Aria of Brookfield

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure food was served at a palatable temperature for three residents (Residents (R)16, R27, R28 ) of three residents reviewed for food palatability. This failure poses the risks of weight loss, reduced quality of life, and foodborne illness for

Inspectors wroteBased on observations, record review, interviews, and review of facility policies, the facility failed to ensure one of one residents (Resident (R) 5) was assessed for self-administration of medication. As a result of this deficient practice the residents had the potential for harm of not receiving physician prescribed medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to properly prepare for the arrival of a resident who had been pre-screened and approved for placement, resulting in a resident being returned to the hospital for one resident (Resident (R)2) of three residents reviewed for admissions. This failure caused a disruption of the resident's continuum of care and could have triggered negative consequences.

Inspectors wroteBased on interviews, record review, and review of facility policies, the facility failed to provide the resident and/or representative with written transfer and bed-hold notices that included where and why the resident was transferred for three residents (Resident (R6), R16, R3) of three residents reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the residents' appeal rights.

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure physician narcotic orders were accurately transcribed to the Medication Administration Record (MAR) in the electronic medical record (EMR) for 2 of 5 residents (Resident (R) 5 and R7). As a result of this deficient practice, residents have the potential for both over medication and under medication.

Inspectors wroteBased on observations, record review, interviews, and review of facility policies, the facility failed to ensure nurses who administered a narcotic, confirmed the dosage administered matched the prescription order on the narcotic sign out sheet and the physician's order on the Medication Administration Record (MAR), for one of four residents (Resident (R) 7) reviewed for administered narcotics. This deficient practice had the potential for resident overdosing.

Inspectors wroteBased on interview and record review, the facility failed to appropriately pre-screen a resident before admission to determine whether the facility could meet the resident's needs and subsequently discharged the resident, because they were unable to provide the required care for one resident (Resident (R1) of one resident reviewed for the Facility Assessment. This failure had the potential to result in undue hardship for residents and disrupt the continuity of care.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to follow Enhanced Barrier Precautions, use proper hand hygiene, and keep soiled linens off the floor for one resident (Resident (R)15) of three residents reviewed for infection control. These breaches in infection control have the potential to cause a spread in disease and affect all the residents.

Inspectors wroteBased on interview and record review, the facility did not ensure prompt resolution of all grievances for 1 of 8 residents (R3) reviewed for grievances. R3's POA (Power of Attorney) voiced concerns related to R3's call light being purposefully disconnected by staff. The facility conducted an investigation but failed to provide follow up to the POA regarding the final results of the investigation into the grievance.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure medications stored in a secure location, and expired medications were discarded appropriately. This had the potential for facility staff to use expired medications and supplies that could potentially not be effective.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to answer a call light and respond for one (Resident (R) 8's) request for assistance in a timely manner out of a sample of 16 residents. This failure caused a delay in meeting the resident's care needs.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure the call button to activate the call light system was accessible for two (Resident (R) 11 and 6) of 16 residents in the sample. This failure placed the residents at risk for accident, injury, or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to protect one out of one resident (Resident (R)2 from misappropriation of property when Licensed Practical Nurse (LPN) 7 took R2 AirPods without R2's permission.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure treatments to surgical wounds were documented as completed and were did not ensure that wound treatment was completed when the wound nurse was unavailable for two (Resident (R) 1 and R8) of three residents reviewed for non-pressure skin wounds. This failure had the potential to cause confusion over whether treatments were completed and to cause wounds to decline.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure treatments to pressure injuries were documented when completed and were completed when a wound treatment nurse was unavailable for two (Resident (R) 1 and R14) of four residents reviewed for pressure ulcers. This failure had the potential to cause confusion over whether pressure injury treatments were completed and to cause wounds to decline.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to report changes in eating and supplement consumption and failed to monitor weights and intakes to ensure interventions were in place for three (Residents (R) 1, R12, and R13) out of five residents reviewed for weight loss. This failure had the potential to result in continued weight loss.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure a resident was transported to dialysis for one (Resident (R) 8) of one resident reviewed for dialysis services. This failure caused the resident to miss a dialysis session and had the potential to result in the resident having fluid overload and abnormal lab results.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R5 and R97) of 5 residents reviewed with pressure injuries. *R5 had a history of pressure injuries and was readmitted to the facility on [DATE]. R5’s skin was not comprehensively assessed by a Registered Nurse (RN) upon readmission. On 9/6/2024, R5 was assessed by the Wound Physician and discovered to have a Stage 3 pressure injury to the right buttock, a Stage 3 pressure injury to the left buttock, and a Stage 3 pressure injury to the coccyx and treatments were initiated to the pressure injuries at that time. Surveyor observed R5 repositioning independently in bed and potentially causing shearing to the skin; [...]

Inspectors wroteBased upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 102 residents.

Inspectors wroteBased on record review and interview, the facility did not ensure resident's that were transferred to the hospital received the required notice information. This was observed with 5 (R65, R13, R10, R4 and R58) of 6 residents reviewed that were transferred out of the facility. * R65, R13, R10, R4 and R58, did not receive written notice at the time of transfer that included: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observation, interview and record review, the Facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, and/or all controlled drugs are maintained and periodically reconciled. *The Facility did not ensure controlled substance logs were maintained for periodic reconciliation on units 1 [NAME] and 2 South. *The Facility did not ensure medication refrigerators were monitored for temperature control and did not ensure corrective action was implemented for frost accumulation build up for the medication refrigerators on 1 E/W (east/west) and 2 South. * R120 was observed to have a lidocaine patch dated 8/22/25 on 8/25/25 when the nurse went to place a new lidocaine patch. [...]

