Aspen Point Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate reconciliation and documentation of destruction of Schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence), Schedule IV and schedule V narcotic controlled substance medications (substances in these schedules have a lower potential for abuse), for one sampled resident (Resident #51) and three additional residents (Resident #46, #27 and #50). Review showed staff documented the number of narcotic medications destroyed as two different amounts on two different forms for Resident #46 and Resident #27. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 opportunities observed, six errors occurred, resulting in a 24.0% error rate, affecting one resident (Resident #45), in a medication administration review of four sampled residents. The facility census was 53. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained infection control practices for one additional resident (Resident #45), in a medication administration review of four residents. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) (a Centers for Disease Control and Prevention recommended infection control intervention for nursing homes designed to reduce multidrug-resistant organism transmission) for one resident (Resident #3), in a review of 18 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean, and homelike environment for three residents (Resident #64, Resident #10, Resident #30) in a sample of 24 residents and one additional sampled resident (Resident #55). The facility census was 55. Review of the facility policy, Resident Environmental Quality, revised 09/01/2021, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change gloves in between dirty and clean tasks, complete appropriate hand hygiene and properly handle dirty linens and trash for four residents (Resident #9, #18, #27 and #51) in a review of 24 sampled residents. The facility census was 55. Review of the facility policy, Infection Prevention and Control Program, revised 04/23/25, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided personal privacy and treated one resident (Resident #4), in a review of 17 sampled residents, with dignity and respect when providing personal care. Staff provided a bed bath to the resident with the resident's privacy curtain and door open while talking to other residents in the hallway. The facility census was 56. Review of the facility policy, Promoting/Maintaining Resident Dignity, last revised 10/01/23, showed the following: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions to prevent unintended weight loss for one resident (Resident #26), in a review of 17 sample residents, who had a 8.61% weight loss in one month. The facility census was 56. Review of the facility policy, Weight Monitoring, last revised 9/1/22, showed the following: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed physician orders for three residents (Residents #5, #14, and #30), in a review of 17 sampled residents. Staff failed to follow physician's orders for oxygen therapy and immunizations/vaccinations for Resident #5, failed to pack a wound as ordered for Resident #14, and failed to apply a soft hand splint for Resident #30. The facility census was 56. Review of the facility policy, Medical Provider Orders, revised 4/7/22, showed the following: -The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three residents (Residents #102, #14, and #12), who relied on staff to assist with their activities of daily living (ADLs), in a review of 17 sampled residents, the necessary care to maintain good personal hygiene. The facility census was 56. Review of the facility's policy, Oral Care, last reviewed/revised 09/01/21, showed it was the practice of the facility to provide oral care to residents in order to prevent and control plaque associated oral diseases. (The policy did not address how often staff were to provide assistance with oral care.) Review of the facility's policy, Providing Nail Care, reviewed/revised 9/1/21, showed the following: -Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide evidence the facility offered the pneumococcal vaccination to three residents (Residents #5, #29, and #36), in a review of 17 sampled residents, and failed to provide education to each resident or resident representative regarding the benefits and potential side effects of the pneumococcal vaccination. The facility census was 56. Review of the facility policy, Pneumococcal Vaccine, dated 9/1/21, showed the following: -It is the facility policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with Centers for Disease Control and Prevention (CDC) guidelines and recommendations; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #26 and #4), in a review of 17 sampled residents, had call lights within reach. The facility census was 56. Review of the facility policy, Call Lights: Accessibility and Timely Response, last revised September 2021, showed the following: -The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance; -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -All residents will be educated on how to call for help by using the resident call system; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for two residents (Residents #405 and #102), in a review of 17 sampled residents. The facility census was 56. Review of the facility's policy, Baseline Care Plans, last reviewed 09/01/21, showed the following: -The facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; -A baseline care plan would be developed within 48 hours of a resident's admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four residents (Resident #2, #3, #4, and #5) in a review of five sampled residents were treated with respect and dignity, when residents reported staff cursed at them when responding to the residents and their needs. The residents reported the comments made them feel bad, worthless, upset, and less than human. The facility census was 53. Review of the facility policy for Resident Rights with a revision date of 9/3/22 showed the following: -The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; -The resident has the right to a dignified existence. 1. Review of Resident #2's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 11/8/24 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) in a review of five sampled residents was free from verbal abuse. The resident reported staff cursed at him/her when responding to the resident and his/her needs. The resident said the verbal abuse made him/her feel angry and upset. The facility census was 53. Review of the facility policy for Abuse, Neglect and Exploitation with a revision date of 8/23/22 showed the following: -It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; [...]

