Autumn Lake Healthcare at Birch Manor

Inspectors wroteThe facility failed to maintain an effective pest control program, which included a failure to seal gaps and holes, or prevent rodents from entering Residents' (R) rooms. As a result, R6 and R13 experienced disrupted sleep at night due to mouse infestation. This was evident for four sampled Residents (R6, R11, R12, and R13) living on the third floor, the facility census was 108. Findings Include: 1. Review of facility policy titled Pest Control Program dated 12-28-2022 and last revised on 10/27/2025 documented that it was the facility policy to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a reporting system of issues that may arise between scheduled visits with the outside pest service and treat them as indicated. [...]

Inspectors wrote2) Review of Resident #59's medical record on 6/6/25, revealed the resident has resided at the facility for several years and had a MDS assessment with an assessment reference date (ARD) of 3/25/25. Further review of the medical record failed to reveal documentation to indicate a care plan meeting had occurred following the March MDS assessment. On 6/6/25 at 3:23 PM an interview with Staff #26 revealed she is sent the MDS dates and her process was to write down every name she sees and then calls the family to schedule a meeting. If she gets a call back then she schedules a meeting. When asked what happens if no call back, Staff #26 stated : usually have a meeting with the unit manager. She went on to indicate she would invite the resident, if deemed capable, and the family. She reported the notification to the resident would be verbal and family notification would be via voice mail. [...]

Inspectors wroteBased on review of resident council meeting notes and interviews it was determined that the facility failed to have an effective system in place to ensure grievance/concerns expressed during Resident Council were addressed and followed up on. This was found to be evident for three out of the past seven months of resident council meeting minutes reviewed.

Inspectors wrote4. On 6/5/25 at 9:36 AM Resident #76 was observed in bed, the resident replied to surveyor greeting with a thumbs up but did not verbally respond. Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year and was totally dependent on staff for activities of daily living such as dressing, eating, transferring from bed to wheelchair and mobility. According to the resident's care plan, the resident had a communication problem related to expressive aphasia (unable to communicate verbally) but was able to communicate by pointing and gestures. On 6/9/25 a further review revealed it was very important to the resident to listen to music s/he likes and to do things with groups; it was somewhat important to be around animals, keep up with the news, go outside to get fresh air when the weather is good and attend religious services. [...]

Inspectors wrote3) On 6/5/25 at 9:36 AM Resident #76 was observed in bed, the resident replied to surveyor greeting with a thumbs up but did not verbally respond. Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year and was totally dependent on staff for activities of daily living such as dressing, eating, transferring from bed to wheelchair and mobility. According to the resident's care plan, the resident had a communication problem related to expressive aphasia (unable to communicate verbally) but was able to communicate by pointing and gestures. On 6/9/25 review of the annual MDS assessment, dated 2/10/25, revealed an interview was conducted with the family, or significant other, for Section F Activities. This assessment revealed it was very important to the resident to listen to music s/he liked and to do things with groups; [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to maintain safe and sanitary conditions to prevent the spread of infection. This has the potential to affect all residents.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure quarterly statements for personal funds were provided to the residents. This was evident in 1 (Resident #54) of 1 resident reviewed for personal funds.

Inspectors wrote2.) On 6/4/25 at 1:37 PM the surveyor observed the spa room on the third floor and noted cracked tile and discoloration in the two shower stalls. On 6/09/25 at 12:35 PM an observation of the spa room on the first floor revealed an out of order sign on one of the three showers. The shower was noted to have a missing shower head and multiple missing tiles. On 6/11/25 at 11:31 AM the Maintenance Director (Staff #8) reported staff informed him of maintenance concerns both verbally and in a maintenance log on each unit. He reported the maintenance logs are checked twice a day. In regard to showers, Staff #8 reported there are six that were currently working and two that were down, but that the one that was out of order on the first floor would be ready later today. [...]

