Armstrong Rehabilitation and Nursing Center

Inspectors wroteBased on review of facility policy, documents, and staff interviews, it was determined that the facility failed to ensure an environment free of hazards which is likely to cause serious injury, harm, impairment, or death when an employee (RN Employee E1) entered the facility with a shot gun and ammunition. This failure created an immediate jeopardy situation for all residents.

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial comprehensive visit for two of five residents (Residents R1 and R2).

Inspectors wroteBased on review of facility policy and documents, and staff interviews it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure an environment free of accidents likely to cause serious injury, harm, impairment, or death when a staff member saw a man walk in with a shot gun and ammunition in his hand. This failure created an immediate jeopardy situation for all residents.

Inspectors wroteBased on review of facility policy, facility records, observations, and resident and staff interviews, it was determined that the facility failed to ensure comfortable room temperature levels were provided for eight out of 22 sampled residents (Residents R1, R2, R3, R4, R5, R6, R7, and Resident R8). Findings Include: Review of the facility policy Safe and Homelike Environment, dated 4/27/26, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. [...]

Inspectors wroteBased on review of facility policy and documentation, staff interviews it was determined that the facility failed to protect resident from sexual abuse for one of three residents (Resident R3).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R3).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for one of three residents reviewed (Resident R1). Findings Include: Review of the facility's Resident Accidents and Incidents policy dated 4/27/26, indicated it is the facility policy to ensure all incidents involving a resident a reported, documented and investigation initiated after the incident is identified. The nursing supervisor immediately notified of incidents. The resident's care plan is updated by the assigned Nurse, Clinical Manager, or Nursing Supervisor. The clinical manager or assigned nurse will ensure the resident care plan is updated with any new interventions identified during clinical rounds. [...]

Inspectors wroteBased on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for eight of ten resident rooms/areas (Rooms 211-2, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, and room [ROOM NUMBER]-1). Findings Include: Review of the facility policy Safe and Homelike Environment, dated 7/1/25, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. [...]

Inspectors wroteBased on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information and failed to set up home care services in preparation for discharge for one of four residents reviewed (Resident R3).

Inspectors wroteBased on facility policy review, clinical record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings Include: Review of the facility policy Missing Resident / Elopement Procedures dated 8/8/25, defined elopement: Occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. This can include locations within the building. [...]

Inspectors wroteBased on review of the facility's job descriptions, employee attendance information, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility. Review of the facility provided Director of Nursing (DON) job description, undated, indicated that the DON position purpose was, Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Included in the listing of Required Qualifications was Current unrestricted license as a Registered Nurse in practicing state. [...]

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the building unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility staff failed to follow a physician order for a Bi-pap machine (used to facilitate breathing during sleep for certain types of sleep apnea. Sleep apnea is a condition that causes breathing to stop and start several times during sleep. A bi-pap machine pushes air into the lungs with two settings a higher pressure when you inhale and a lower pressure when you exhale) for one of three residents (discharged Resident R1).

Inspectors wroteBased on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of five residents (Resident R1).

Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, personnel records and staff interviews it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA) (NA Employees E4, E5, E6, E7, and E8).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in three of five medication rooms (Second Floor (2C) Medication Room, Third Floor (3A) Medication Room, and Third Floor (3C) Medication Room) and failed to properly store medication in two of three medication carts (3BC Medication Cart and 2BC Medication Cart).

Inspectors wroteBased on review of facility financial documents, interviews with residents, resident's families, and staff it was determined that the facility failed to pay bills in a timely manner.

Inspectors wroteBased on review of facility policies, review of clinical record, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to failing to use Personal Protective Equipment (PPE) appropriately in Droplet Isolation (a type of isolation that requires a gown, gloves, N95 (a respirator mask), and eye protection, which created the potential for the cross-contamination and the spread of diseases and infections for four out of four resident rooms (Rooms 301, 304, 305, and 312), failed to clean residents rooms appropriately after isolation was discontinued for three of three rooms (rooms [ROOM NUMBER]), and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 12 of 12 [...]

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, E8, and Licensed Practical Nurse (LPN Employee E9).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for six of seven staff members (Nurse Aide (NA) Employee E4, NA Employee E5, NA Employee E6, NA Employee E7, NA Employee E8, and Licensed Practical Nurse (LPN) E9).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) E9).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).

Inspectors wroteBased on review of personnel records, and staff interview it was determined that the facility failed to ensure that three of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E5, E6, and E8).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).

Inspectors wroteBased on review of facility admission packet, facility policy, clinical records, observation, and staff interviews it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two residents (Resident R3 and R44).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R3, and R64).