Inspectors wroteBased on interview and record review, the facility failed to safely transfer one cognitively intact resident (Resident #157), who had a diagnosis of quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), in a review of 17 sampled residents. Per the resident's interview, two unidentified staff (only identified by gender) failed to maintain control of the resident during a mechanical lift transfer, causing the resident's legs to hit the lift. When the resident was over the bed, staff hit the emergency release instead of the lowering button, and the resident dropped to the bed with his/her legs bent underneath him/her. During assessment, staff identified the resident had skin tears to both of his/her legs. The resident had pain and swelling in his/her legs and was sent to the hospital for evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet the residents' needs in the event of an emergency for two residents (Residents #25 and #157), in a review of 17 sampled residents. The residents' care plans directed for four staff to lower the resident to the ground with a sling and drag the residents out of the building to safety on a lift pad in the event on an emergency evacuation. The facility staffing showed three or less staff worked on the night shift on seven days between 7/12/24 and 8/26/24. Insufficient staff to evacuate the resident had the potential to cause serious injury, harm or death in the event of an emergency requiring an emergency evacuation. The facility assessment identified five staff were needed on the night shift to meet the residents' needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility was not administrered in a manner to ensure the well-being of each resident. From October, 2023- the facility had six changes in the licensed nursing home administrator position, which is responsbile for the overall oversight and supervision of employees and resident care. An allegation of verbal abuse was not reported to the state agency. Sufficient nursing staff were not present to ensure the health and safety of residents. Mechanical equipment was not maintained in a safe manner. Nurse aides were not trained to perform job functions and ongoing inservice training was not completed. The facility census was 54. 1. Record review of administrator records received by the licensure and certification unit showed the following: Administrator A worked at the facility from 10/13/23-4/9/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized Enhanced Barrier Precautions as required by facility policy when providing care and treatment to three residents (Residents #38, #46 and #12), who had wounds or an indwelling medical device, in a review of 17 sampled residents. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to track infections in the facility by organism and location. The facility failed to complete Tuberculin Skin Tests (TST) and/or annual evaluations as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for eight of eight new employees reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective training program for Certified Nurse Assistants (CNA) that included training on dementia and abuse prevention. The facility identified specific training needs in the facility assessment and the facility did not have documentation or evidence the required training was completed for four employees (CNA O, CNA Y, CNA AA and CNA BB) of nine employees (employees who have been working at the facility for at least one year) reviewed, or a current plan to ensure the training would be completed. The facility did not ensure CNAs received a minimum of 12 hours of training annually. The facility census was 54. Review of the Facility Assessment, Staff training/education and competencies section, dated [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a comfortable and homelike environment ensuring the residents' walls were painted and free of marring, resident room doors were painted and free of gouges and scuff marks, floor tiles were maintained without chips, cracks, and dirt buildup, and the handrails on the 100 and 300 hallway were free of chipping paint and scuff marks. The facility census was 54. Review of the facility's policy, Safe and Homelike Environment, reviewed 09/01/21, showed the following: -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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served food that was palatable and served at a safe and appetizing temperature. The facility census was 54. Review of the facility policy titled, Food Safety Requirements, date implemented 9/1/21, showed the facility is to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 1. During an interview on 08/20/24 at 12:43 P.M., Resident #25 said his/her food was never hot. During an interview on 08/20/24 at 3:14 P.M. Resident #23 said sometimes his/her food was cold. During an interview on 08/20/24 at 3:30 P.M. Resident #49 said the food was awful and it was regularly served cold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used to transfer residents was maintained in good repair and in safe operating condition. The facility census was 54. Review of the facility policy, Safe Resident Handling/Transfers, dated 09/01/21, showed the following: -Staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly; -Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy; -The lift will be cleaned and disinfected according to manufacturer's instructions and after each resident use. 1. Review of equipment checks provided by an outside vendor, dated April 2023, showed the following: -Three mechanical lifts in service; [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one resident (Resident #157), who had unexplained fractures in his/her legs, and failed to report an allegation of staff to resident verbal abuse for one resident (Resident #49), in a review of 17 sampled residents, to the state survey agency within two hours of the allegation or identified injury. The facility census was 54. Review of the facility policy, Unexplained Injuries, dated 09/01/21, showed the following: -Observations of any unexplained injuries shall be reported immediately to the resident's nurse; -An incident report form shall be completed. If an allegation of abuse is made or if the injury is of unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an injury of unknown origin for one resident (Resident #157), who had unexplained fractures in his/her legs, in a review of 17 sampled residents, and failed to investigate an allegation staff to resident verbal abuse for one resident (Resident #49). The facility census was 54. Review of the facility policy, Unexplained Injuries, dated 09/01/21, showed the following: -Observations of any unexplained injuries shall be reported immediately to the resident's nurse; -Care and treatment shall be provided to the resident as needed. This includes physician notification and implementation of physician orders or facility protocols; -An incident report form shall be completed. [...]