Inspectors wroteBased on document review and interview it was determined that the facility failed to implement their grievance policy. This was evident for two (# 16, #517) of two residents reviewed for personal property during the survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to report allegations of abuse. This was evident for one (Resident #50) out of three investigated for Abuse.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to investigate allegations of abuse. This was evident for one (Resident #50) out of three investigated for Abuse.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to provide written notice of the bed hold policy and transfer to the resident's responsible party; and failed to ensure all required information was included in the forms currently being used to provide notification of transfer and bed hold. This was found to be evident for one (Resident #76) out of four residents reviewed for hospitalization during the survey.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#94) out of 2 Residents reviewed for dental care.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure staff provided medication as ordered. This was found to be evident for one (Resident #59) out of five residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to have an order to monitor a resident's air mattress. This was found to be evident for one (Resident #76) of four residents reviewed for pressure ulcer care and prevention.

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice for tracheostomy residents. This was evident for one (Resident #109) of two residents reviewed for respiratory care during this survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide routine dental services to a Medicaid funded residents. This was evident in 1 (Resident #71) of 1 resident reviewed for dental care.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 out of 3 units observed during the recertification survey.

Inspectors wrote1) Review of Resident #59's medical record revealed the resident had resided at the facility for more than a year. The resident was seen regularly by a primary care physician and a nurse practitioner in addition to a pain management nurse practitioner. a. A review of a note written by physician (Staff #30) for a visit on 4/25/25 revealed the visit was a monthly follow-up for ongoing management of dementia with behavioral disturbance, mood disorder, chronic pain and kidney disease. The section titled Plan included the following: Lorazepam 0.5 mg TID [three times a day] PRN [as needed] for anxiety. This Lorazepam (also known as Ativan) order indicated the resident was to receive the medication only when the resident was experiencing symptoms of anxiety and staff would be expected to document the symptoms and the effectiveness of the medication. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the development and ongoing implementation of a facility-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program that included at least one current Performance Improvement Project (PIP) in the past 12 months.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings.

Inspectors wroteBased on record review, observation, and interviews it was determined that the facility failed to ensure that critical medical equipment was plugged into generator power supplied outlets. This was evident for one (Resident #102) out of two residents reviewed for respiratory care.

Inspectors wroteF584 - §483.10(i) Safe Environment S/S: E Regulation: §483.10(i) mandates a safe, clean, comfortable, and homelike environment, which includes exercising reasonable care for the protection of residents' property from loss or theft. This requirement obligates the facility to document and secure residents' belongings through an inventory system upon admission, during the resident's stay, and at discharge, with a signed acknowledgment by the resident or their representative. F584 - Honor the resident's right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. [...]

Inspectors wroteF609: Reporting S/S= D Based on observation, record review and interviews during a complaint survey, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than two hours to the state survey agency (Office of HealthCare Quality) for 2 (Residents #5 and #33) of 12 reportable incidents reviewed. Specifically, when Resident #33 was observed with an injury of an unknown origin on 1/4/22, it was not reported to the state survey agency until 1/6/22 and when Resident #5 was observed with injuries of an unknown origin on 10/9/24, the facility did not report the injury.

Inspectors wroteBased on medical record review and resident and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission. This was evident for 2 (#224, #63) of 2 residents reviewed for care plans, 2 (#45, #228) of 5 residents reviewed for hospitalization, and 1 (#227) of 1 residents reviewed for hospice

Inspectors wroteBased on medical record review and observation, it was determined the facility staff failed to review and revise care plans for Resident #27 to reflect accurate and appropriate interventions for (elevated cholesterol) and the facility staff failed to provide the interventions as indicated on the care plans (suction at the bedside, floating of bilateral heels at all times and pillows between skin to skin) for Resident #27. This was evident for 1 of 3 residents selected for review of care plan participation during the annual survey process.

Inspectors wroteBased on medical record review, observation, and interview with facility staff, it was determined that the facility failed to 1. void a resident's MOLST form when an updated MOLST form was completed (#45, #228, #227, #224) 2. transcribe a medication from a physician order correctly (#19) and 3. have documentation that pharmacy consults were completed and on the chart. (#31) This was evident for 6 of 55 residents reviewed during the annual survey.

Inspectors wroteBased on a random observation of interactions between activity staff and a resident, it was determined that facility staff failed to interact with a resident in a respectful manner by speakling loudly but not changing her position to bend down when speaking so that the resident, who was seated in a chair, was able to better understand/hear what she/he was saying to them.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the physician of a sudden weight gain for Resident #60. This was evident for 1 of 6 residents reviewed for nutrition and 1 of 55 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview with the facility staff, it was determined that the facility failed to document timely notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare. This was evident in 1 of 3 (#66), residents reviewed regarding liability notices.

Inspectors wroteBased on the review of a facility reported incident involving a fall, observations, and medical record review, it was determined that the facility failed to provide privacy for a resident during activities of daily living (ADL) care.

Inspectors wroteBased on surveyor observation throughout the annual recertification survey, it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior. This was evident for resident rooms, the dining room and activity room.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to document the transfer of a resident in the medical record including the reason for the transfer and information provided to the receiving provider to ensure a sae and effective transition of care. This was evident for 1 (#45) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#228, #45) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 2 of (#45, and #80) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#228) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Resident #59). This is evident for 1 of 2 residents selected for review during an annual survey.

Inspectors wroteBased on medical record, interview and observation, it was determined the facility staff failed to provide care to Residents (#42 and #60) in order to promote the highest practicable well-being. This was evident for 1 of 4 residents selected for review of medication pass and 1 of 26 opportunities for error and 1 of 55 residents selected for review during the annual survey.

Inspectors wroteBased on medical record and observation, it was determined the facility staff failed to apply hand splint and knee brace as ordered for Resident #27. This was evident for 1 of 1 residents selected for review of limited motion during the annual survey process.

Inspectors wroteBased on medical record review and observation, it was determined the facility staff failed to provide Resident #2 with ice cream consistently and failed to provide Resident #2 with chicken/tuna sandwiches on lunch tray as indicted on the meal tray ticket and failed to obtain a weight as ordered, failed to provide a blue adaptative mug with a handle and failed to provide a morning snack for Resident #31. This was evident for 2 of 6 residents selected for review of nutrition 2 of 7 residents selected for review of food during the annual survey.

Inspectors wroteBased on medical record review, it was determined the facility staff failed to ensure residents (#27, #31 and #35) were free from unnecessary medications. This was evident for 1 of 5 residents selected for review of unnecessary medication review and 2 of 55 residents selected for review during the annual survey.

Inspectors wroteBased on observations, it was determined the facility staff failed to date medications upon opening them and removed expired medications. This was found to be evident for 2 out of 3 medication carts reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and observation, it was determined the facility failed to ensure that a resident noted with a lactose intolerance did not receive milk on the food tray (Resident #2). This was evident for 1 of 7 residents selected for review of food and 1 of 6 residents selected for review of nutrition during the survey process.

Inspectors wroteBased on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have an updated facility assessment to include information relevant to the needs of the residents the facility serves.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident for 1 resident bathroom observed on the 1st floor of the facility.

Inspectors wroteBased on a review of a self reported incident submitted by the facility, it was determined that staff #23 had not received training, although permitted to work in the facility. This was true for 1 out 1 employee reviewed for allegations of abuse.

Inspectors wroteBased on medical record review and resident and staff interview, it was determined the facility failed to develop a base line care plan within 48 hours of a resident's admission. This was evident but not limited to 3 of 31 residents in the final sample. (#109, #83, #92)

Inspectors wrote3) Observations of resident #13, on 7/26/18, revealed resident lying in bed with noted bilateral hand contractures. (A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints.) The resident was not noted to have any type of hand and or arm splints applied to hand contractures. Review of the physicians' orders revealed an order, written on 1/26/18, as Bilateral resting hand splints to be worn 6 hrs.on/6 hrs. off as tolerated per 24 hr. period. Skin checks to be performed when splints are removed. Monitor for positioning during wear time. Additional orders related to contractions were written as Increase Bivalve cast to left arm 1 hour per day (until 6 hours) or as much as tolerated until next appointment every shift. [...]

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to evaluate resident care plans. This was evident for 6 (#43, #44, #70, # 93, #111, #91) of 45 residents investigated during the annual survey.

Inspectors wrote4. The facility failed to maintain a medical record in the most complete and accurate form for resident #30. Melatonin is a dietary supplement use to promote a normal sleep pattern. Ambein is used to treat insomnia. Review of the Resident # 30's medical record, on 8/2/18 at 9AM, revealed the resident was admitted to the facility on [DATE]. A care plan was initiated on 4/27/18 for insomnia. According to the care plan, the resident was receiving Ambien for Insomnia. Continued review of the medical record revealed the resident was ordered Melatonin for Insomnia not Ambien. During interview with the Unit Manager on 8/3/18 at 9:30AM, he/she stated the Ambien was entered in error. Based on medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records. [...]

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to monitor a reach-in freezer to assure safe storage of ice cream in the freezer. This was evident during a follow-up tour of the kitchen.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the physician of a significant weight loss. This was evident for 2 (#73, #81) of 4 residents reviewed for nutrition.

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to provide housekeeping and maintenance services to keep the resident's environment clean and in good repair. This was evident on 3 of 3 nursing units.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#29, #90, #103, #70, # 97) of 45 residents reviewed.

Inspectors wroteBased on surveyor observation, review of the medical record, hospital records and interviews with staff, it was determined that the facility staff failed to provide quality of care and services in accordance with the resident's goals for care and professional standards of practice to meet each resident's physical, mental and psychosocial needs. This was evident for 2 (#97 and #91) of 56 residents reviewed.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (#70) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview, and facility documentation review, it was determined that the facility failed to 1) ensure that medication and treatment carts were locked when unattended, 2) failed to discard medications after the expiration date and 3) failed to date medications once opened. This was evident for 2 of 3 nursing unit hallway observed, of 2 medication carts observed and on 1 of 2 nursing units observed.

Inspectors wroteReview of the Dishwasher Checklist for the month of May revealed that the facility failed the monitor the water temperatures and chlorine sanitation levels for the last 11 days for the month of May. At 11:50 AM, the food service manager (staff#7) was asked to show how they test for proper chemical sanitation. The food service manager obtained the vial of chorine test strips and ran a plate pellet through the dishwasher and placed the test strip into a small puddle of water remaining on the plate pellet. The food service manager revealed a 0 level of sanitation. The food service manager had utilized another test strip and got the same result of 0 chlorine sanitation level. The food service manager then replaced the chlorine sanitation bottle with a new bottle of chlorine sanitizer. [...]

Inspectors wroteBased on medical record reviews and interviews with staff, it was determined that the facility staff failed to implement the facility developed POC (plan of correction) from the annual survey (2017). Quality Assurance (QA) encompasses all managerial, administrative, clinical, and environmental services. It is an organizational structure, processes, and procedures designed to ensure that care practices are consistently applied and is responsible for identifying quality concerns and developing and implementing plans of action to correct these quality concerns and measure the outcomes of the process over time.

Inspectors wroteBased on review of facility documentation and interview with staff, it was determined that the facility failed to have a system to monitor antibiotic use. This has the potential to affect all residents. The evidence includes: During a review of facility infection prevention logs that took place with the Infection Preventionist at 8/2/2018 at 1:45 PM, no evidence was found of a system to monitor current use of antibiotics in the facility. This was confirmed by one of the corporate nurses on 8/2/2018 at 2:15 PM. This concern was reviewed with the Director of Nursing and corporate staff during survey exit.

Inspectors wroteBased on resident and staff interview and medical record review, it was determined the facility failed to include the resident and the resident's representative in the development and implementation of the resident's person-centered care plan after a significant change assessment by failing to have a care plan meeting to review the updated care plan. This was evident for 1 (#29) of 4 residents reviewed for care plan meetings.

Inspectors wroteBased on observation, staff interview and medical record review, it was determined that the facility staff failed to ensure access to the nurse call bell for a resident who was totally dependent on nursing staff for daily care due to impaired mobility. This was evident for 1 (#43) of 45 residents investigated during the annual survey.

Inspectors wroteBased on resident observation, review of the medical record and interview with staff, it was determined that the facility staff failed to notify the resident and/or the resident's representative before a room change. This was evident for 1 of 56 residents reviewed.

Inspectors wroteBased on record review, interview the resident, and the facility staff, it was revealed the facility failed to provide quarterly statements (Resident #66). This is evident for 1 of 1 residents selected for review.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to report an injury of unknown origin to the State Survey Agency. This was evident for 2 (#73, #111) of 15 residents reviewed for abuse.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to thoroughly investigate an injury of unknown origin and report it to the to the State Survey Agency within 5 working days of the incident. This was evident for 1 (#73) of 15 residents reviewed for abuse.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to document the emergent discharge of a resident in the medical record including the reason for the transfer and information provided to the receiving provider to ensure a safe and effective transition of care. This was evident for 2 (#73, #262) of 13 residents reviewed for hospitalization.

Inspectors wrote4) Review of the medical record for resident #13 on 7/30/18 revealed the resident was sent to the hospital for pneumonia and septic shock on 6/18/18. Further review of the medical record failed to produce written evidence that the responsible party was notified in writing of the transfer. 5) Review of the medical record for resident #108 revealed that resident #108 was transferred to the hospital on 6/10/18. Continued review of the medical record did not reveal evidence that the resident or resident's responsible party was notified in writing of the transfer. Interview of the Administrative team on 8/1/18 at 4:45 PM confirmed that the facility has not been providing the written documentation as per the regulatory requirement. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This is identified for 2 (#73, #108) of 13 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed, encoded and electronically transmitted to the CMS System. This was evident for 1 (#1) of 4 residents reviewed for resident assessments for a discharge during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and signed by a registered nurse. This was evident for 1 (#1) of 4 residents reviewed that had been discharged from the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of the residents, and failed to develop a resident centered care plan related to activities with achievable goals and measurable objectives. This was evident for 2 (#70, #103) of 4 residents reviewed for dementia care.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 2 (#43,#13 ) of 4 residents reviewed for mobility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to keep a resident's environment free from accident hazards. This was evident for 1 (#81, #92) of 5 residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to conduct an in-depth assessment for a resident's urinary incontinence. This was evident for 1 (#81) of 2 residents reviewed for bladder incontinence.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to 1) timely assess a resident with weight loss, 2) immediately notify the physician, dietician and family of unplanned significant weight loss and 3) failed to revise a care plan for nutrition when weight loss was recognized. Failure of the facility staff to immediately assess and notify the physician and dietician of weight loss delayed interventions that the physician could have put in place at the first sign of weight loss. This was evident for 1 (#73) of 3 residents reviewed for nutrition.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that the physician reviewed a resident's plan of care which included treatments, and signed off that the treatment was appropriate for the resident. This was evident for 1 (#44) of 2 residents reviewed for bladder incontinence.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to provide a resident centered dementia treatment and services plan by failing to create and implement resident centered care plans with achievable goals, measurable objectives and evaluations related to daily activities. This was evident for 2 (#70, #103) of 4 residents reviewed for dementia care.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility pharmacist failed to identify and report irregularities in the resident's drug regimen to the physician, facility's medical director and the director of nursing. This was evident for 2 (#70, #107) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility ordered and administered an excessive amount of Tylenol to Resident #107. This was true for 2 of 6 residents reviewed for pain medication regimen.

Inspectors wroteBased on surveyor observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 2 of 32 resident call light observations.

Inspectors wrote4) Review of the medical record for resident #13 on 7/30/18 revealed that the resident was sent to the hospital for pneumonia and septic shock on 6/18/18. Further review of the medical record failed to produce written evidence that the responsible party was given written notice of the bed hold policy. 5) Review of the medical record for resident #108 during the survey revealed that resident #108 was transferred to the hospital on 6/10/18. Continued review of the medical record did not reveal evidence that the resident or resident's responsible party was given written notice of the bed hold policy. Interview of the Administrative team, on 8/1/18 at 4:45 PM, confirmed that the facility had not been providing the written documentation as per the regulatory requirement. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care. This was evident on 2 of 3 nursing units observed during the start of the annual survey.

Inspectors wroteBased on observations and staff and resident interviews, it was determined that the alternate food choices are not communicated to the residents in advance. This is evident on 3 of 3 nursing units.