Inspectors wroteBased on review of clinical records and staff interviews it was determined that the facility failed to develop a person-centered care plan with interventions for one of three residents reviewed (Resident R7).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R8).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview it was determined that the facility failed to provide adequate supervision for one of three residents with mental health concerns to prevent attempts of suicide (Resident R7).

Inspectors wroteBased on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of three residents (Resident R8) records reviewed.

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R3 and R65).

Inspectors wroteBased on review of facility policy, clinical documentation and staff interview it was determined that the facility failed to provide sufficient and timely social services to one of three residents reviewed (Resident R7).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R36).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post complete contact information for State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit as required, and failed to post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on three of three floors (First Floor, Second Floor, and Third Floor).

Inspectors wroteBased on review of facility policy, facility provided documents, clinical record review, and staff interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Residents R1). This was identified for past non-compliance for Resident R1.

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for two of four residents (Resident R1 and R2).

Inspectors wroteBased on review of facility policy, resident records, a facility tour, and staff and resident interview it was determined that the facility failed to implement transmission-based precautions and test for scabies for two of four residents (Residents R1 and R2).

Inspectors wroteBased on review of clinical record and staff interview it was determined that the facility failed to ensure that in preparation for a room change each resident/responsible party received written notice, including the reason for the change before the resident room was changed for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for one of six residents identified as high risk for wandering/elopement (Residents R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of six residents (Resident R1).

Inspectors wroteBased on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration for one of two residents reviewed (Resident R1) which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1.

Inspectors wroteBased on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1.

Inspectors wroteBased on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for one of three residents (Resident R2).

Inspectors wroteBased on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance, including eating and toileting for four of seven residents (Resident R4, R5, R6, and R7).

Inspectors wroteBased on review of clinical records, facility policy, job descriptions, and resident and staff interviews, it was determined that the facility failed to have sufficient staff to provide nursing services including toileting for three of seven residents reviewed (Residents R5, R6, and R7).

Inspectors wroteBased on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for eight of 49 resident rooms (209, 212, 218, 219, 221, 302, 303, and 305). Findings Include: Review of the facility policy Safe and Homelike Environment indicated the facility will provide a safe, clean, comfortable, and homelike environment. The facility will provide and maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. Observations conducted on 6/10/25, from 2:32 p.m. to 2:59 p.m. with the Maintenance Director, Employee E7 revealed the following air temperatures: [...]

Inspectors wroteBased on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for two of four residents (Resident R4 and Resident R5).

Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of three residents (Resident R5).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three of ten residents (Residents R1, R2, and R3). Findings Include: Review of the facility policy, Resident Showers dated 12/3/24, indicated residents will be provided showers as per request or as per facility schedule protocols and based on resident safety. During an interview on 3/4/25, at 10:13 a.m. Resident R1 stated I didn't get a shower on Monday because they were low on staff. I am scheduled for showers on Mondays and Thursdays. Now I have to wait until Thursday. This isn't the first time this has happened. It happens a lot. [...]

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of two nursing floors (Second floor).

Inspectors wroteBased on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of two residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, facility documents, resident interview, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1).

Inspectors wroteBased on review of facility policy, facility grievance forms, group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from facility grievances and failed to respond to concerns in a timely manner for six out of six months (June 2024 through November 2024).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, Adult Protective Service information, Medicare Fraud Unit information, and how to file a complaint with State Agency on two of two nursing floors (Second and Third Floor).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (Second, and Third Floor).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Residents R17, R18, and R47).

Inspectors wroteBased on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of twelve residents (Residents R1, R17, and R91).

Inspectors wroteBased on a review of the clinical record, resident council group, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four of four weeks (December 2024).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for five of 20 residents (Residents R17, R45, R47, R50, and R53).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts (3A medication cart), and in one of three medication rooms (Medication room [ROOM NUMBER]BC) and failed to properly secure a medication cart for one of three medication carts (3A medication cart).

Inspectors wroteBased on review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of six residents (Resident R17, R34, and R66).

Inspectors wroteBased on review of facility policy, clinical records, group interview, and staff interviews, it was determined that the facility failed to inform residents in advance of the proposed care for two of seven residents (Resident R39 and Resident R66).

Inspectors wroteBased on clinical record review, staff and resident interview, it was determined that the facility failed to accommodate resident needs and preferences for one of six residents (Resident 71).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of two residents (Resident R47, and R142).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family and/or physician of a change in condition in a timely manner for two of six residents (Resident R17 and R39).