Inspectors wroteBased on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 2 of 2 medication carts observed.- 2 bottles of controlled narcotic medications were found in the top drawer of the medication cart, outside of the narcotic lock box. -numerous stock medications were observed on the carts past the manufacturers expiration date. -8 residents (R13, R53, R65, R29, R85, R88 and R84) of 8 resident using insulin pens did not have an open date and/or were past the discard date.-an unlabeled 1 milliliters (ml) syringe, with unknown clear liquid, was observed in the top drawer of medication cart. - 9 loose, unknown pills were found throughout the medication cart, the first 2 were thrown into the regular garbage.

Inspectors wroteBased on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler, and a container with egg salad wrote on the label with an expired-on date that was already passed was observed. Open food was observed in the refrigerator in the resident 2nd floor main kitchen with no open or use by date. *Resident refrigerators on both floors had unlabeled and undated food items inside of them. Both resident refrigerators also had spilled liquids inside of them. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (R18, R43. R50, R75 R120) of 5 residents. * The facility failed to ensure Clostridium Difficile (c-diff) Enteric Contact Precautions Policies were followed by staff when providing cares for R50. * The facility failed to ensure Enhanced Barrier Precaution (EPB) Policies were followed by staff when providing cares for R75. * The facility failed to ensure Enhanced Barrier Precaution Policies were followed by staff when providing cares for R18. * Staff were observed not sanitizing medical equipment and completing hand hygiene when providing care to R43. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R119) of 1 sampled resident with an indwelling catheter received appropriate treatment enhancing self-esteem and providing dignity for R119. *R119 was observed multiple times with R119's catheter drainage bag uncovered in public view.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R26) of 1 resident's preference to receive double portions at mealtimes was implemented and that the resident (R26) was informed of changes in orders when request was revised.

Inspectors wroteBased on interview and record review, the facility did not ensure psychotropic medications were limited to 14 days when ordered as needed (PRN) for 1 (R58) of 6 residents reviewed for unnecessary medications. R58 had an order on admission for the antianxiety medication lorazepam 0.5 mg every four hours as needed with no stop date at 14 days.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure residents with an enteral tube (gastrostomy [PEG-tube]) receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This was observed with 2 (R43 and R20) of 3 residents observed with enteral tubes for feeding. * R43 did not have prescribed orders for enteral tube care and had unknown liquids in tube feeding administration bags hanging in their room. *R20 had tube feeding administered without any identifying labeling on the formula administration bag. The facility's policy and procedure “Placement and Residual Volume check for Enteral Feeding Tubes” dated 12/18/24, documents: 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents receiving respiratory care was consistent with professional standards of practice for 1 (R8) of 1 residents reviewed for oxygen use. R8 was receiving oxygen via nasal cannula with no orders for oxygen therapy.

Inspectors wroteBased on observation, interview and record review the facility did not ensure it maintained a medication error rate below 5 percent during observations of medication administration affecting 3 (R43, R49 and R120) of 3 residents observed. Seven medication errors were observed out of twenty-seven opportunities, for a total error rate of 25.93%. R43 was observed to receive 5 medications orally but her physician's orders documented to give the medication via her gastrostomy (G) tube. R49 was observed to receive 5,000 International Units (IU) of Vitamin D but her physician's orders documented to give 50,000 IU of Vitamin D. R120 was observed to receive expired calcium carbonate.

Inspectors wroteBased on interview and record review, the facility did not ensure there were systems in place to establish coordination of care services between the facility and contracted hospice services for 1 (R113) of 4 residents reviewed for receiving hospice services. *The facility did not ensure Hospice required documentation was maintained in R113's medical record. The facility did not have an order for hospice services in R113's orders. The facility did not have a care plan for hospice services started after admission on to hospice services.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 (Resident #3) of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure the facility wide security alarm system is communicated throughout the facility when triggered. This failure indicates a critical gap in the alarm system's ability to effectively alert staff facility-wide during a potential security or emergency event. This finding suggests a limitation in the current alarm system's ability to communicate alerts comprehensively across all critical areas within the building which could potentially affect the safety of all residents and staff.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure that at the completion of the narcotic count both nurses who participated in the counting documented the accurate count at the change of each shift for three of four medication carts (1 South, 1 East, and 2 South B) reviewed for accuracy of narcotic counts. As a result of this deficient practice, not signing the correct narcotic count creates the potential for misappropriation of narcotics and missed doses for residents.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to protect the resident's right to be free from abuse by a family member for one of three residents (Resident (R)17) reviewed for abuse out of a total sample of 23. R17 experienced an altercation with his family member (FM2) during a family visit and FM2 hit R17 on the forehead. Failure to protect resident from abuse had the potential to result in injury to residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were secure and medication carts were locked for two of two medication carts observed at the second floor south nursing unit. As a result of this deficient practice medications may be unsecured and available for diversion.

Inspectors wrote2.) R23's diagnoses include hemiplegia & hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side, aphasia, dysarthria, dysphasia, facial weakness and gastrotomy. R23's admission MDS (minimum data set) with an assessment reference date of 11/13/2024, had a BIMS (brief interview mental status) score of 15. A score of 15 indicates that R23 is cognitively intact. R23's functional abilities and goals section, under eating, has a score of 3, which indicated partial to moderate assist is needed with eating. R23's care plan interventions for alteration in nutrition dated 11/18/2024 documented: Provide, serve diet as ordered, texture upgrade on 1/23/2025, from mechanical soft to regular diet. Under the above-mentioned care plan, it had registered dietitian to evaluate and make diet change recommendations as needed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 (R26) of 3 Residents reviewed. * R26 was prescribed Zoloft (Sertraline), Lexapro (Escitalopram) and Remeron (Mirtazapine) for depression. R26 was also prescribed Prozac (Fluoxetine) for major depressive disorder and generalized anxiety disorder. The facility did not have a written, signed consent for the prescribed psychotropic medications including the risks and benefits to R26's activated Health Care Power of Attorney (HCPOA). Findings Include: The facility's policy Psychotropic Drug Use effective 1/11/21 documents: Objective: . All Residents have the right to be free from unnecessary medications imposed for the purposes of discipline or convenience and not required to treat medical symptoms. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 4 (R22, R28, R29, R30,) of 4 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R22 transferred to another room on 1/9/25 and there is no documentation R22 received prior written notice for the reason for the transfer. *R28 was transferred to another room on 12/29/24 and there is no documentation R28 received prior written notice for the reason for the transfer. *R29 was transferred to another room on 1/5/25 and there is no documentation R29's Activated Health Care Power of Attorney (HCPOA) received prior written notice of the reason for the transfer. [...]