Inspectors wroteRefer to 1R4813. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 4/17/24. Based on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents # 1, #2, and #11 ), who were unable to perform their own activities of daily living (ADLs), in a review of 11 sampled residents, the necessary care and services to maintain bathing, grooming to include shaving, personal hygiene, and nail care. The facility also failed to check one resident (Resident #5) for incontinence for a prolonged period of time which resulted in the resident being wet and soiled. The facility census was 60.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, received necessary care and services in accordance with professional standards of pactice when staff failed to obtain laboratory tests and administer lactolose (a liquid medication used to treat liver failure by removing ammonia from the blood, a waste product normally processed in the liver and removed through the urine. Ammonia build up in the blood can be very dangerous and can be toxic to the brain) as ordered by the resident'sphysician. [...]

Inspectors wroteRefer to event IR4812 Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for eight residents (Residents #1, #4, #5, #9, #13, #14, #20, and #21), in a review of 28 sampled residents, and failed to ensure licensed staff were scheduled as per the facility's assessment to meet the residents' needs. The facility census was 65.

Inspectors wroteRefer to event IR4812 *This deficiency is uncorrected. For previous examples, see Statement of Deficiencies dated 2/23/24. Based on observation, interview, and record review, the facility failed to provide housekeeping services to maintain a clean, safe, and comfortable homelike environment. The facility failed to ensure resident rooms, hallways and common areas were clean and free of odors, failed to ensure the floors were clean and free of debris, and failed to empty trash in the resident rooms. The facility census was 65.

Inspectors wroteRefer to event IR4812 Based on observation, interview, and record review, the facility failed to follow professional standards of practice when they did not administer medications to two residents (Residents # 9 and #21) in a review of 28 sampled residents within the time frame designated for morning medication pass. The facility failed to ensure one resident (Resident #8) took his/her medication when staff left the resident's medications on the resident's bedside table and left the room without observing the resident take the medication. The facility failed to administer a controlled medication to one resident (Resident #29) as ordered by the physician. The facility census was 65.

Inspectors wroteRefer to event IR4812 Based on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #1, #4, and #5), who were unable to perform their own activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care and services to maintain bathing, grooming to include shaving, personal hygiene, and nail care. The facility census was 65.

Inspectors wroteRefer to event IR4812 *This deficiency is uncorrected. For previous examples, see Statement of Deficiencies dated 2/23/24. Based on observation, record review, and interview, the facility failed to ensure the director of nursing (DON) did not work as a charge nurse during a time the facility census was greater then 60 residents on 4/1/24, 4/3/24, 4/4/24, 4/8/24, and 4/9/24. The facility census was 65.

Inspectors wroteRefer to event IR4812 Based on observation, interview, and record review, the facility failed to provide necessary treatment and services consistent with standards of practice to assess, prevent, and promote healing of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #1), in a review of 28 sampled residents. The facility census was 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for eight residents (Residents #1, #4, #5, #9, #13, #14, #20, and #21), in a review of 28 sampled residents, and failed to ensure licensed staff were scheduled as per the facility's assessment to meet the residents' needs. The facility census was 65. Review of the facility's policy, Nursing Services and Sufficient Staff, dated 9/1/21, showed the following: -It was the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; [...]

