Aurora Valley Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure swallow interventions were developed and implemented for 1 of 3 residents (Resident 1). This failure placed residents at risk for inconsistent implementation of care and services from staff, poor oral intake, poor nutrition and potential harm.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary environment for 3 of 4 residents (Resident 2, 3 and 4). This failure placed residents at risk of lack of dignity, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 residents (Resident 1). The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an adequate supply of bed linens, gowns, towels and washcloths to ensure residents were maintained in a clean, comfortable, dignified manner for 15 of 15 sampled residents (Residents 4, 12, 63, 72, 77, 29, 48, 21, 31, 34, 38, 46, 19, 27, and 43 ) reviewed for safe, clean, homelike environment. In addition, the facility failure to ensure room temperatures for rooms 29 through 39 on the Southeast unit were at safe and comfortable levels. In addition, Resident 19 and 43's wheelchairs were not maintained in a clean manner. Those failures placed residents for potential decreased quality of life and care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were available to meet the care needs for 7 of 9 sampled residents (Residents 17, 19, 29, 5, 43, 48, and 7) reviewed for activities of daily living (ADLS), and 3 of 3 sampled residents (Residents 44, 43, and 19) reviewed for restorative nursing (a personalized program that combined therapeutic techniques, exercises, and intervention to promote a resident's ability to maintain or improve their ADLS). These failures placed the residents at risk for unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility administration failed to effectively use its resources to maintain facility compliance with federal regulatory requirements, to provide clean bed and bath linens that were in good repair. Specifically, bed linens were often returned from the laundry provider soiled, stained, wet and malodorous. Additionally, there was an insufficient supply of linens for the resident needs, which resulted in the residents using slightly soiled linens or going without them. These failures caused residents to have a potential decreased quality of life and care.

Inspectors wroteBased on interview and record review the facility failed to have a written transfer agreement with one or more local hospitals as required. This failure placed all residents at risk of delay in emergency medical treatment, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide laundry services that included handling, storing, processing, and transporting linens in a manner to prevent the spread of infection. In addition, staff failed to perform hand hygiene when indicated during 2 of 3 medication administration observations. This failure placed residents at risk of potentially avoidable infections and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 4 of 5 sampled residents (Residents 21, 34, 38, and 46) interviewed during the Resident Council meeting. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure contact information of all pertinent State regulatory and advocacy groups were provided and/or posted for 4 out of 5 residents interviewed (Residents 38, 21, 34, and 46) during Resident Council. Failure to ensure contact information was posted at levels that were readable and accessible to residents in wheelchairs, placed the residents at risk of not being fully informed of their rights, potential abuse and/or neglect, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents and/or visitors were informed of the location of the State Recertification Survey results documents/binder, and that the binder location was known for 4 of 5 sampled residents (Residents 21, 34, 38, and 46). This failure placed residents and visitors at the risk of not being able to access the Survey results.

Inspectors wroteBased on interview and record review the facility failed to provide residents and/or their representatives a written notice that included the reason for transfer or discharge and failed to send a copy of the notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations), as required for 2 of 3 sampled residents (Residents 86 and 2) reviewed for discharges. This failure placed residents at risk of inappropriate transfers or discharges.