Inspectors wroteBased on interview and record review the facility did not report 1 (R24) of 2 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. On 1/27/25 R24 reported to Surveyor yesterday during the 3rd shift CNA-SSS told R24 to pee & poop in her diaper, refused to place R24 on the bed pan as requested and walked out of R24's room. R24 reported this incident to CNA-TTT. CNA-TTT did not report this allegation and when Surveyor asked NHA-A about this incident, NHA-A was unaware.

Inspectors wroteThe facility did not ensure in response to 1 (R24) of 2 allegations of abuse, and/or neglect the facility prevented further potential abuse. On 1/27/25, R24 reported to Surveyor yesterday during the 3rd shift CNA-SSS told R24 to pee & poop in her diaper, refused to place R24 on the bed pan as requested and walked out of R24's room. R24 reported this incident to CNA-TTT. CNA-TTT did not report this allegation, which allowed CNA-SSS to continue to provide resident care during the rest of the shift until 6:30 a.m.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 (R27) of 9 Residents reviewed. *On 12/13/24, R27 has a Patient Health Questionnaire (PHQ-9) score of 14, indicating moderate depression. R27 is prescribed Doxepin for depression, anxiety, and sleep and Trazadone for depression. R27 does not have a mood/psychosocial needs care plan in place with person centered interventions.

Inspectors wroteThe facility's policy and procedure titled, Bathing Policy, dated 3/1/21 documents: Policy: .It is the policy of this facility to provide Residents with a bath or shower in order to cleanse the skin, observe the skin, increase circulation, and prevent infection. Guidelines: 1. All Residents are offered a bath or shower at least once a week or per Resident's preference. 4. Documentation of the Resident's shower or bath must be completed. If the Resident refuses the shower/bath, the nurse needs to be informed for reapproach. If the Resident continues to refuse, the refusal must be documented by the licensed nurse. 2) R27 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Paroxysmal Atrial Fibrillation, Morbid Obesity, End Stage Renal Disease, Adult Failure to Thrive, Dependence on Renal Dialysis, Major Depressive Disorder, and Generalized Anxiety Disorder. [...]

Inspectors wrote3.) R30 was admitted on [DATE] with diagnoses of metabolic encephalopathy, thrombocytopenia, hypo-osmolality, hyponatremia, dementia, and end stage renal disease/dialysis. R30's Quarterly Minimum Daily Set (MDS) with the assessment reference date of 12/26/24, documents a Brief Interview for Mental Status (BIMS) score of 99, indicating that R30 is cognitively unable to complete the interview. R30's Cognitive Skills for Daily Decision Making with the assessment reference date of 12/26/24, documents a score of 3, indicating that R30 is severely impaired for daily decision making. R30's Fall assessment dated [DATE] documents a score of 12, indicating that R30 is at high risk for falling. R30's Fall assessment dated [DATE] documents a score of 15, indicating that R30 is at high risk for falling. [...]

Inspectors wroteBased on interview and record review, the Facility did not comprehensively assess to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R22) of 2 Residents reviewed for behavior health services. *R22 has diagnoses of Vascular Dementia Without Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Attention-Deficit Hyperactivity Disorder, Alcohol Dependence and Opioid Abuse. R22 has had significant behavioral changes and has not received behavioral health services in order for R22 to attain the highest practicable physical, mental, and psychosocial well-being. The facility did not offer behavioral health services related to diagnoses of both alcohol and drug substance abuse.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services to meet the needs of for 1(R26) of 2 Residents reviewed. * R26 was discharged on 11/26/24 from the facility and was sent home with discontinued medications of Abilify, Prozac, and Zoloft. The facility did not follow procedure of removing the medications from the medication cart and returning the discontinued medication to the pharmacy. * R26 did not receive scheduled medications one hour before or one hour after the scheduled time 22 times between 11/1/24 and 11/26/24.

Inspectors wroteBased on observation, interview and record review, the facility did not provide 1 (R27) of 4 Residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets. *R27 did not receive preferred items per meal ticket for breakfast on 1/29/25. Findings Include: The facility's undated policy and procedure Accuracy and Quality of Tray Line Service documents: Policy: Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the fool and nutrition services staff, and by the service staff prior to serving the meal to the individual. Procedure: 4. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. 5. [...]

Inspectors wroteThe facility's policy Infection and Control Guidance for COVID-19 last revised 10/25/24 documents: 2) Adherence to the core principles of COVID-19 infection and prevention to mitigate risk associated with potential exposure as follows: -Facility will provide instructional guidance to all who enter the facility for signs and symptoms of COVID-19 -Proper hand hygiene is performed -Staff will wear a well-fitting facemask that fully covers the mouth and nose, in accordance with CDC guidelines -Instructional signage throughout the facility(hand hygiene, face coverings, social distancing, signs and symptoms of COVID-19, infection control precautions) -Appropriate use of Personal Protective Equipment(PPE) I Implement Source Control Measures 5. Eye protection(goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters II. [...]