Inspectors wroteBased on interview, review of facility documents, and facility policy review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was implemented to drive quality assurance (QA) measures which addressed resident smoking and safety, weight loss, timely administration of medications, and accuracy of narcotic reconciliation with the potential to affect 60 census residents. Additionally, the facility had not reviewed or updated their written QAPI plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice when they did not administer medications to two residents (Residents # 9 and #21) in a review of 28 sampled residents within the time frame designated for morning medication pass. The facility failed to ensure one resident (Resident #8) took his/her medication when staff left the resident's medications on the resident's bedside table and left the room without observing the resident take the medication. The facility failed to administer a controlled medication to one resident (Resident #29) as ordered by the physician. The facility census was 65. Review of the facility's policy, Medication Administration, reviewed 9/11/22, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #1, #4, and #5), who were unable to perform their own activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care and services to maintain bathing, grooming to include shaving, personal hygiene, and nail care. The facility census was 65. Review of the facility's policy for activities of daily living (ADLs), dated November 2017, showed the following: -The facility would ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable; -A resident who was unable to carry out activities of daily living (bathing, dressing, grooming, and toileting) would receive the necessary services to maintain good grooming, and personal and oral hygiene. 1. [...]

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to provide interventions to address significant weight loss and notify the physician about significant weight loss for three of five residents (Residents (R)18, R34, R41) reviewed for nutritional status out of 26 sampled residents. The census was 60.

Inspectors wroteBased on interview and staffing record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours in a 24-hour period for one day in the last 30 days. This had the ability to affect 60 census residents.

Inspectors wroteBased on interview and record review, the facility failed to offer a daily bedtime snack to four of 28 sampled residents (Residents #1, #2, #4, #5, #14 and #17). The facility census was 65. Review of the facility policy, Offering/Serving Bedtime Snacks, dated 9/1/21, showed the following: -It is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis; -All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the resident's name and room number; -Dietary services staff delivers bedtime snacks to each nurse's station. The charge nurse is made aware of the delivery of the snacks; -Nursing staff delivers and serves snacks to the residents. 1. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff supervised residents with a history of aggression resulting in verbal abuse for two (Residents (R) 56 and 30) of two residents reviewed for verbal abuse of 26 sampled residents. The census was 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services consistent with standards of practice to assess, prevent, and promote healing of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #1), in a review of 28 sampled residents. The facility census was 65. Review of the facility's policy Pressure Injury Prevention and Management, dated 9/1/21, showed the following: -Facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers/injuries; -Pressure Ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; [...]

Inspectors wroteRefer to ZNHX13 Based on interview and record review, the facility failed to obtain and administer pain medication in a timely manner after pain was identified, failed to obtain a prescription from the resident's physician for the pain medication, and failed to ensure the medication was available for administration for two residents (Resident #1 and #2), in a sample of eleven residents. Resident #1 had an order for morphine sulfate (a narcotic medication used to treat severe pain), and oxycodone (a narcotic medication used to relieve moderate to severe pain) for pain, and Lyrica (a medication used to treat nerve and muscle pain). The facility failed to obtain Resident #1's morphine sulfate and oxycodone, resulting in the resident having increased pain, becoming angry and upset and ultimately self-discharging from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for two residents(Resident #1 and Resident #2) out of seven sampled. Staff failed to notify the physician when Resident #2, who is dependent upon oxygen, had oxygen levels fall below the recommended range as ordered by the physician, causing the resident to become incoherent and having difficulty breathing and required hospitalization. Staff also failed to document the change in condition for Resident #1 and failed to monitor and document the resident's oxygen saturation (SPO2 levels). Staff failed to follow professional standards for Resident #1, when the resident experienced a change in the ability to swallow and staff used to a syringe to give the resident food and fluids without the order from the physician or consulting speech therapy. The facility census was 65. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the resident room, equipment and flooring in good repair for three residents (Resident #2, #3, and #5) out of seven sampled residents. The facility census was 65. The facility did not provide a policy for keeping the facility floors clean and in good repair. 1. Review of Resident #2 medical record showed the resident was admitted to the hospital on [DATE]. Observation on 12/12/23 at 11:24 A.M. of the resident's room showed: -A dirty bed pan in the bathroom leaning up against the toilet; -The bottom right side was damaged with the particle board falling off; -Broken and loose tile around the bed and by the air conditioning unit. Some tiles were not the same size as others with gaps of the concrete floor exposed. Several tiles were broken and coming up off the floor and slid when walked on; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement oxygen interventions according to standards of practice by failure to ensure that humidification and oxygen tubing were changed, labeled and stored per physician's orders for three residents (Resident #3, #5 and #4), in a review of seven sampled residents. The facility census was 65. The facility did not have a policy for changing, labeling or storing humidification and oxygen tubing. 1. Review of Resident #2's comprehensive Minimum Data Set (MDS), a comprehensive assessment instrument completed by staff,d dated 10/5/23 showed: -Able to make self understood and able to understand others; -Able to make decisions; -Dependent upon staff for Activities of Daily Living (ADL's); -Receives continuous oxygen, use of BiPAP or CPAP not marked; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's (Resident #2's) physician and responsible party after the resident experienced a change of condition which resulted in the resident going to the emergency room for evaluation. The facility census was 65. Review of the facility policy for Notification of Changes dated 9/01/21 showed: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident #1, #3 and #5), in a review of seven sampled residents, were free from misappropriation of property when Licensed Practical Nurse (LPN) A misappropriated residents' narcotic medications. The facility census was 67. On 12/4/23 at 8:05 A.M. the administrator was notified of the past noncompliance which occurred on 11/9/23. On 11/9/23 the administrator identified LPN A misappropriated Resident #1's narcotic pain medication (oxycodone, an opioid pain medication). Upon discovery, staff suspended LPN A, conducted an investigation, followed the facility policy, and notified appropriate parties, including local law enforcement. [...]

Inspectors wroteRefer to ZNHX12 Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for two residents (Resident #1 and #2) in a sample of 24 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #1 and #2 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #1 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). [...]

Inspectors wroteRefer to ZNHX12. Based on interview and record review, the facility failed to ensure three confidential residents (Resident #700, #800 and #900), in a review 24 residents, felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation from staff members. The facility also failed to ensure staff treated residents with dignity and respect for one resident (Residents #10) when staff failed to assist the resident up from a fall mat. The facility census was 70. Review of the facility's policy, Resident Rights, revised December 2016 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. [...]

Inspectors wroteRefer to ZNHX12. Based on observation, interview and record review, the facility failed to provide care and supervision in a safe manner for three residents (Resident #5, #6, and #15) in a review of 24 sampled residents. When providing incontinence care for Resident #6, staff failed to ensure proper and safe positioning at all times that resulted in the resident being pushed too far toward to the edge of the bed and fell out of bed sustaining an injury requiring care at the emergency room. Staff also failed to ensure the resident's air loss mattress was at the correct setting for the resident's weight. Additionally, facility staff failed to properly transfer Resident #5 during a Hoyer (a mechanical lift used to transfer a resident from one surface to another) lift transfer by transferring the resident with only one staff member. [...]

Inspectors wroteRefer to ZNHX12. Based on interview and record review, the facility failed to ensure adequate staffing to provide resident care and protective oversight for residents in the facility. The facility's assessment showed the number of residents the facility was licensed to provide care for was 180 with an average daily census range of 70-80. The staffing plan showed the average number of licensed nurses providing direct care was three to four and the average number of nurse aides was between 5-10. The facility failed to provide the staff that their facility assessment indicated was necessary from 11/5/23 at 11:00 P.M. to 11/6/23 at 3:52 A.M. when there were three staff caring for 71 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure systems were in place to clearly document residents' choice for code status. The facility also failed to clearly communicate the choice of code status to direct care staff so staff knew immediately what actions to take in the event of an emergency for four residents (Residents #2, #3, #4, and #5) in a review 79 residents. This had the potential to result in a resident who wished to be full code status not receiving cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) in the event of an emergency, or residents receiving CPR who wished to be a do-not-resuscitate (DNR) (when a person elects to not have CPR attempted on them if their heart or breathing stops). The facility census was 79. The administrator was notified on [DATE] at 11:10 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with pressure ulcers and skin conditions received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and worsening of pressure ulcers and skin conditions for one resident (Resident #6). On 8/15/23, staff documented the resident had open areas to the left great toe, right rear thigh and left rear thigh. No measurements or staging of the wounds was documented. On 8/16/23 staff obtained treatment orders for the wound on the left toe. On 8/25/23, staff documented the resident had open areas, identified as pressure, to the right gluteal fold and right hip. On 8/26/23 staff obtained treatment orders for the wounds to the buttocks and right hip. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one resident (Resident #1) who resided on the locked dementia unit. The resident had a diagnosis of dysphagia (difficulty swallowing, taking more time and effort to move food from the mouth to the stomach) and was identified by the facility as a choking risk. The resident had an order to receive a mechanical soft diet and, per his/her physician orders, staff were to supervise and cue the resident due to unsafe eating habits (eating too fast and not completely chewing food). On 8/16/23, the resident obtained oatmeal pies as well as half a peanut butter sandwich without staff knowledge from an unsupervised snack cart. Certified Nurse Assistant (CNA) A was the only staff member on the unit for 15 residents. [...]

Inspectors wroteBased on interview and record review, facility staff failed to communicate pharmacy recommendations to the physicians of multiple residents, for three months, to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census was 79. Review of the facility's policy, titled Medication Regimen Review, revised 5/4/22, showed the following: -The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart; -Policy Explanation and Compliance Guidelines: 1. Medication Regimen Review (MRR), or Drug Regimen Review, is an evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure gradual dose reductions (GDRs; the stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discontinued) were attempted, or the physician documented the rationale for not attempting a GDR on antipsychotic medications (medications that affects brain activities associated with mental processes and behavior) and antidepressant medications for five residents residents (Residents #27, #30, #32, #35 and #38). The facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days, as required, except if an attending or prescribing physician believed and documented that it was appropriate for the PRN order to be extended beyond 14 days, for one resident (Resident #17). The facility census was 79. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quality assessment and assurance (QAA) committee meeting quarterly to identify and address issues necessary with respect to quality assurance. The facility failed to provide evidence the facility consistently implemented a Quality Assurance and Process Improvement (QAPI) program with measurable data, actions and evaluations. Further review showed neither the Medical Director nor his designee or Infection Preventionist attended quarterly QAA committee meetings. The facility census was 79. Review of the Facility Assessment Tool, last updated 8/25/22, showed the following: -Facility resources needed to provide competent support and care for our resident population every day and during emergencies included QAPI; -Policies and procedures for provision of care: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and to ensure a system to monitor antibiotic use was in place. The facility census was 79. Review of the Facility Assessment Tool, last updated 8/25/22, showed the following: -Services and care offered based on our resident's needs included infection prevention and control; identification and containment of infections and prevention of infections; -Facility resources needed to provide competent support and care for our resident population every day and during emergencies included infection control and prevention; -Staffing plan included one infection preventionist. Review of the facility policy titled, Antibiotic Stewardship Policy, last revised 8/18/22, showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual, in the roll of the Infection Preventionist (IP), who was responsible for implementing programs and activities to prevent and control infections. The facility census was 79. Review of the Facility Assessment Tool, last updated 8/25/22, showed the following: -Services and care offered based on our resident's needs included infection prevention and control; identification and containment of infections and prevention of infections; -Facility resources needed to provide competent support and care for our resident population every day and during emergencies included infection control and prevention; -Staffing plan included one infection preventionist. Review of the facility policy titled, Antibiotic Stewardship Policy, last revised 8/18/22, showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, facility staff failed to act promptly upon the grievances and recommendations of the Resident Council concerning issues of resident care and quality of life in the facility, and failed to provide the Resident Council with rationale, responses, and actions taken regarding their concerns. The facility census was 79. Review of the facility policy, Resident Council Meetings, last revised 4/7/22, showed the following: -This facility supports the rights of residents to organize and participate in resident groups including a resident council. This policy provides guidance that promotes structure, order and productivity, in these group meetings; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and treatment in accordance with professional standards of practice for ten residents (Resident #2, 3, 15, 18, 28, 29, 33, 34, 37, and 39). The facility failed to report a red, itchy rash to a resident's bilateral extremities for one resident (Resident #18) to the physician and obtain orders in a timely manner. The resident was noted to have a red rash to his/her bilateral extremities on 8/29/23. The resident said he/she had the rash for about a week and had reported it to the facility staff, the rash itched and kept him/her awake at night. The facility also failed to follow physician orders for an x-ray after one resident (Resident #15), had a fall and complained of pain in his/her left arm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff followed menus and served the appropriate portion sizes for the meal. The facility failed to ensure food items were available to serve at the scheduled meals as outlined in the facility's menus. The facility census was 79. Review of the facility policy, Serving a Meal, dated November 2017, showed it is the policy of this facility to serve meals that meet the nutritional needs of the residents. Review of the facility's menu for Tuesday 8/29/23 showed the following: -Chicken Jambalaya; (requested the menu from the facility, with regular portion size indicated for each resident for the Jambalaya received a copy for the recipe serving 80 residents, but it did not indicate the portion size individually) -Biscuit, serving was one for each resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer a routine nourishing snack to each resident when substantial meals were served over 14 hours a part. The facility census was 79. Review of the facility policy, Frequency of Meals dated 5/10/22 showed the following: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals; -The facility has scheduled three regular meal times, comparable to normal mealtimes in the community, per day and has scheduled regular snack times. There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this meal time span; [...]