Aurora Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, facility staff failed to label eye drops in accordance with professional standards and failed destroy expired medications. The facility census was 66.1. Review of the facility's Medication Storage policy, dated 05/01/25, showed it is the policy of the facility to ensure all medications housed on the premises will be stored according to the manufacturer's recommendations. The consultant pharmacist routinely inspects for discontinued, outdated defective or deteriorated medications with worn illegible, or missing labels. These medications are destroyed. 2. Observation on 12/09/25 at 8:02 A.M., showed the 400-hall medication cart contained: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two residents (Resident #6 and #73) out of 3 residents sampled who were hospitalized . The facility census was 66.1. Review of the facility's Bed Hold policy, dated 08/01/25, showed at the time of transfer for hospitalization, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. In the event of emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policy. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to complete a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility. Facility census was 75.1. Review of the facility's Facility Assessment policy, Review of the facility assessment, dated 10/09/25, showed: -Average daily census of 77 residents;-Dayshift to include: one-two Registered Nurse (RN)'s, zero-three Licensed Practical Nurse (LPN)'s, three-five Certified Nurse Aide (CNA)'s, and zero-two Certified Medication Technician (CMT)'s;-Nightshift to include: zero-one RN, zero-two LPN's, two-five CNA's.-Evening shift to include zero-two CMT's;-The assessment did not contain direction or guidance of shift times;-The assessment did not contain direction or guidance to include staffing needs for each resident unit. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to wear appropriate Personal Protective Equipment (PPE) during provisions of care for two resident's (Resident #12 and #13) out of two sampled residents who required Enhanced Barrier Precautions (EBP), and failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for two residents (Resident #14 and #16) out of two sampled residents. The facility census was 75.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete pre-employment screenings Criminal Background Checks (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nurse Aide (CNA) Registry for six sampled employees Registered Nurse (RN) G, CNA F, Certified Medication Technician (CMT) V, housekeeper W, CNA S, and housekeeper U out of ten sampled employees sampled. The facility census was 75. 1. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 05/01/25, showed:-Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property and the facility will maintain documented proof of the screening. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report allegations of abuse and neglect for two residents (Resident #17, and #15) to the Department of Health and Senior [NAME] (DHSS) within the required time frame of two hours for allegations of abuse and neglect. The facility census was 75. 1. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 05/01/25, showed it is the policy of the facility to provide protections for health, welfare, and rights of each resident. The facility will develop policies that prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure ten residents (Residents #1, #3, #5, #6, #9, #12, #13, #14, #15, and #16) out of 18 sampled residents, who were dependent on staff for activities of daily living (ADLs) received necessary care and services to maintain good personal hygiene. The facility census was 75.1. Review of the facility's Bathing a Resident policy, dated 08/01/25, showed it is the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/25/25, showed staff assessed the resident as:-Cognitively impaired;-Dependent on staff for bathing, dressing and personal hygiene;-No behaviors or rejection of care;-Diagnosis of stroke and anxiety. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide sufficient staff according to facility assessment provide nursing care to meet the care needs of five residents (Resident #1, #3, #5, #9, and #14) out of 18 sampled residents to ensure adequate care and comfort. This had the potential to affect all residents. The facility census was 75.1. Review of the facility's Facility Assessment, dated 10/09/25, showed: -The Facility Assessment includes an evaluation of staff needed to ensure enough staff to meet resident needs as identified through resident assessment and care plans;-Resident daily schedules (waking, bathing, activities, rest periods, meals, bedtime, etc.) are considered;-Staff needed to care for resident population include: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The census was 75.1. Review of the Facility Assessment, dated 10/09/25, showed: -Average daily census of 77;-The DON is identified as needed to care for the resident population;-The assessment does not indicate if the DON is a full-time staff member or how many hours are dedicated to the role of DON;-The assessment does not indicate if the DON is allocated to direct care. 2. Review of the facility's nursing schedule dated 09/01/25 through 9/30/25 showed the DON as charge nurse: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the hospital discharged the resident. The facility census was 80.1. Review of the facility's Transfer and Discharge policy, revised 04/23/25, showed staff were directed to:-Once admitted , the resident has the right to remain in the facility unless their transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;-The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify the physician and family/resident representative in a timely manner of a change in condition for one resident (Resident #1) who had a medical emergency, and failed to notify the family/resident representative for one resident (Resident #1) who sustained a fall. The facility census was 71. 1. Review of the facility's Notification of Changes policy, revised 9/1/21, shows the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his/her authority, resident representative when there is a change requiring notification. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/16/25, showed staff assessed the resident as follows: -Cognitive impairment; [...]

Inspectors wroteBased on observation and interview, facility staff failed to maintain wheelchairs for three residents (Resident #5, #7 and #8) of nine sampled residents. The facility census was 76. 1. Review of the facility's policy, Physical Environment: Space and Equipment, dated 02/03/25, showed staff were directed inspection of resident care equipment will be completed routinely and as needed to maintain and ensure safe operating conditions according to manufacturer's recommendations. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Uses a wheelchair. Observation on 03/20/25 at 12:11 P.M., showed Resident #5 in his/her wheelchair with both arm rest torn. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet the hygiene needs for four residents (Resident #3, #5 and #6) out of seven sampled residents when staff did not provide nail care and assist with facial hair. The facility census was 76. 1. Review of the facilities policy, Activities of Daily Living, dated 01/01/25, showed staff are directed to assist a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The policy did not provide direction for staff in regard to when and how to provide personal hygiene. 2. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not exhibit behavior of rejecting care; [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of seven resident's (Resident #2, #3, #4, #5, #6, #7, and #8) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/22/22, showed misappropriation defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's permission. 2. Review of the facility's investigation, dated 9/12/24, showed staff had suspicions the narcotics count were off when they identified LPN A had subtracted various pills inaccurately for multiple residents. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of misappropriation of narcotics to the State Survey Agency within the 24 hour time frame, in accordance with their policy, and state law for seven residents (Resident #2, #3, #4, #5, #6, #7, and #8) out of 10 sampled residents. The facility census was 78. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 8/2022, showed reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframe's. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to protect one resident (Resident #1) from neglect when staff failed to properly secure a resident while they transported the resident in the facility vehicle. Facility staff failed to secure the shoulder strap across the resident and when the vehicle came to an abrupt stop, the resident fell over his/her lap belt and from his/her wheelchair which resulted in fractures of both femurs, thoracic spine fractures, and an upper arm fracture. The facility census was 78. The administrator was notified on 8/13/24 of past non-compliance, which occurred on 8/07/24. Staff assessed the resident, notified the resident's physician, sent the resident to the hospital, and in-serviced all transportation staff on the proper way to secure a resident in the van during transport. The IJ was corrected on 8/8/2024. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 83. 1. Review of the facility's Dishwasher Temperature policy, reviewed January 2024, showed manufacturer's instructions shall be followed for machine washing and sanitizing. For low temperature dishwashers with chemical sanitation the washer temperature shall be 120 degrees Fahrenheit (F). Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes. Review showed facility records did not contain a dishwasher temperature log for the month of June 2024. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure resident's personal medical information was protected for two residents (Resident #9 and #281) of 11 sampled residents when staff left the Electronic Medical Information (EMR) open and unattended in a public area, posted care instructions for residents in a public hallway and failed to provide personal privacy for . The facility census was 83. 1. Review of the facility's Resident Rights policy, dated 09/01/22, showed the resident has a right to personal privacy and confidentiality of his or her personal and medical records. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. 2. [...]

Inspectors wroteBased on interview and record review, staff failed to maintain professional standards of care when staff failed to document follow-up neurological assessments after a fall for four (Resident #47, #60, #73, and #258) of four sampled residents. Facility staff failed to follow physician orders for two (Resident #21and #73) out of nine residents who required tube feedings and/or skin assessments, failed to complete weekly weights for one (Resident #21) of four newly admitted residents. Staff failed to clarify a medication order and obtain lab values for one (Resident #5) of one resident who received Lithium (mood stablizer). The facility census was 83. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide bathing and personal hygiene for six (Resident #9, #17, #21, #32, #46, and #47) out of twelve sampled dependent residents . The facility census was 83. 1. Review of the facility's Resident Showers policy, dated 2021, showed it is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. The Certified Nurse Aid (CNA) will assess the skin for any changes while performing bathing and inform the nurse of any changes. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/15/24, showed staff assessed the resident as: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure residents' environment remained free of accident hazards when staff did not remove chemicals in the dining room during a meal service, and failed to assess self-administration of medication safety for two (Resident #45 and #283) out of two sampled residents who had medication in his/her room in reach. The facility census was 83. 1. Review of the facility's policies showed staff did not provide a policy for chemical storage or chemical safety. 2. Observation on 06/25/24 at 11:52 A.M. through 1:18 P.M., showed a container of sanitizing wipes on dining room table. Five residents sat at the table with the sanitizing wipes. During an interview on 06/28/24 at 8:42 A.M., Certified Nurse Aide (CNA) D said chemicals should not be stored in the dining room or any resident could get hurt with them. [...]

Inspectors wroteBased on record review and interview, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications for three (Resident #20, #32, and #45) of seven residents, and failed to ensure as needed psychotropic medication orders were limited to 14 days for one (Resident #60) of seven residents. The facility census was 83. 1. Review of the facility policies provided showed the policies did not contain instructions to obtain an appropriate diagnosis for the use of psychotropic medications. 2. Review of Resident #20's Physician Order Sheet (POS), dated 05/22/24, showed an order for Clonazepam (an anti-anxiety medication). Review of the resident's medical record showed the record did not contain a diagnosis for the medication Clonazepam. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain an reason for use of a urinary catheter (tube inserted into the bladder to drain urine) for two (Resident #46 and #281) of three residents who had a urinary catheter, failed to obtain orders for the catheter size and update a care plan for one (Resident #46) of three residents, and failed to appropriately document catheter care for one of three residents (#281). The facility census was 83. 1. Review of the facility's Catheter Care policy dated September 2021, showed the policy did not contain direction for catheter orders, care planning, documentation or indication for use. 2. Review of Resident #46's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/14/24 showed staff assessed the resident as cognitively intact and intermittently catheterized. [...]

Inspectors wroteBased on observation, interview, and record review, facility staffed failed to post required nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 83. 1. Review of the facility's Nurse Staffing Posting Information policy, dated 09/01/21, showed staff are instructed to make staffing readily available in a readable format to residents and visitors at any given time: -The daily staffing sheet will be posted on a daily basis and will contain the following information: facility name, the current date, facility current resident census, and the total and actual hours worked by the following categories of licensed and unlicensed staff direction responsible for resident care per shift; [...]

Inspectors wroteBased on record review and interviews, the facility staff failed to ensure residents were allowed to make choices about aspects of their lives in the facility when facility staff failed to allow four residents (Resident #1, #2, #3, and #4), who was his/her own responsible person to smoke. The facility census was 73. 1. Review of the Facility's Resident Rights Policy, not dated, showed staff are directed as follows: -The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 2. Review of the resident #1's annual Minimum Data Set (MDS), a federally mandated assessment, dated 02/12/24, showed the staff assessed the resident as follows: [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical and nursing needs for four residents (Residents #1, #2, #3 and #4) who smoke cigarettes. The facility census was 73. 1. Review of the facility's Resident smoking policy, revised 9/22/22, showed staff were directed to the following all residents shall be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS) assessment process. 2. Review of the facility's policies showed the facility did not provide a policy for the development of comprehensive care plans. 3. Review of the Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment, dated 02/12/24, showed the staff assessed the resident as follows: -Moderate cognitive impairment; [...]

Inspectors wroteBased on interviews and record review, facility staff failed to notify the resident's guardian in a timely manner of an allegation of abuse and an injury of unknown source for one resident (Resident #1). The facility census was 68. 1. Review of the facility's Notification of Changes policy, revised March 2022, showed a facility representative will notify the resident, his/her family, or representative when there is a change in condition to include deterioration in health, mental, or psychosocial status. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 12/16/23, showed staff assessed the resident as severely cognitively impaired. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a thourough investigation when one resident (Resident #1) reported a staff member held him/her down. Staff did not interview additional residents, witnesses and other who might have knowledge of the allegation. The facility census was 68. 1. Review of the facility's Abuse and Neglect policy, revised 8/22/22, showed the policy is designed to provide protections for the health, welfare and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property: -Investigation of alleged abuse: an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur; [...]

Inspectors wroteSee 0Q2H12. F622. Based on interview and record review, the facility failed to allow two residents (Resident #39 and #401) to return to the facility after a hospital stay and failed to provide a discharge location for the residents in their emergency discharge notices. The facility census was 76. 1. Review of the facility's Resident Transfer and Discharge Policy -Emergency policy, revised August 2018, showed staff are directed that residents will not be transferred unless: -The transfer or discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility; -The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; -The health of individuals in the facility would otherwise be endangered. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly clean and sanitize mechanically washed dishes to prevent cross-contamination. Facility staff failed to allow mechanically washed dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to store food in manner to prevent contamination and out-dated use. The facility census was 73. 1. Review of the facility's Food Safety Requirements policy, date 04/07/22, showed: -Food will be stored, prepared and served in accordance with professional standards for food service safety; -Food safety practices shall be followed throughout the facility's entire food handling process. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff failed to knock, announce themselves and wait for permission before entering resident rooms for four residents (Resident #9, #48, #55, #368), hung signs that instruct staff how to care for residents for two residents (Resident's #12 and #38), failed to provide privacy or fully cover the residents with a bath blankets while moving the residents from the spa for two residents (Resident #30 and #368), maintain a dignified dining room experience for one resident (Resident #11), and failed to care for the resident in a manner to promote his/her quality of life when they failed to recognize the resident was exposed, and failed to intervene in a timely manner for one resident (Resident #381). The facility census was 73. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow two residents (Resident #39 and #401) to return to the facility after a hospital stay and failed to provide a discharge location for the residents in their emergency discharge notices. The facility census was 76. 1. Review of the facility's Resident Transfer and Discharge Policy -Emergency policy, revised August 2018, showed staff are directed that residents will not be transferred unless: -The transfer or discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility; -The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; -The health of individuals in the facility would otherwise be endangered. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to maintain professional standards of care by not following physicians order for two residents (Resident #25 and #378) and staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) following unwitnessed falls, and falls with a known head injury, for four residents (Resident #25, #35, #36, and #56). Additionally, staff failed to appropriately label a multi-use vial of Humulin (a type of insulin given to control the amount of glucose in your bloodstream) with the open and expiration date. The facility census was 73. 1. Review of the facility's Medical Provider Orders Policy, revised 04/7/22, showed staff are directed as follows: [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekend. The facility census was 73. 1. Review of the facility's Activities Program policy, revised 04/07/2022, showed the following: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident.; -Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. 2. Review of the facility's Activity Calendar, dated August 2023, showed the following: -Sunday, 8/6/23: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly propel two residents (Resident #37, and one unknown resident) in wheelchairs in a manner to prevent accidents, failed to provide safe propulsion of one resident (Resident #30) down the hall in a shower chair, and failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store razors/sharps, and medications. Staff failed to ensure hallway and emergency exits were kept clear of obstacles. The facility census was 73. 1. Review of the facility's policy titled, Wheelchair, Safe use, dated 05/04/2022, showed staff were directed to do the following: -Leg rests should be used when transporting a resident in a wheelchair; -Check the residents' legs and feet for proper placement on the leg rests prior to transport. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to obtain orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), and failed to have a system in place for ongoing communication with the dialysis clinic for three residents (Resident #49, #372, and #377 ) who receive dialysis. The facility census was 73. 1. Review of the facility's policy titled, Hemodialysis, dated March 2022, showed staff were directed to do the following: -The facility will assure that that each resident receives care and services for the prevision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice; -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; [...]

Inspectors wroteBased on interview and record review the facility staff failed to communicate pharmacy recommendations to the physicians for four residents (Resident #11, #34, #49, and #55) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census was 73. 1. Review of the facility's Pharmacy Services - Role of the consultant pharmacist Policy, revised April 2019, showed: -The facility shall obtain and retain the services of a consultant pharmacist. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to: [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to ensure medication were stored in a safe and effective manner for two of two medication carts, and medications left in two residents' rooms (Resident #8 and #26). Additionally facility staff failed to keep medication and treatment carts securely locked when not in use. The facility census was 73. 1. Review of the facility's medication storage policy, revised 04/07/22, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitization, temperature, light, ventilation, moisture control, segregation and security; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for three residents (Resident #12, #22, and #40), failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after use for three residents (Resident #14, #20, and #23), failed to maintain transmission based precautions for two residents (Resident #6 and #373) in order to prevent the transmission of shingles (a viral infection that causes a painful rash) and clostridium difficile [C-diff- a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)] infection and failed to ensure the two-step purified protein derivative (PPD) (skin [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to post in a form and manner accessible to residents, the Department of Health and Senior Services (DHSS) Elder Abuse and Neglect hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA). The facility census was 73. 1. Review of the facility's Abuse, Neglect and Exploitation policy, revised 09/22/2022, showed the policy did not contain direction on the requirement for the posted information. Observations from 08/28/23 at 1:00 P.M., to 8/31/23 at 3:00 P.M., showed the facility did not have the name, address, and toll free telephone number for the DHSS Elder Abuse and Neglect Hotline, in a prominent manner for residents or visitors to use if needed. [...]

Inspectors wroteBased on interview and record review facility staff failed implement their background screening investigations policy when they did not check the staff's employee disqualification list (EDL) check quarterly. The facility census was 73. 1. Review of the facility's Background Screening Investigations policy, revised November 2015, showed the EDL - Through Department of Health and Senior Services - ran prior to hire and quarterly. During an interview on 08/30/23 at 10:24 A.M., the human resources director said he/she was told by corporate the EDLs only had to be ran annually. During an interview on 08/30/23 at 10:43 A.M., the administrator said the facility ran the EDL checks once a year but was not sure how often the checks were required. During an interview on 08/31/23 at 02:21 P.M., the Director of Nursing (DON) said he/she did not know the requirement for the EDL checks.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. The facility census was 73. 1. Review of the facility's Disposal of Garbage and Refuse policy, dated 09/01/21, showed Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered with not in actual use. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop a Quality Assurance and Performance Improvement Plan (QAPI) (written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved). The facility census was 73. 1. Review of the facility's records showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. During an interview on 08/31/23 9:27 A.M., the Administrator said the QAPI and QAA program meetings should be quarterly but the facility policy states the meetings should be monthly, and that was his/her expectation. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 73. 1. Review of the facility's policy titled, Antibiotic Stewardship Program, dated 08/18/2022, showed: -It is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The Purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program includes antibiotic use protocols and a system to monitor antibiotic use; -The facility uses the McGreer's criteria (criteria used for infection surveillance) to define infections; -All prescriptions for antibiotics shall specify the dose, duration, and indication for use; [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 73. 1. Review of the policies provided by facility staff showed no policy in regard to specialized training for an IP. During an interview on 08/30/23 at 10:19 A.M., the Assistant to the Director of Nursing (ADON) said he/she had not taken the required classes or test to be certified as an IP. The ADON said he/she enrolled in the IP training the previous day. During an interview on 8/31/23 at 3:30 P.M., the Administrator said all the staff are new, including herself, and the ADON had not been signed up for the required training until the previous day. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #5, #58, and #66) out of three sampled residents. The facility's census was 73. 1. Review of the facility's Bed-Holds and Returns policy, revised September 2021, showed at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. 2. Review of Resident #5's record showed the following: -Cognitively intact; -discharged from the facility on 08/12/23 and readmitted to the facility on [DATE]. [...]