Inspectors wroteBased on interview and record review the facility failed to complete interdisciplinary team (IDT, at a minimum consisting of the resident's attending physician, nurse and nurse aide responsible for the resident, a member of food and nutrition services, the resident and/or the resident representative) care planning conference meetings to enable resident and/or the resident representative participation in development, review, and revision of the plan of care for 9 of 9 sampled residents (Resident 5, 7, 9, 27, 41, 43, 44, 48 and 63), reviewed for care conferences. This failure placed residents at risk of unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide assistance with bathing, nail care, and eating for 7 of 9 sampled residents (Residents 5, 7, 17, 19, 29, 43 and 48) reviewed for activities of daily living (ADLs) for dependent residents. Those failures placed the residents at risk for diminished quality of life and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and oversee a comprehensive restorative nursing program for 3 of 3 sampled residents (Resident 44, 43, and 19), reviewed for restorative services. This failure placed residents at risk for complications and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to administer medication according to provider orders for 3 of 5 residents (Resident 9, 43, and 63) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that the Medical Director received and reviewed the content of Quality Assurance & Performance Improvement (QAPI) meetings when they were not present, communicated with and participated in the QAPI process, as required. This failure minimized the effectiveness of the interdisciplinary Quality Assessment & Assurance (QAA) team's ability to identify potential quality of care deficiencies and develop and implement corrective action. This failure placed residents at risk for complications, unmet needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure direct care staff received training on effective communication, as required. This failure placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure all staff received training on the Quality Assurance and Performance Improvement (QAPI, a systemic interdisciplinary comprehensive data-driven approach to maintaining and improving safety and quality in nursing homes) program, as required. This failure placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents that explained the potential risks and benefits associated with the use of psychotropic medications (medications that affected mood or emotions) were obtained from the resident or their representative prior to their administration for 2 of 5 sampled residents (Residents 27 and 63) reviewed for unnecessary medications. This failure placed the residents and/or their representatives at risk of not being fully informed of the potential risks and benefits of receiving the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review [PASARR, an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions] was completed after an exempted hospital stay (when the resident remained in the facility longer than thirty days) finished for 1 of 5 sampled residents (Resident 43), reviewed for PASARR services. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received proper foot care in accordance with professional standards for 1 of 5 sampled residents (Resident 27) reviewed for skin care concerns. Specifically, Resident 27 had diagnoses and conditions that made them prone to the development of foot problems and had extremely dry, flaky skin on their feet. This failure put this high-risk resident at increased risk of complications and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate and assess a resident for safe smoking abilities for 1 of 5 sampled residents (Resident 54), reviewed for accident hazards and supervision. This failure placed residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Review of the facility policy titled, Smoking-[NAME] Center No Smoking revised June 2023, documented smoking tobacco or tobacco related products or substitutes were not permitted on the facility property. The policy further documented that all residents were screened for smoking when admitted to the facility and those residents who decided to continue smoking would have their decision included in their care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services necessary to improve bowel and bladder functions for 1 of 2 residents (Resident 63), reviewed for incontinence care. This failure placed the resident at risk for skin and medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed maintain intravenous (IV) access consistent with professional standards of practice to include obtaining and implementing orders for saline flushes (a syringe of saline used to clear the IV and prevent it from clogging) and IV dressing changes (a transparent dressing over the insertion site) for 1 of 1 residents (Resident 35), reviewed for IV access maintenance. This failure placed resident at risk for medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory equipment was implemented as ordered, functional and maintained in a clean manner for 2 of 2 residents (Resident 43 and 27), reviewed for respiratory care. Specifically, Resident 27's continuous positive airway pressure machine (CPAP, machine that helped people breathe by delivering pressurized air into their lungs through their nose, or nose and mouth) was not implemented as ordered by the physician or maintained in a functional manner. In addition, Resident 43's oxygen tubing and oxygen concentrator (a machine that delivers oxygen) were not maintained in a clean and sanitary manner. These failures placed residents at risk for impaired sleep, infections, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety measures were in place and followed for 1 of 3 residents (Resident 35), reviewed for dialysis (a process of using a machine to filter the blood from excess fluid or waste when the kidneys were unable to do so). Staff often checked Resident 35's blood pressure on the same arm as their dialysis fistula (an access made by joining an artery and vein in the arm). This failure placed residents at risk for medical complications and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a psychological evaluation was completed and behavioral health services were offered as recommended to 1 of 2 sampled residents (Resident 1) reviewed for mood and behavior. This finding placed the resident of unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to timely act upon the pharmacist's monthly medication regimen review recommendations for identified irregularities for 1 of 5 sampled residents (Resident 63), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, medication complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were discarded appropriately in 1 of 2 medication rooms (North) observed. In addition, the facility failed to ensure temperatures in the medication room and medication refrigerator were consistently monitored in 1 of 2 medication rooms (TCU) observed. This failure placed residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely follow-up dental appointments for 2 of 3 sampled residents (Residents 41, 29), reviewed for dental care. This failure placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to perform hand hygiene when indicated during the meal service. This failure placed residents at risk for foodborne illnesses.

Inspectors wroteBased on observations, interviews and record reviews, the governing body failed to ensure the facility had resources to supply residents with an adequate supply of clean linens. Additionally, the governing body failed to respond to repeated staff concerns about insufficient quantity of linens, poor quality of current laundry service, requests for resources and/or a change in laundry vendors in a timely manner. This failure impacted all residents and placed them at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify a designated interdisciplinary team member, to act as a liaison for coordinating care and communication with the hospice provider for 1 of 1 sampled residents (Resident 61), reviewed for hospice services. This failure placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview, and record review the facility failed to provide the necessary care and services to ensure that a dependent resident received assistance with toileting for 1 of 3 residents (Resident 1). This failure placed the resident at increased risk for skin breakdown and unmet care needs.

Inspectors wroteBased on interviews and record review, the facility failed to revise and implement a comprehensive plan of care to included resident specific information for 1 of 3 residents (Resident 1). The failure to establish and implement a care plan that was individualized, accurately reflected assessed care needs related to their ability and need for assistance to eat and provided direction to staff on this topic, placed the resident at risk to receive inappropriate and inadequate care to meet their individualized needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health needs were met for 1 of 3 residents (Resident 1) reviewed for behavioral-emotional health. Failure to seek mental health services after the resident was identified in a facility assessment as having symptoms of moderate depression, failure to seek mental health services in a timely manner after the medical provider ordered mental health services to occur, failure to identify behavioral health needs and utilize person-centered interventions developed by an interdisciplinary team (IDT). This failure placed at risk for potential skin injury and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow-up on necessary dental services for 1 of 3 residents (Resident 1). Failure to follow-up on a referral to a denturist for ill-fitting dentures, that had caused an open sore, placed the resident at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 3 sampled residents (Resident 1 and 2), reviewed for accidents related to substance use disorder. This failure placed residents at risk of potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from neglect for 1 of 3 residents (Resident 1) reviewed for neglect. The failure of the facility to address identified concerns for incontinence and personal hygiene resulted in a diminished quality of life and led to Resident 1 being removed, by family, from the facility Against Medical Advice (AMA) (occurs when a person decides to leave a medical facility before the medical team recommends discharge).

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential neglect were reported immediately to the State Agency as required, for 1 of 3 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk for possible neglect.

Inspectors wroteBased on observation and interview, the facility failed to ensure quarantine and isolation precautions were followed for 4 of 5 Residents (Residents 1, 2, 3 and 4) and proper personal protection equipment (PPE's) was used by 1 of 5 staff (Staff H), during a COVID outbreak, in accordance with Centers for Disease Control (CDC) guidelines. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus.

