Administrator and failed to complete and investigation of the allegation. This affected one (#48) of one resident reviewed for abuse. The facility census was 125.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report an allegation of abuse to the Administrator. This affected one (#48) of one resident reviewed for abuse. The facility census was 125.

Inspectors wroteBased on record review, staff interview, review of facility policy, the facility failed to investigate an allegation of abuse involving one (#48) of one resident reviewed for abuse. The facility census was 125.

Inspectors wroteBased on record review and staff interview, the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one (#3) out 25 residents reviewed for MDS accuracy. The facility census was 125.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code he discharge location on the Minimum Data Set (MDS) assessment for one (#116) of 25 residents reviewed for accuracy of MDS assessments. The facility census was 125.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to develop care plans to address medication use and indwelling urinary catheter use. This affected two (#12 and #28) of 25 residents reviewed for care planning. The facility census was 125.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to review and revise care plans for three (#79, #88, and #103) of 25 residents reviewed for care plans. The facility census was 125.

Inspectors wroteBased on medical record review, policy review and staff interviews, the facility ensure a resident's code status was consistent through out the medical record. This affected one (#103) of 32 residents reviewed in the initial sample for code status. The facility census was 125.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure an audiology follow-up services for a resident was completed and the resident received services to repair a hearing aide. This affected one (#84) of two reviewed for vision and hearing services. Facility census was 125.

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to monitor Resident #31's meal intakes and ensure the resident received nutritional interventions implemented by the speech therapist and follow two (#67 and #18) resident's fluid restrictions. This affected three (#31, #95, and #18) of six residents reviewed for nutritional and fluid intake. The facility census was 125.

Inspectors wroteBased on observation, review of medical record review, resident and staff interviews, the facility failed to ensure resident oxygen tubing was changed on a routine basis. This affected three (#18, #48, and #95) of three residents reviewed for respiratory care. The facility identified eleven residents currently receiving oxygen in the facility. The facility census was 125.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure accurate medical records were maintained for residents with unclear tube feeding physician orders. This affected two (#15 and #48) of 25 residents whose medical orders were reviewed for accuracy. The facility sample was 125.