Inspectors wroteBased on a review of facility documents and staff interview, it was determined that the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) form notice were provided timely for one of three residents (Resident R76).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three medication carts (2A Medication Cart).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R6) and failed to conduct a criminal background check prior to the start of employment for one of five staff (Dietary Employee E21).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required timeframe one of three residents (Resident R6).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents (Resident R6).

Inspectors wroteBased on a review of facility documents, and resident and staff interview, it was determined that the facility failed to not distinguish between residents based on their source of payment when providing services that are required to be provided for two of twelve residents (Resident R45, and R87). Findings Include: Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/26/24, indicated diagnoses of high blood pressure, muscle weakness, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression, and decrease in functional abilities). [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents with facility-initiated transfers (Residents R18 and R47).

Inspectors wroteBased on review of facility policy, clinical records, resident, and staff interviews, it was determined that the facility failed to complete quarterly wander guard (a device that triggers alarms when close to an exit) assessments for two of two residents (Resident R8, and Resident R53).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one two residents (Resident R36).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R39).

Inspectors wroteBased on review of facility policies, observations, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R17).

Inspectors wroteBased on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of one dialysis resident (Resident R64).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36 and R85).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R56).

Inspectors wroteBased on review of clinical records, hospital records review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident's total program of care, including medications and treatments, were reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 1).

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for one of three nurse aide personnel records (Nurse Aide Employee E26).

Inspectors wroteBased on review of facility policy, review of clinical documentation. observation and staff interview it was determined the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R55).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two of two residents (Resident R48, and Resident R53).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was promptly notified about abnormal laboratory test results for one of two residents (Resident R34)

Inspectors wroteBased on review of facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide timely dental services for one of two residents reviewed (Resident R45).

Inspectors wroteBased on a review of facility documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for one of six residents (Resident R87). Findings Include: Review of the clinical record revealed that Resident R87 was admitted to the facility on [DATE]. Review of Resident 87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/3/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time). [...]

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R12).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R84)

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of two nursing units (Second Floor).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of four medication carts (Medication Cart 3C).

Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for surgical wound care for one out of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Residents R1, R2, R3, R4). Findings Include: Review of the facility policy Accidents and Supervision dated 5/24/23, last reviewed 9/12/24, indicated each resident will receive adequate supervision and assistive devices to prevent accidents. [...]

Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing and failed to ensure that references were checked from previous employers and/or current employers for one of one newly hired nurses reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance.

Inspectors wroteBased on facility policy and clinical record review, and staff interview, it was determined the facility failed to notify a resident of a room change and the physician for a change in condition for three of five residents (Resident R12, R34, and R85).

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, facility supplied documentation, and staff interview it was determined that the facility failed to report allegations of abuse for four of six residents (Resident R12, R43, R84, and R85).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse for four of six residents reviewed (Resident R12, R43, R84, and R85).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for four of six residents (Resident R1, R34, R63, and R237).

Inspectors wroteBased on review of facility policy, clinical records, observation and staff interviews it was determined that the facility failed to maintain resident dignity by not clothing a resident on the Third floor (Resident R74) and failing to cover a resident's catheter bag (Resident R14) for two of five residents.

Inspectors wroteBased on review of facility policy, notice of non-coverage documents, clinical record review and staff interview, it was determined that the facility failed to provide the Advanced Beneficiary Notice prior to discharge from Medicare Part A services for one of three sampled residents (Resident R83).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of two nursing units (second floor), and two of two facility elevators (Elevator A and Elevator C). Findings Include: Review of the facility policy Safe and Homelike Environment dated 2/21/23, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment. Observation on 1/2/23, at 9:20 a.m. Resident R21's resident room [ROOM NUMBER]A, indicated a ceiling tile above the head of the bed area that was stained brown. Observation on 1/2/23, at 9:42 a.m. Resident R187's resident room [ROOM NUMBER], indicated peeling plaster down the wall by the window, with lifted and jagged edges protruding from wall. Observation on 1/2/23, at 9:53 a.m. [...]

Inspectors wroteBased on review of facility policy, observations of resident areas and nursing units, and staff interview it was determined that the facility failed failed to post all required information to submit a grievance on two of three resident areas (Second floor and Third floor).

Inspectors wroteBased on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of six residents reviewed (Resident R31).

Inspectors wroteBased on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of four residents receiving hospice services (Resident R21).

Inspectors wroteBased on review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) user's manual, facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two sampled residents (Resident R74).

Inspectors wroteBased on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of six residents (Resident R14, R44, and R63).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R40).

Inspectors wroteBased on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (second floor).

Inspectors wroteBased on facility policy, review of facility documents, and staff interviews, it was determined the facility failed to accurately track infections in the facility for one of six months (December 2023).