Arlington Residence and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for seven of twelve Resident rooms (Rooms #1, #2, #3, #4, #5, #6, and #7) on the Sunflower Hall, and one of three shower rooms observed for cleanliness. The facility failed to ensure Resident Rooms #1, #2, #3, #4, #5, #6, and #7 on the Sunflower Hall were thoroughly cleaned and sanitized. The facility failed to ensure the shower room on the Sunflower Hall was thoroughly cleaned and sanitized. These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 3 of 6 residents (Residents #1, #7, and #34 ) reviewed for care plan. The facility failed to ensure Resident #1 was care planned for catheter (flexible tube inserted into the bladder to remove the urine) care when he was re-admitted to the facility on [DATE]. The facility failed to ensure Resident #7's care plan reflected an intervention which included bed being in the lowest position and fall mat alongside bed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for six of eighteen residents (Residents #7, #34, #41, #54, #66) reviewed for accident hazards. The facility failed to ensure Residents #7 and #66 had physician orders for a scoop mattress (a scoop mattress features raised sides and a concave center). The facility failed to ensure Residents #34 and #41 had Quarterly Smoking Assessments completed. The facility failed to ensure Resident #41 did not have tobacco products in his room. The facility failed to ensure there was no container of odor neutralizer left inside Resident #54's room on 04/07/2026. These failures could prevent the residents from having an environment that was free from accidents, potential injury, and exposure to toxic chemicals.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for four of eighteen residents (Resident #20, #22, #39, and #67) reviewed for medication storage.1. The facility failed to ensure Resident #22 did not have a roll-on medication inside her room on 04/07/2026.2. The facility failed to ensure Resident #20's zinc oxide was not left on top of the resident's overbed table beside the resident's food tray on 04/07/2026.3. The facility failed to ensure Resident #39's zinc oxide was not left on top of the resident's drawer on 04/7/2026.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The Dietary Manager failed to wear a head cover and she failed to ensure a vendor was wearing a beard cover in the kitchen while food was being prepared. The facility failed to properly label and date stored food received from vendors. The facility failed to ensure the ice machine in the kitchen was thoroughly cleaned. The facility failed to ensure the deep fryer was properly cleaned. These failures placed residents at risk of exposure to food contamination and illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 three of eighteen residents (Resident #19, #23 and #86) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene and changed her gloves during Resident #19's incontinent care on 04/07/2026. 2. The facility failed to ensure CNA D performed hand hygiene, changed her gloves, did not put gloves inside her pockets, and wore a gown during Resident #23's incontinent care on 04/08/2026. 3. The facility failed to ensure LVN A performed hand hygiene before checking Resident #86's blood sugar on 04/08/2026. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #34 and Resident #60) of twenty residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #34 and Resident #60's rooms was in a position that was accessible to the resident on 04/07/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for two of twenty residents (Resident #7 and Resident #19) reviewed for privacy and confidentiality.1. The facility failed to ensure LVN A closed, locked, or minimized his laptop monitor before leaving his cart, thus exposing Resident #7's medical information, on 04/08/2026. 2. The facility failed to ensure CNA C closed the blinds of Resident #19's window, which was overlooking to the parking lot, during incontinent care on 04/07/2026. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 3 residents (Residents #7) reviewed for assisted nutrition and hydration. The facility failed to notify the Dietician of Resident #7's weight loss of over 12% within a week. This failure could prevent the Dietician from reviewing the resident's plan of care and addressing the excessive weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of three residents (Resident #7) reviewed for feeding tube management. The facility failed to ensure LVN A checked Resident #7's g-tube placement and flushed the g-tube before and after medication administration as ordered on 04/08/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and dehydration.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to treat residents with respect and dignity for one of six residents (Resident #1) reviewed for resident rights. The facility failed to ensure RN A did not stand over Resident #1 while opening his brief and looking at his genitals with the door open and no curtain used, for anyone to see from the hallway on 08/29/25. This failure could affect residents who require assistance with ADLs of not wanting to get staff assistance if it were not done in private which could cause a decrease in the resident's self-esteem and psycho-social well-being resulting in embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure when discharge is anticipated, a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. 