Inspectors wrote4.) R13 was admitted to the facility on [DATE] with diagnoses that include benign neoplasm of meninges, Metabolic encephalopathy, Type 2 Diabetes, Chronic kidney disease, Seizure history, and Congestive heart failure. R13 was discharged from the facility to the hospital on [DATE] after a change of condition. R13's admission Minimum Data Set assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 9, indicating R13 is moderately cognitively impaired. R13 uses a walker. R13 needs partial to moderate assistance when walking 50 feet. R13 is dependent when walking 150 feet. R13's Care Area Assessment (CAA) for functional abilities dated 11/12/24, documents, in part: [R13] triggered for [Activities of daily living] Self Care and Mobility Deficit related to [R13] being physically deconditioned [status post] recent hospitalization . [...]

Inspectors wrote* On 12/9/24, at 12:19 p.m. Surveyor observed there is a brown water stain on the ceiling tile leading from the 2 South unit into the 2 East [NAME] unit covering approximately one third of the ceiling tile. * On 12/9/24, at 12:29 p.m., Surveyor observed there are multiple scattered pieces of cereal on the piano as well as the piano bench which is located in the 2 South dining room. On 12/9/24, at 2:11 p.m., Surveyor observed there is still multiple scattered pieces of cereal on the piano and piano bench. * On 12/9/24, at 12:32 p.m., on the wall located between R20 & R21's rooms there are four metal pieces on the wall which appeared to have hung a picture from. The bottom two pieces are approximately six inches above the hand rail and are approximately 1/4 inch in size. On 12/10/24, at 4:11 p.m., Surveyor observed the four metal pieces are still on the wall between R20 & R21's rooms. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming for 2 (R15 & R11) of 6 residents reviewed for bathing. * R15 & R11 did not consistently receive showers or bed baths.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary respiratory care and services for 1 (R17) of 3 residents receiving oxygen therapy. * R17's oxygen humidification bottle was observed to be empty or dry.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain legible nurse staffing documents for 39 days. This has the potential to affect all 101 residents currently residing in the facility. * The facility Nurse Staff Posting form does not contain legible documentation in the daily census. This document is found at the front desk of the building and is for staff, residents, and visitors of the facility to know the amount of direct care staff that is currently working at that time or day.

Inspectors wrote3.) R3 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction with dominant side weakness, end stage kidney disease, peripheral vascular disease, and diabetes mellitus type 2. R3 was discharged to the hospital for a gall bladder surgical procedure on 9-23-24. R3's Discharge MDS (Minimum Data Set) documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R3 is cognitively intact. R3 returned to the facility on 9/27/24 to hospice. R3's hospice assessment dated [DATE] documents: Indicate ambulation finding total care, indicate transfer findings total care, indicate bathing findings total care, indicate dressing findings total care. Indicate level of consciousness semi-comatose, indicate assessment finding periods of confusion. Indicate frequency of Bowel incontinence 1 x a day. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that 1 of 1 resident (R5) reviewed for elopement was provided adequate supervision and interventions to prevent elopement and ensure safety. R5 had a Wanderguard placed on admission for exit seeking behaviors. R5 was assessed as a non-smoker on admission. On 10/8/24, R5 cut his Wanderguard off. A new Elopement Risk Assessment was completed and scored a higher risk for elopement than the assessment on admission, but the facility staff determined that R5 did not require the Wanderguard. Additional supervision was not put in place by the facility. On 10/8/24, Psychiatric Nurse Practitioner (NP)-R documented that R5 was an active smoker and that R5 needed to continue taking Seroquel for agitation and start taking Zoloft for anxiety and depression. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the residents received treatment and care in accordance with professional standards of practice, individual assessment, the comprehensive person-centered care plan, and the resident's choices for 2 (R4 and R6) of 9 residents. * R4 was admitted to the facility on [DATE]. There wasn't a comprehensive assessment or monitoring ordered for R4's midline surgical incision. On 10/10/24 R4 went to the hospital for an infection to the midline surgical incision. On 10/15/24 (R4 was not in the facility at the time) a care plan was initiated for R4's midline incision. R4 was re-admitted to the facility on [DATE] with treatment orders for the midline incision. R4's care plan was not revised until 10/21/24 and R4's midline treatment/ monitoring orders for the midline incision were not implemented until 10/21/24. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure proper foot care for 2 (R1 and R3) of 3 Residents. R1 and R3's toenails were very long and in need of trimming. R3 had care planned interventions to monitor feet that was inconsistently implemented.

Inspectors wroteBased on interview, and record review the facility did not ensure 1 (R5) of 7 residents reviewed received medically related social services to attain their highest practicable mental and psychosocial well-being. R5 was admitted to the facility with moderately severe symptoms of Depression. A care plan with resident centered interventions and monitoring was not developed by the facility. R5's Discharge planning evaluation completed on 10/4/24 documented R5's discharge goal and plan as uncertain and unknown. R5 eloped from the facility on 10/18/24. (Cross-reference F689). R5 reported to Surveyor that R5 left the facility because I don't like it here. Upon return to the facility, R5 still verbalizes R5's desire to leave the facility. The facility has not documented any follow up on the 10/4/24 discharge planning evaluation to determine R5's goal and plan for discharge.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R5) of 3 residents were free from significant medication errors. R5 was seen by Psychiatric Nurse Practitioner (NP)-R on 10/8/24. NP-R documented that R5 needed to continue taking Seroquel (an antipsychotic medication) for agitation and start taking Zoloft (an antidepressant medication) for anxiety and depression. The facility did not enter the Zoloft medication order and start offering R5 the medication until 10/14/24. R5 refused multiple doses of Seroquel and Zoloft. The facility did not document that NP-R was made aware of multiple refusals of Seroquel and Zoloft after the 10/8/24 visit. R5 was sent to the emergency room (ER) on 10/19/24 for evaluation. R5 returned to the facility on the same day. [...]

Inspectors wroteBased on record review, observations and interviews, the facility did not ensure the coordination of services between hospice and the facility for 2 (R3 & R2) of 2 residents reviewed for hospice care. * R3 did not have hospice services coordinated so that R3 received consistent and professional services for the treatment of R3's pressure injury. * Hospice visit notes were not updated in R2's medical record or in R2's hospice binder until Surveyor requested the information. Hospice was not aware of pressure injuries to R2's bilateral feet.

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 1 out of 3 Residents (R) reviewed for physician notification (R5). R5 had a change of condition and the facility failed to consult the physician regarding the change of condition. R5 had weights that increased or decreased out of parameters and the physician was not updated. This is evidenced by: Facility policy, titled, Change in Condition Process, last reviewed 3/01/21, states in part . Policy Statement: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change in condition is defined as an improvement or decline in their physical, or psychosocial status. Procedure: Change of Condition: 1. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure each resident (R) receives adequate supervision and assistance to prevent accidents for 3 of 4 residents reviewed (R4, R3 and R12). R4 has a history of being verbally aggressive towards others. R4 was verbally aggressive towards R12 and verbally aggressive and physically hit R3. R4 was not supervised when he was out of his room and interacting with other residents. Evidenced by: R4 was admitted to the facility on [DATE]. R4's diagnoses include metabolic encephalopathy, dementia and diabetes. R4's most recent MDS (Minimum Data Base), with an ARD (Assessment Reference Date) of 6/19/24, indicates R4 has moderate cognitive impairment and can independently wheel his wheelchair. R4's care plan focus areas include, in part, the following: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure a safe, clean, comfortable, and homelike environment for 102 residents residing in the facility. * In R67's bathroom, on the wall to the right of the toilet, there is a brown material which appeared to be BM (bowel movement) in two different areas. On the floor to the right of the toilet, there is a piece of BM and multiple areas of what appeared to be BM splattered on the floor. There are orange stains on the floor of the bathroom near the sink. Under R67's bed towards the head of the bed, there are multiple pieces of paper and dirt. Under R67's bed there are multiple pieces of paper, food, and dirt particles. This was observed on multiple days & times. * On the floor between R53's bed and the wall, along the cove base there is a piece of candy, a straw, and multiple pieces of paper and food particles. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for non-pressure wounds for 4 (R26, R77, R53, and R99) of 7 residents reviewed. *R26 had a surgical wound to the back. The treatment order for a wound vac was not transcribed into the Treatment Administration Record (TAR) as written, treatments orders had conflicting administration times that were not clarified, and treatments were not consistently signed out as being administered. *R77 had multiple Moisture Associated Skin Damage (MASD) wounds to abdominal skin folds, under breasts, behind knees, skin folds across chest, and midline folds that would appear and resolve over time. Multiple treatments were ordered to the same area. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R99) of 1 residents who voiced a desire to self administer their medication was assessed to determine if able to self administer medication.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R67) of 5 residents was provided with personal privacy. On 7/9/24 during a toileting observation, R67's bathroom door was not closed and R67's roommates (R502) privacy curtain was not closed. R502 was observed on his right side, not asleep, and was able to see R67 sitting on the toilet.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R501 and R99) of 7 residents reviewed received a prompt resolution of grievances filed, including steps taken to investigate the grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued. R501 filed three grievances with the facility and there is no evidence if the grievances were confirmed or not or if R501 was informed of the corrective actions taken by the facility and resolution. R99 filed grievances with the facility and there is no evidence if the grievances were confirmed or not or if R99 was informed of the corrective actions taken by the facility and resolution.

Inspectors wroteBased on interview and record review the Facility did not develop and implement and effective discharge planning process focusing on the resident's discharge goal, preparation for transition and reduction in factors leading to preventable readmission for 1 (R501) of 1 residents reviewed for discharge planning. R501 was living independently in the community when she suffered a fall, was transferred to the hospital where she was diagnosed with a subdural hematoma, left elbow fracture, right ring finger fracture and an elevated A1C (blood test that provides information about the average levels of blood glucose, blood sugar over the last 3 months). R501 underwent surgical repair of the left elbow fracture and was newly diagnosed with Diabetes and started on insulin. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R99) of 1 residents received the necessary services to maintain ability to practice good grooming and personal hygiene. R99 did not consistently receive showers twice a week.

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R67 & R53) of 5 Residents reviewed for pressure injuries. * R67 did not have a pressure relieving cushion in the wheelchair according to R67's plan of care. * Wound Physician-H's 6/25/24 order was incorrectly transcribed by the facility. R53's treatment with a start date of 5/29/24 for zinc oxide was not discontinued after Wound Physician-H on 7/2/24 ordered a treatment of Santyl, alginate calcium, and gauze island with border dressing daily. [...]

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT Based on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 2 (R67 & R53) of 5 Residents. * R67, who is at high risk for falls, was not transferred with a gait belt. * R53's bed was observed not at the lowest position and the call light was not in reach according to R53's care plan.