Inspectors wroteBased on interview and record review the facility failed to assess a change in condition, respond to the change of condition and notify the medical provider in a timely manner for 1 of 5 residents (Resident 5) reviewed for quality of care. This failure placed the resident at risk for medical complications, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to repeatedly implement an effective discharge planning process, evaluate and document resident's discharge needs and discharge plan to avoid unnecessary delays in discharge, and document who determined why discharge to the community was not feasible for 3 of 3 sampled residents (Resident 4, 1, and 5), reviewed for discharge planning. This failure placed residents at risk of unsafe discharges, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to repeatedly identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 3 of 3 sampled residents (Resident 1, 2, and 3), reviewed for substance use disorder. This failure placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to accurately assess urinary status, follow provider orders, provide appropriate care and services to restore or improve normal bladder function, and provide indwelling urinary catheter (flexible tube inserted into the bladder to drain urine) care according to standards of practice for 1 of 3 sampled residents (Resident 4), reviewed for urinary catheter management. These failures placed residents at risk of medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to schedule a dental appointment for 1 of 1 sampled resident (Resident 59), reviewed for dental services. Resident experienced on-going mouth pain when there was a delay in coordination of a dental extractions appointment. This failed practice placed residents at risk of diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits were completed every 30 days, for the first three months after admission, then every 60 days, as required, for 8 of 14 sample residents (Resident 12, 15, 21, 24, 39, 42, 52, 60) reviewed for physician visits. This failure placed the residents at risk for delayed identification and treatment of medical needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 3 of 9 sampled residents (Residents 36, 42 and 80) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene was performed when indicated for 1 of 1 residents (Resident 78) during a medication pass observation, and enhanced barrier precautions (EBP) were implemented for 2 of 4 sampled residents (Residents 12 and 17) reviewed for infection control. Specifically, Resident 12 had a history of antibiotic resistance and had weeping leg wounds and was not on EBP, and staff did not implement EBP during wound care of a pressure ulcer for Resident 17. Also, the facility failed to develop, implement and review a water management plan. These failures placed residents at risk for transmission of disease, antibiotic resistance, water-borne infections, and unintended health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dignified dining experience for 4 of 6 sampled residents (Resident 1, 6, 9, 45) reviewed for dining. The failure to provide clothing protectors per the residents' preferences during meal service placed the residents at risk for embarrassment, humiliation, and an undignified dining experience.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medications prior to administration of the first dose, as required, for 3 of 5 sampled residents (Resident 19, 21, 333) reviewed for unnecessary medications. This failure placed the resident and representative at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare Part A.) for 2 of 3 sampled residents (46, 62) reviewed for beneficiary notice requirements. This failure placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to receive unopened mail for 6 of 6 sampled residents (Resident 1,19,29, 42, 45, 47) reviewed for privacy. This failure resulted in a lack of privacy and potential diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss, and to reimburse the resident timely for the loss of a cell phone for 1 of 3 sampled residents (Resident19) investigated for personal property. This failure caused the resident to replace their cell phone from their own funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR) were completed or implemented as required for 2 of 6 sampled residents (Resident 12, 21) reviewed. Resident 21 did not have a PASARR completed prior to admission to the facility, and Resident 12 had Level II behavioral health recommendations that were not implemented. This failure placed the residents at risk for a decline in their mental health and a decrease in their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions were followed for 3 of 4 sampled residents (Resident 39, 54, 67) reviewed for care planning. Failure to follow the care planned interventions regarding positioning, mobility, and displays of affection placed residents at risk for unmet care needs and decreased quality of life and caused other residents to be uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for 1 of 2 residents (Resident 56) and failed to honor discharge preferences for 1 of 2 residents (79) reviewed for discharge planning processes. These failures placed the residents at risk for lack of necessary care and services, an unsafe living environment, and dissatisfaction with their living situation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with assistance completing their activities of daily living (ADLs) for 2 of 4 sampled residents (Resident 60, 75) reviewed. Specifically, Resident 60 was not provided showers and assistance, cueing, supplements and referrals necessary to promote their nutrition, and Resident 75 was not provided showers. This failure put residents at risk for skin breakdown, unintended weight loss and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received an ongoing program of activities that met their interests for 1 of 2 sampled residents (Resident 54) reviewed for activities. This failure placed the residents at risk for social isolation, mental decline, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a bowel management protocol when indicated for 2 of 3 residents (Resident 21, 75) reviewed for constipation. This failure placed residents at risk for worsening conditions, and unintended health consequences when unable to have bowel movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a vision appointment for 1 of 1 sample residents (Resident 59), reviewed for vision services. This failure placed the resident at risk for worsening vision and decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to remove a urinary catheter (a small flexible tube inserted into the bladder to drain urine) and provide bladder training as ordered for 1 of 1 sampled residents (Resident 2), reviewed for catheter use. This failure placed the resident at increased risk of acquiring potentially preventable catheter associated urinary tract infections and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health care services for 1 of 1 sampled residents (Resident 80), reviewed for behavioral health. This failure placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 5 sampled residents (Resident 9, 78) observed during 32 medication opportunities, that resulted in an error rate of 9.38 percent. The failure to administer medications correctly placed the residents at risk for receiving subtherapeutic effects of their medications and possible adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure controlled medications were properly stored in 1 of 2 medication storage rooms (North Medication Room), and expired medications were removed from 1 of 2 medication rooms (South Medication Room) and 1 of 2 medication carts (North Medication Cart), reviewed for medication storage. These failures placed the residents at risk for receiving medications with decreased efficacy and increased the risk for diversion of controlled substances.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager had the required credentials. This failure placed all resident at risk for receiving dietary services that did not provide the necesary nutritional requirements and foods prepared according to industry standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable, attractive meals at a safe and appetizing temperature for 6 of 8 sampled residents (1, 9, 26, 42, 47, 338) reviewed for food. These failures placed the residents at risk for unplanned weight loss and dissatisfaction with their dining experiences.

Inspectors wroteBased on interview and record review, the facility failed to provide at least three meals daily for 1 of 1 sampled residents (42), reviewed for frequency of meals. Specifically, Resident 42 attended outside medical appointments every Monday, Wednesday and Friday and did not return to the facility for the regularly scheduled evening meal. This failure placed the resident at risk for unplanned weight loss, and nutritional deficits.

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate with the hospice provider about bathing services for 1 of 1 sampled residents (Resident 15), reviewed for Hospice services. Specifically, Resident 15 did not receive a shower or sponge bath from either the Hospice or facility staff for over 7 weeks, due to a scheduling error. This failed practice placed the resident at risk for skin breakdown and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to act timely after altercations between Resident 1 with a roommate (Resident 2) for 1 of 4 sampled residents (Resident 1), reviewed for abuse. Resident 1 experienced verbal abuse and psychosocial harm evidenced by anxiety, tearfulness, lack of sleep, and expressed fear and not feeling safe in the facility because of their roommates' behaviors. This failure placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently implement interventions to reduce fall hazards, monitor for intervention effectiveness, and modify interventions when necessary for 1 of 3 sampled residents (Resident 4), reviewed for falls. This failure resulted in Resident 4 sustaining repeat falls and placed residents at risk for avoidable accidents, significant injury, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide trauma informed care by ensuring trauma survivors were appropriately assessed, implement trauma care plans with potential triggers identified to prevent potential re-traumatization, and limit a resident's exposure to potential trauma triggers for 1 of 1 sampled residents (Resident 3), reviewed for trauma informed care. This failure placed residents at risk of becoming retraumatized, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop and implement person-centered care plans with individualized interventions to address behaviors for 1 of 2 sampled residents (Resident 2), reviewed for dementia care. This failure placed residents at risk of increased behaviors, unmet needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to identify verbally and physically aggressive resident to resident incidents as potential abuse, and report incidents to the State Survey Agency as required for 4 of 6 sampled residents (Resident 3, 4, 5, and 6), reviewed for abuse. In addition, the facility failed to identify a missing wallet with contents as potential misappropriation of resident property, and report the incident to the State Survey Agency as required for 1 of 6 sampled residents (Resident 2), reviewed for abuse. These failures placed residents at risk of potential abuse, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure facility-initiated discharges had a valid basis for discharge, and the discharge documentation included the required components 2 of 3 sampled residents (Resident 1 and 2), reviewed for facility-initiated discharge. These failures placed residents at risk of discontinuation of medical services, untreated conditions, unsafe living conditions, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently monitor tolerance to dialysis (procedure to remove fluid and waste from the body when the kidneys stop working properly) treatments and collaborate care with the dialysis center for 1 of 3 sampled residents (Resident 1), reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information, including information for agency and contract staff, was correctly electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for Quarter 3 of 2023, reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 2 of 3 sampled residents (1 and 2) reviewed for abuse. This failure placed residents at risk for possible abuse. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility educated, completed substantial training, and began monitoring compliance for reporting of allegations of abuse, by 03/06/2024, of staff. The facility was notified of the past non-compliance on 03/07/2024.

Inspectors wroteBased on interview and record review the facility failed to consistently assess fall risk, timely initiate fall care plans and implement new safety interventions for 2 of 4 sampled residents (Resident 1 and 2), reviewed for falls. Resident 1 sustained repeat falls when safety interventions were not initiated timely. This failure placed residents at risk for potentially avoidable accidents, injuries, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor for a potential injury, for 4 of 6 residents (1, 2, 3 and 4), who experienced falls at the facility. Failure to monitor for the development of injuries after a fall, placed the residents at risk for a delay in treatment and possible decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement identified safety interventions and consistently provide adequate supervision to ensure resident safety for one of three sample residents (Resident 1) reviewed for accidents. This failure placed Resident 1, as well as other residents at risk for avoidable injury.

Inspectors wroteBased on interview, and record review, the facility failed to provide pain medication timely for one of three sampled residents (1), reviewed for pain. This failure placed the resident at risk for inadequate pain control and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and intervene timely for 2 of 2 sample residents (9, 17), who experienced changes related to medication management. These failures caused actual harm to Resident 9, a resident with mental health diagnoses, who did not receive necessary medication secondary to required lab work not being completed and experienced anxiety, inadequately controlled insomnia, and a diminished quality of life, and placed Resident 17 at risk for worsening symptoms of heart failure.

Inspectors wroteBased on interview and record review, the facility failed to provide annual abuse training for 6 of 7 staff (G, H, I, J, K and L), reviewed for abuse training. These failures placed residents at risk for potential abuse and neglect related to untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of misappropriation for 2 of 5 sample residents (8, 6), and potential physical abuse for 2 of 5 sample residents (21, 15), were reported immediately to administration and the State Survey Agency as required, and that allegations of neglect were reported within 24 hours to the State Survey Agency for 1 of 5 sample residents (12). These failures placed the residents at risk for potential additional abuse, neglect, and misappropriation.