1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply, for 1 of 1 facility. The facility's emergency water supply consisted of 0 gallons of water on hand for a census of 68 residents. This failure could place all residents in the facility at serious risk for complications from dehydration and sanitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 16 rooms (Rooms #118, #126, and #147) and 2 of 14 residents (Resident #37 and Resident #66) reviewed for clean, comfortable, and homelike environment and clean bed and bath linens that are in good condition. 1. The facility failed to replace stained ceiling tiles in room [ROOM NUMBER] 2. The facility failed to repair a ceiling HVAC vent in room [ROOM NUMBER]. 3. The facility failed to maintain a clean environment for Resident #37. 4. The facility failed to ensure there was an adequate supply of linens to meet resident needs. 5. The facility failed to repair the room door for Resident #66. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and of exploitation of residents and misappropriation of resident property for 1 of 8 employees (CNA D) reviewed for employment registry screenings. The facility failed to ensure a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This failure could place residents at risk for abuse, neglect, exploitation and misappropriation of property. Record review of CNA D's personnel file reflected a hire date of 07/07/23 and no EMR/NAR check was completed prior to this date. Interview on 02/06/22 at 12:12 PM with the HR Manager revealed she began working at the facility in March of 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 14 residents (Residents #29, #48, and #57) reviewed for ADLs. The facility failed to ensure Resident #29, #48, and #57 received showers as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 1 secure unit reviewed for activities. The facility failed to ensure there were organized activities provided to the residents in the secure unit . The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation.

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 2 (CNA D and CNA E) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA D and CNA E had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 7 residents (Residents #8) reviewed for pharmacy services. Facility failed to ensure Ranolazine 1000 mg ER (extended release) used for chest pain was administered on 02/03/25, 02/04/25 and 02/05/25 as ordered for Resident #8. This failure could place residents at risk of not receiving the therapeutic value of the ordered medications and leading to potential hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. The facility failed to ensure stove backsplash was kept clean from buildup grease. This failure could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 washing machines (Washer A) reviewed for essential equipment. The facility failed to maintain a laundry washing machine (Washer A) in operating condition. This failure could place residents at risk of not having clean linen for their beds or personal clothing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 7 rooms (room [ROOM NUMBER], #117, #118, #120, #122, # 127, and #144) of 30 rooms reviewed for privacy. The facility failed to provide full privacy for residents of rooms #110, #117, #118, #120, #122, # 127, and #144 This failure could place residents at risk of no privacy.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain and effective training program for 8 of 11 staff (CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, LVN H,) reviewed for training. The facility failed to ensure CNA A, CNA B, CNA, C, CNA D, CNA E, LVN G, and LVN H were provided with training on dementia and abuse, neglect and exploitation. These failures could place residents at-risk for abuse and neglect due to lack of training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for 1 of 4 residents (Resident #9) reviewed for restraints. The facility failed to care plan for Reisdent #9's half bedrails. This failure could place the resident at risk of entrapment or restraint.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurate in accordance with accepted professional standards and practices for 1 of 7 residents (Resident #1) whose clinical records were reviewed. The facility failed to ensure Resident #1's MAR was accurately and completely documented in their permanent clinical record on [DATE]. This failure could place all the residents, who resided in the facility, at risk for inaccurate or incomplete clinical records.