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 3 (R67, R53, & R99) of 5 Residents. * Staff did not perform appropriate hand hygiene during toileting observations for R67. * Appropriate hand hygiene was not observed during a treatment for R53 and staff were not wearing gowns during care observation for R53 who is on EBP (enhanced barrier precautions). * LPN (Licensed Practical Nurse)-F did not wear a gown during a pressure injury treatment observation with R99 who is on EBP.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 2 (R26 and R81) of 21 residents had acceptable care and treatment. R26 had an appointment to have a cystoscopy and left ureter stent removal on 2/29/24. R26 did not make it to that appointment and another appointment was scheduled on 4/11/24 for the same procedure. R26 did not make it to the 4/11/24 appointment due to being transferred to the hospital for a change in condition. The hospital record indicates R26 was admitted with sepsis and had the stent removed. The facility has no evidence R26 was educated on risk and benefits of canceling the 2/29/24 appointment for the stent removal. The facility has no evidence R26's urologist was consulted regarding R26 canceling the 2/29/24 stent removal appointment. R81 developed blisters on their buttocks that were not comprehensively assessed upon discovery. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 3 (R40, R259 and R77) of 5 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. On 4/15/24 R40 developed a stage 2 pressure injury to the coccyx area and treatment orders were for zinc ointment to the area. On 4/24/24 the pressure injury worsened and was assessed to have 50% slough in the wound bed. The Wound Nurse Practitioner (NP)-L continued to stage the pressure injury as a stage 2 and continued the zinc ointment. R40's pressure injury continued to have slough and no signs of healing were identified. On 5/15/24 the pressure injury worsened to 90% slough and 10% granulation and stage 4. Wound NP-L then prescribed aquacel to the wound. On 5/22/24 Surveyor observed wound treatment with Wound NP-L. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 4 residents (R67, R18, R40 & R11) at risk for or with a history of falls had comprehensive assessments to prevent falls and the completion of root cause analysis with possible care plan revisions to prevent future falls. -R67 was at risk for falls. R67 obtained head lacerations requiring hospital sutures on 2/10/24 and 3/26/24 following falls within the facility. On 2/17/24 a hospital evaluation was needed post fall for a possible head injury. The falls were not comprehensively assessed, the interventions were not reviewed to determine effectiveness or to determine if revisions were needed to prevent future falls. -R18, who is dependent on staff for bed mobility, sustained a fall out of bed on 2/3/24. R18 was found on the floor with tube feeding coming out of her mouth. R18 was sent to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment potentially affecting 104 of 104 residents in the facility. PBJ (Payroll Based Journal) staffing data report from CMS (Centers for Medicare and Medicaid Services) triggered for low weekend staffing October through December of 2023. R32 voiced staffing concerns during the Resident Council interview.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect 104 of 104 residents residing in the facility. * Dietary Aides DD and EE were observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. * Dietary Aides DD and EE were observed not changing gloves and washing hands after touching non-sanitized food surfaces. * Food temperatures were observed not obtained at breakfast service on 1st and 2nd floor kitchenettes. * Staff did not ensure that food was labeled with open or use-by dates. * Staff did not wear beard restraints while working in the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the infection control program was implemented which had the potential to affect all 104 residents. * From December 2023 to May 2024 the facility did not monitor infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. * The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R17, R81 and R75 were observed with indwelling medical devices, without indication they were on enhanced barrier precautions to prevent potential infections.

Inspectors wroteBased on interview and record review, the facility did not ensure they implemented an effective antibiotic stewardship program with the potential to affect all 104 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics, indicate antibiotic use without documentation of appropriate use, surveillance, and tracking information.

Inspectors wroteBased on observation and interviews, the facility did not ensure a clean, sanitary and homelike environment. This was observed on 4 of 6 Units in the facility. -2 [NAME] Unit resident rooms observed with dirty, sticky floors with debris scattered about, resident beds without fitted sheets and dining room observed with dirty, sticky and stained floors. -2 South Unit clean linen room observed with incontinent products, used gloves, linen, gripper socks and debris scatter on the floor. -2 East Unit (currently closed but remains accessible to residents and staff. The unit is adjacent to the 2 [NAME] Unit dining room and common area.) 2 East Unit observed with debris on the floor, medical supplies in unoccupied rooms, garbage cans full of debris, food and used linens. -During Resident Council group meeting R32 expressed concerns related to housekeeping and lack of linens. [...]

Inspectors wroteBased on interview and record review the facility did not implement their abuse prevention policy by ensuring 3 of 8 facility staff had the necessary background information disclosure (BID), form completed upon hire in order to work at the facility. The BID form is 1 of a 3 part screening process which requires applicants/employees to disclose various information such as; if they have any criminal charges pending against them, if they have ever been convicted of a crime in federal, state, local, military, and tribal courts, if any government agency found the individual to have committed child abuse or neglect or if they have ever been found to have abused or neglected any person or client. The deficient practice had the potential to affect all 104 residents residing in the facility at the time of the survey. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all medications were labeled in accordance with standard of practice for 3 of 6 medication carts (1 West, 1 South, and 2 West) and 2 of 3 (1 [NAME] and 1 South) medication storage rooms with the potential to affect 51 of 104 residents residing in those units.

Inspectors wroteBased on interview and record review, the facility did not implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for 3 (R27, R64, R34) residents; and did not ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect 47 of 104 residents who resided in the facility that entered into the binding arbitration agreement.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R82) of 4 sampled residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. *R82 was observed multiple times with their catheter drainage bag system uncovered.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure the resident who has not been adjudged incompetent designated a representative and delegated that representative to speak for the resident for 1 (R16) of 1 residents reviewed. R16 did not have an activated Power of Attorney (POA). R16 did not sign any facility documents for consent to treat, medication consents, the admission agreement, and the Do Not Resuscitate State form. All documents were signed by an individual that was not designated to speak on R16's behalf until R16 was deemed incompetent and the POA was activated.

Inspectors wroteBased on record review and interview, the facility did not ensure grievances were documented or make prompt efforts to resolve grievances for 1 (R58) of 4 residents reviewed for grievances. *R58 had two cell phones go missing and no grievance forms were completed or followed up on and R58 had a concern of a pair of missing pants that were not resolved.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure the Residents's medial record included documentation as to the reason for discharge and appropriate information is communicated to the receiving health care institution or provider for 2 (R64, R96) of 2 Residents reviewed for transfer/discharge. R64 was transferred to the hospital on 3/9/24. The Facility did not document the reason R64 was transferred, where R64 was transferred, the effective date of the transfer, their transfer appear rights and who to notify if choosing to appeal the transfer. R96 was transferred from the facility and admitted to the hospital on [DATE] and 3/4/24. No documentation was found of R96's medical status prior to leaving the facility. Evidenced by: Policy review: Notice of Requirements before transfer/ discharge, dated 5/1/2021 Intent: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 3 of 3 (R158, R259, R261) residents reviewed for discharge received a completed discharge summary in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. R158 was discharged from the facility on 4/4/24 and there is no documented evidence a discharge summary was completed to include a recapitulation of stay, final summary of resident status at discharge, reconciliation of medications and post discharge plan of care. R259 was discharged from the facility on 4/26/24 and there is no documented evidence a discharge summary was completed to include a recapitulation of stay, final summary of resident status at discharge, reconciliation of medications and post discharge plan of care. [...]

Inspectors wroteBased on observation and record review, 1 (R82) of 5 dependent residents reviewed were not provided with bathing assistance in accordance with their care plan.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident with a g (gastrostomy)-tube received the appropriate treatment. This was observed with 1(R17) of 1 resident reviewed for tube feeding. -R17 was observed receiving a un-prescribed tube feeding formula; tube feeding formula bag and water bag did not include the date, time the tube feeding began, the rate at which the feeding was being administered or the total run time.

Inspectors wroteBased on interview and record review, the facility did not act upon the recommendation of the pharmacist per the drug regimen review for 2 (R64, R11) of 5 residents reviewed for unnecessary medications. On 2/29/24, the pharmacist reviewed R64's drug regimen and made a recommendation. The facility was not able to provide a copy of the pharmacist's recommendation or were they had to provide evidence the physician was aware of the recommendation and acted upon it. R11's record indicated pharmacy recommendations were noted on 3/31/24. R11's record does not include the pharmacy reviews or specifically note what was reviewed or noted.

Inspectors wroteBased on record review and interview, the facility did not ensure adequate monitoring of side effects for antipsychotic medications was completed timely for 2 (R85 and R64) of 5 residents reviewed for unnecessary medications. *R85 received the antipsychotic medication aripiprazole and R85 had no record of having an Abnormal Involuntary Movement Scale (AIMS) assessment completed. *R64 received the antipsychotic medication brexpiprazole and the last AIMS assessment was completed on 4/5/2023, one year ago.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R258) of 2 residents reviewed had complete and accurate documentation in their medical record. R258 was on hospice services while at the facility and died on [DATE]. The facility did not document the assessment that was completed when R258 died. The facility did not document when hospice was made aware of R258 death. The facility also documented assessments from a fall dated [DATE] after R258 death.

Inspectors wroteBased on record review and interview, the facility did not ensure information including the hospice plan of care, the hospice election form, and communication of hospice visits was available to facility staff from the hospice agency for 1 (R16) of 1 resident reviewed for hospice services. R16 did not have any hospice records of visits after 2/22/2024 in the medical record. No documentation was found of the hospice agency attending any care conferences to coordinate care between the facility and the hospice agency.

Inspectors wroteBased on record review and interviews, the facility did not ensure a resident fall was comprehensively assessed, and documented in the medical record. This was observed with 1 (R1) of 3 residents reviewed with falls in the facility. R1 had a fall on 2/7/24 that was not document as being comprehensively assessed for injury. An assessment for possible care plan revisions also was not completed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 2 of 3 residents (R7 and R8) of eight sampled residents observed with empty medications cups at bedside were assessed for self-administration of medication. This failure had the potential for medications not being taken when required.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure the wound care was documented as being provided for 2 of 2 residents (R1 and R5) reviewed for non-pressure wounds. This failure to provide wound care had the potential to affect the healing process of the wounds.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure 1 of 3 residents (R3) reviewed for limited mobility, received restorative services as needed to address limited mobility, to maintain or improve mobility for the goal to reach the maximum practicable independence.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure resident rooms, dining rooms, and hallways were clean and or in good repair creating a homelike environment for the 106 current residents at the time of survey.

Inspectors wroteExample 2 The facility policy, entitled Wound Management - Wound Prevention and Treatment, dated [DATE], states: .Protecting against external mechanical forces: All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours (unless a tissue tolerance test indicates otherwise). This repositioning should also take place when residents are in a chair or wheelchair . .Pressure redistribution devices: Residents who are constantly immobile should have pressure reducing devices used to totally relieve pressure on heels and raise the heels completely off the bed . .Proper side lying position: Don't ever position a resident directly on their side or trochanter. This 90-degree position will cause breakdown on the hip. Position a resident at a 30-degree angle when they are to turn on one side or the other. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain acceptable parameters of nutritional status, such as usual body weight for 3 of 7 (R17, R2, and R12) residents reviewed for nutritional status. R17 is cited at severity level 3. R17's nutritional interventions and care plan were not revised or implemented to address R17's decreased food and fluid intake. This resulted in an unplanned severe weight loss of 13.65% in 4 months and impaired wound healing, as R17 developed a stage 4 and stage 3 Pressure Injury (PI). R2 was admitted with a high risk for weight loss and malnutrition. There was no evidence documented that the facility made attempts to encourage or assist R2 with her meal intakes, no weight monitoring, and no care plan interventions to attempt or assist R2 with improving meal intakes. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not ensure there was a Registered Nurse (RN) on duty for a minimum of eight consecutive hours a day, seven days a week. This had the potential to affect all 110 residents of the facility. -In the previous four months the facility did not have eight consecutive hours of RN coverage on 14 days.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment; this has the potential to affect 9 residents (R) R22, 35, 38, 43, 44, 16, 19, 23, 17) throughout the building and residents residing on the first floor. The facility did not repair corner guards, leaving areas that were hard to clean and potentially hazardous. Residents (R) R22, R36, R38, R43, and R44's rooms were found to have briefs, trash, and crumbs on their floors, and rooms had large yellow/orange stains around the toilets. The first-floor hallway and resident common areas have damage to walls, toilets, doors, and floors. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 5 residents (R33, R34, R31, and R26) reviewed. The facility did not ensure R33 and R34 were administered insulin appropriately based on the observation of Licensed Practical Nurse (LPN) not priming the insulin pen before administration. The facility did not ensure all insulins have an opened date recorded when insulins were opened for R31, R26, and R34. The facility did not ensure proper storage of insulin pens for R33, R31, R26, and R34. The insulin pens were all stacked together in the top drawer of the South medication cart. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. An abbreviated medication administration observation was conducted in which Licensed Practical Nurse (LPN) II did not wash or sanitize her hands between residents (R), affecting R24, R30, R29, R28, R27 and R25, did not don gloves prior to obtaining a blood glucose level on R34 and did not sanitize the multi-resident glucometer machine between residents R29 and R32. Staff did not perform hand hygiene when changing gloves during dressing change for R15. [...]

Inspectors wroteBased on interview and record review, the facility did not notify the resident's family with a significant change in the resident's condition. This occurred for 2 residents (R17 and R13) of 4 residents reviewed. R17's responsible party, power of attorney (POA) was not notified when weights were not obtained as ordered and a significant weight loss occurred during the time the weights were not obtained as well as notification of pressure injury (PI) progression and support surface use for PI prevention. The facility did not notify R13's power of attorney (POA) after R13 was found to have a fractured leg. This is evidenced by: R17 was admitted to the facility on [DATE] with diagnoses in part included traumatic subdural hemorrhage, cerebral infarction, hemiplegia, and hemiparesis to left non-dominant side, muscle weakness, cognitive communication deficit, and mild neurocognitive disorder. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain personal privacy during personal cares for 2 of 36 residents (R), R3 and R18. Staff did not close privacy curtain when completing cares for R3 while roommate R7 remained in the room and observed the care being provided. Staff did not close privacy curtain when completing cares for R18.

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 of 11 residents (R2) reviewed for dependence of staff for Activities of Daily Living (ADLs), received the necessary services to maintain good grooming and personal hygiene. Facility also did not ensure practices were in place to identify, intervene and educate R2 when cares were refused. R2 was to receive daily sponge bathing with showers twice weekly on Wednesday mornings and Saturday evenings (per bathing/shower task documentation). There was no evidence located that facility provided these services to R2. This is evidenced by: The facility policy titled Activities of Daily Living, dated 1/1/2021, states, in part, It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 6 sampled resident (R7). The facility did not thoroughly assess R7's pain according to standards of practice. This is evidenced by: The facility policy titled, Pain Management Program dated 01/11/21, reads in part . Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: g. Facial expressions: grimacing, frowning, fear, grinding of teeth. k. Sighing, groaning, crying, breathing heavily. Assessment and evaluation by appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of pain. e. Determining factors that make pain better or worse. i. Note all treatments the patient is receiving for pain, including non-pharmacological therapies. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure consistent communication for 1 of 3 residents (R1) reviewed who receive dialysis services. R1 was readmitted from the hospital on [DATE] with a new order for intravenous (IV) antibiotics. The medication order was not relayed to the pharmacy by the facility or dialysis center.

Inspectors wroteBased on interview and record review, the facility must ensure that a resident is free of any significant medication errors for 1 of 3 residents (R1) reviewed that received dialysis services. The facility did not ensure R1 was administered intravenous (IV) antibiotic on three separate occasions as ordered from physician. The order was not transcribed, entered in R1's medication record, and staff did not provide evidence that the medication was available to administer. This is evidenced by: The facility policy, entitled Admission/readmission Policy, dated 10/21/21, states: Information about resident admission is communicated in a timely manner to the appropriate departments. The admitting nurse completes the nursing assessment and obtains admitting orders. Once the admitting orders are verified, the orders are transcribed onto the POS, MAR, and TAR. [...]

Inspectors wroteBased on observation and interview the facility did provide a clean homelike environment on 2 of the 4 (2 east and 1 south) units observed which had the potential to affect 17 of 17 residents residing on the 2 east unit and 20 of 20 residents residing on the 1 south unit. *Surveyor observed two garbage/soiled linen bins in the hallway of 2 east. These bins were visibly full of malodorous contents. *Surveyor observed a pile of bed linens lying on the floor in the hallway of 1 south.

Inspectors wroteBased on interview and record review, the facility did not make a prompt effort to resolve grievances for 4 (R41, R52, R10, R67) of 7 residents who had expressed grievances/concerns to the facility. *R41 had voiced concerns to the facility regarding interaction with two agency certified nursing assistants (CNAs) during cares. The facility did not investigate and provide resolution to a grievance voiced by R41. *Resident Council members expressed concerns to administration staff during Resident Council meetings in November and [DATE] and January, February and [DATE] regarding concerns with Hoyer lifts and batteries not being charged properly. The grievance documents do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. [...]

Inspectors wroteBased on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 1 (R21) of 4 residents reviewed for hospitalization. *R21 was hospitalized on [DATE] and 3/25/23. The facility did not provide a bed hold notice for R21's hospitalizations on 3/10/23 and 3/25/23.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 (R61, R27) residents reviewed for activities of daily living. R61 required assistance with bathing/showering and grooming. Assistance was not provided with grooming until Surveyor inquired and assistance with a shower wasn't provided during the onsite survey. R27 required assistance with nail care. R27 requires assist of 1 staff for Activities of Daily Living.

Inspectors wroteBased on interview and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 4 (R1 and R24) residents reviewed for weight loss. *R1's dietician recommended a re-weight due to a 7.49% weight loss in under two months. The facility did not document a reweight for three months. *R24 did not have weights completed as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident received the appropriate treatment during enteral feeding through a gastrostomy tube to prevent possible complications for 1 (R14) of 1 resident reviewed for enteral feeding. R14 received enteral feeding without ensuring the gastrostomy tube was appropriately placed in the stomach prior to the medication administration. On 5/9/23, Licensed Practical Nurse (LPN)-O did not auscultate or aspirate the gastronomy tube prior to administering the medication.