Inspectors wroteResident 15 Per the 11/18/2022 admission assessment, Resident 15 was able to make decisions regarding their care, and needed assistance from one to two staff to complete activities of daily living, such as toileting and turning in bed. Review of a grievance form dated 12/16/2022 at 1:23 PM showed Resident 15 had reported to Staff GG, Occupational Therapist, that a male staff (unnamed) that worked night shift was not respectful when assisting them with care. In addition, the form stated the staff member had been suspended pending an investigation, and education had been provided on how to treat residents. Review of the facility's mandatory reporting log showed that no entry related to Resident 15's allegation of abuse had been made, and no documentation was found or provided to show the facility had investigated the allegation of potential abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of a comprehensive assessment (an assessment tool used to identify a resident's specific care needs), for 1 of 1 sample residents (11), reviewed for hearing deficits. Failure to accurately assess the resident's hearing needs placed them at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet resident's medical, nursing, mental and psychosocial needs for 5 of 9 sample residents (21, 39, 9, 457, 11), reviewed for care plans. Failure to have resident specific interventions for mood, behavior, skin, and smoking placed the residents at risk for accidents, worsening wounds, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents and/or their representatives the opportunity to participate in the development of their care plan for 4 of 5 sample residents (16, 28, 6, 46), reviewed for care planning. In addition, the facility failed to ensure care plan interventions were implemented for 1 of 2 sample residents (17) reviewed for edema. These failures placed the residents at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide showers for 5 of 5 sample residents (39, 21, 36, 37, 6), nail care for 3 of 5 sample residents (39, 21, 36), and shaving for 1 of 5 sample residents (37), reviewed for dependent residents requiring assistance with activities of daily living (ADL). These failures placed the residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a system to maintain records for controlled drug reconciliation for 1 of 2 medication rooms. This system failure placed the facility at risk of untimely identification of drug diversion from the facility's emergency medication kit (E-kit).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 6 staff (M, Y, JJ, KK, LL, MM), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by a virus which is characterized mainly by a fever and cough, and is capable of progressing to severe symptoms and in some cases death). In addition, the facility failed to ensure fit testing (a test done to ensure an N-95 mask formed a tight seal) was completed for 4 of 6 staff (M, JJ, KK, NN), reviewed for fit testing, which also placed residents and staff at risk for contracting COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive antibiotic stewardship program was developed and implemented, to prevent 1 of 3 sample residents (8), reviewed for antibiotic use, from receiving inappropriate antibiotics. This failure placed the resident at risk to receive unnecessary antibiotics with potential adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a completed Physician's Order for Life-Sustaining Treatment [POLST] (a form which instructed medical staff what treatment the resident wished to have done in the event they were seriously ill or their heart stopped beating), for two of three sample residents (32, 17), reviewed for advance directives. This failure placed the residents at risk for not having their wishes and choices regarding end-of life care honored.

Inspectors wroteBased on interview and record review, the facility failed to inform 2 of 3 sample residents (6, 18), reviewed for beneficiary notification, of their potential liability for payment related to Medicare services ending. This failure placed the residents at risk of not having adequate information to make financial decisions regarding their continued stay at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 sample residents (11), reviewed for communication. This failure had the potential to compromise Resident 11's ability to reach the highest practical well-being, meet their hearing needs, and dimish their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report a resident fall to other staff, monitor the resident for injury, complete a thorough and timely investigation, and implement interventions to prevent additional falls for 1 of 3 sample residents (17), investigated for accidents. This failure placed the resident at risk for continued falls.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures with required timelines for monthly drug regimen reviews for 1 of 5 sample residents (9), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications, adverse side effects and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store refrigerated medication under proper temperature controls for 3 of 3 refrigerators containing medications. This failure placed residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily menu and alternative menu were provided for 4 of 7 sample residents (16, 6, 28, 21), reviewed for meals. This failure denied the residents the right to choose their meal preference, and had the potential to negatively affect their nutritional needs and create a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was offered an influenza and/or pneumococcal immunization as required for 3 of 5 sample residents (17, 18, 45), reviewed for immunizations. This failure prevented the residents from making decisions about their care, and placed the residents at risk for illness, and possible health complications.