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative and the Office of the State Long-Term Care Ombudsman representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of three residents reviewed for discharge rights. The facility failed to provide a copy of the written notice of immediate discharge to Resident #1 and the Ombudsman when the facility decided that Resident #1 needed to be immediately discharged on 10/02/24, due to non-compliance with the smoking policy. This failure placed residents at risk of not having access to available advocacy services, discharge options, and appeal processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4 was provided with adequate supervision to prevent him from eloping from the facility's secured unit that was not in proper working condition on 07/24/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/24/24 and ended on 07/26/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of harm, severe injury, and possible death to residents who require supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Residents #1 and #2) of four residents reviewed for dignity. 1. The Maintenance Director on 09/10/24 recorded Resident #1 with his personal cell phone while Resident #1 yelled and cursed at the facility staff. 2. CNA A took Resident #2's cell phone away when Resident #1 stated he was going to call 911 on 06/20/24. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that menus were followed for 1 of 3 meals (lunch on 09/10/24) reviewed for meal accuracy. The facility failed to serve pureed bread during the lunch meal on 09/10/24 to all eight residents (Residents #5, #8, #9, #10, #11, #12, #13, and #14) who required a pureed diet. This failure could place residents at risk for poor intake and weight loss.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests 1 of 5 (Resident #6) resident rooms, and 1 of 3 (Sunflower hallway) dining areas reviewed for environment. The facility failed to ensure Resident #6's room and Sunflower hallway were free of small brown bugs on 09/10/24 and 09/11/24. This failure could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of three staff (Cook C) and one of one kitchen reviewed for kitchen sanitation. Cook C failed to wear a beard restraint on 09/10/2024 while in the food preparation area and while serving the lunch meal service. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one (Resident #1) of five residents reviewed for ADL care. The facility failed to remove Resident #1's facial hair. This failure could place residents at risk for social isolation, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nurse staffing information was posted on a daily basis for one of twenty-nine days (08/29/24) reviewed for nursing services and postings. The facility failed to update the posting of the daily staffing information on 08/29/24. This failure could place residents at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for bed hold. The facility failed to re-admit Resident #1 after he was treated at a behavioral health hospital, when his discharge back to the facility was anticipated on 06/26/24. This failure could place residents at risk of not getting the care and services required.

Inspectors wroteBased observation, interview, and record review, the facility failed to 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 1 (Resident #2) of 6 residents observed for infection control. The facility failed to ensure Resident #2's urinary catheter was positioned safely off the floor. This failure could place the residents at risk of cross-contamination and the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 resident (Resident #1) of five residents reviewed for environment. The facility failed to ensure Resident #1 had a functional call light. This failure placed residents at risk of not being able to get staff assistance when they need it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 11 residents (Residents #1, #2, and #3) reviewed for accidents. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent an unwitnessed fall with injury (non-displaced sacrum ring fracture) on 03/18/24. 2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility's secured unit on 01/31/24. 3. The facility failed to ensure the staff break room was locked at all times and residents did not have access to the microwave. Resident #3 sustained burns on his left foot first toe and second toe. An Immediate Jeopardy (IJ) situation was identified on 03/28/24 at 1:41 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 9 of 9 residents (Residents #48, #3, #43, #6, #76, #45, #135, #7, and #23) and 3 of 3 zones (Zones #1, #2, and #3) reviewed for environment. The facility failed to ensure temperatures were above 71 degrees Fahrenheit after the heater went out on the night of 01/08/24 to the morning of 01/09/24. An Immediate Jeopardy (IJ) situation was identified on 01/09/24. While the IJ was removed on 01/10/24, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of hypothermia and extreme cold.

Inspectors wroteBased on interview and record review, the facility failed electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 3 of 4 FY quarters reviewed (FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 1 2023 ([DATE]-[DATE]), FY Quarter 3 2023 (April 1-June 30), and FY Quarter 4 2023 (July 1-[DATE]). The facility's failures could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for five (01/01/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23) of 90 days. This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage .

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 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 on two of four medication carts (back and front nurses' carts) and 3 of 3 staff (LVN R, RN NN, and LVN L) reviewed for pharmacy services. The facility failed to ensure the back and front nurses medication cart contained accurate narcotic logs for Residents #184, #62, and #43. LVN R, RN NN and LVN L failed to document the administration of narcotic medications in a correct and timely manner. This failure could place residents at risk for drug diversion and delay in medication administration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide 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 1 (front hall and back hall ) of four medication carts and one of one refrigerator reviewed for pharmacy services. 1. The facility failed to ensure expired medications in nurse medication carts for front hall and refrigerator were removed and destroyed. 2. The facility failed to ensure insulin were dated with opening dates. 3. The facility failed to ensure vaccines were stored at the right temperatures and refrigerator temperatures were being maintained within normal ranges. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 5 residents (Resident #184, Resident #59, Resident# 38, and Resident #2) reviewed for infection control. LVN B and MA D failed to perform hand hygiene between residents while administering medications to Residents #184, #59, #38 and #2. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #39) of 18 residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #39's diagnosis of bullous pemphigoid (rare skin condition causing large, fluid-filled blisters). This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #39) of 18 reviewed for ADLs. The facility failed to ensure Resident #39's contractured hands were kept clean and free of odor. This failure had the potential to affectcould place residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot mobility and good foot health for 1 (Resident #72) of 18 residents reviewed for foot care. The facility did not ensure Resident #72 received toenail care. This failure could place residents at risk for not receiving foot care which is consistent with professional standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of four residents (Resident #73) reviewed for feeding tubes. The facility failed to follow physician's orders of providing Resident #73 with his 20 hours of feeding intake. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of g-tube care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of 3 residents (Resident #184) reviewed for oxygen therapy. The facility failed to acquire oxygen orders for Resident #184. This facility failure could place residents at risk of missing or receiving inadequate treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #53) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide special eating equipment and utensils for one (Resident #5) of two residents reviewed for meal service. The facility failed to provide Resident #5 a divided plate at lunch on 01/08/24 to assist her with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook H) of 3 staff reviewed for kitchen sanitation. Cook H failed to properly wear a hair restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for four (01/04/24, 01/05/24, 01/06/24, and 01/07/24) of 4 days reviewed for nurse staffing information. The facility failed to post the required staffing information for 01/04/24, 01/05/24, 01/06/24, and 01/07/24. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure Resident #1 did not physically abuse Resident #2 during their interactions on 08/29/23. This failure could place residents at risk of being abused.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation or misappropriation of resident property for 1 (Resident #1 ) of 5 residents reviewed for abuse. The facility failed to implement their policies and procedures related to reporting allegations of abuse when Resident #1 and Resident #2 were in a physical altercation on 8/29/23. This failure could place residents at risk of not being protected from abuse, neglect, and/or misappropriation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1 ) of 5 residents reviewed for abuse and neglect. RN A failed to report to the Administrator when Residents #1 and #2 got into a physical altercation on 08/29/23. This failure could place residents at risk of incidents of abuse, neglect, and/or exploitation not being reported timely and thoroughly investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 (Residents #3) of 3 residents reviewed for accidents and supervision. The facility failed to ensure Resident #3 did not have cigarettes and a lighter in his possession and failed to supervise the resident while smoking. These failures could place the residents at risk of injury and harm.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #1, #2, and #3) reviewed for Activities of Daily Living (ADLs) care provided to dependent residents. The facility failed to ensure Residents #1, #2, and #3 received adequate activities of daily living care with baths or showering, nail care, or dressing. This failure placed residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one (Secure Unit) of three halls reviewed for environment. The facility failed to ensure temperatures on the secure unit did not rise above 81 degrees Fahrenheit. These failures increased the risk of residents experiencing decreased comfort and could affect the wellbeing of residents.

Inspectors wroteBased on observation and interview, the facility failed to equip each room to assure full visual privacy for each resident for 4 (Rooms 124 A bed, 117 A bed, 130 A and B bed, and 133 A bed) of 10 rooms reviewed for privacy. The facility failed to provide curtains to ensure residents privacy in 4 dual occupancy rooms throughout the facility. This failure could place residents at risk of decreased self-worth by being exposed during resident care.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for two (Residents #11 and #12) of three residents reviewed for PASRR services. 1. The facility failed to submit Resident #11's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #11 by the specific deadline. 2. The facility failed to submit Resident #12's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #12 by the specific deadline. These failures could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, it was determined the facility failed to inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #10) of one resident reviewed. The facility failed to notify Resident #10's state mental health agency or intellectual disability agency of a significant change for Resident #10 when he expired on [DATE]. This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents.