Autumn Lake Healthcare at Loch Raven

Inspectors wroteBased on medical record review and facility staff interview, the facility staff failed ensure that residents, who are unable to ambulate using stairs, are able to exercise their right to have visitors during their stay when the facility's only elevator malfunctioned. This was evident for all residents who have 2nd floor rooms and are unable to ambulate the stairs. These residents were reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, facility staff failed to assess residents (#1, #11, #13, #15, and #16) for smoking safety at least once every three (3) months between comprehensive assessments. This was evident for 5 out of 10 residents reviewed for smoking safety during the facility's complaint survey.

Inspectors wroteBased on a review of documentation and interviews it was determined that the facility staff failed to complete a thorough investigation of incidents reported to the state agency. This deficient practice was evidenced in 2 (Resident #1 and Resident #2) of 7 investigations reviewed during the complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to complete a person-centered care plan for residents that received peritoneal dialysis (#7) and had mobility limitations (#6) . This deficient practice was evidenced in 2 (#6 and #7) of 16 medical records reviewed for person centered care plans.

Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to document whether a resident refused a shower. This deficient practice was evident in 1 (#5) of 1 medical record reviewed for ADL care during the complaint survey.

Inspectors wroteBased on a review of the staffing sheets and interview it was determined that the facility staff failed to include the census on the unit when the staff sheets were completed. This deficient practice was evidenced in 19 of 19 staffing sheets reviewed during the complaint survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and staff interviews, it was determined that the facility failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for 1) the initial observation of the kitchen upon facility entry, and 2) 1 of 1 observation of the second floor nourishment room. This failure has the potential to affect all residents.

Inspectors wroteBased on observations, medical record reviews, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was found to be evident during the recertification survey. This deficiency has the potential to affect all residents.

Inspectors wroteBased on a tour of the second floor medication storage room and staff interview, it was determined that the facility failed to discard expired supplies. This was evident for 1 of 1 medication storage rooms that were reviewed during the annual survey.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to treat dependent residents with dignity while dining. This was evident for 1 (Resident #41) of 2 dependent residents observed during the dining observation, a facility task in the recertification survey.

Inspectors wroteBased on interviews, it was revealed the facility failed to provide quarterly financial statements. This was found to be evident for 1 (Resident #10) out of 3 residents reviewed for accounting and records during the recertification survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to protect residents' clothing from loss. This was evident for 1 (Resident #13) out of 3 residents reviewed for loss of personal property during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure that residents were free of exploitation. This was evident for 1 (#114) of 5 residents reviewed for misappropriation of resident property.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to create and implement a baseline care plan for 1) a resident with a stage 4 sacrum pressure ulcer and 2) a resident with Chronic Myeloid Leukemia (CML) requiring chemotherapy medication. This was found to be evident for 2 (Resident #73 and Resident #7) of 5 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to revise resident's care plan after a change in condition. This was evident for 1 resident (Resident #3) out of 2 residents reviewed for hospitalization after a change in condition during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to follow a physician's order. This was evident for 1 (#111) of 2 residents reviewed for pain management.

Inspectors wroteBased on surveyor observation, review of the medical records, and interview with facility staff, it was determined the facility failed to provide quality care to residents by 1) not following physician orders for oxygen therapy and 2) not reporting a change in condition. This was found to be evident for 2 residents (Residents #45 and #47) out of 4 residents observed on oxygen therapy and 1 resident (Resident #115) of 2 residents reviewed for pressure ulcer complaints during the facility's recertification survey.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility 1) failed to provide services for pressure ulcer for a new admission and 2) to document and provide ordered treatment to promote healing of pressure injuries. This was found to be evident for 2 (Resident #115 and Resident #113) of 4 residents reviewed for pressure injuries during the survey.

Inspectors wroteBased on observations, interview with staff, and record review, it was determined that the facility failed to implement an intervention, determined to be necessary, for residents who were identified as a fall risk. This was evident of 2 of 5 residents (Resident #11 and Resident #55) reviewed for accidents during the annual survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record reviews, and interviews, it was determined that facility staff to 1.) ensure safe and sanitary storage of dialysis equipment and supplies, 2.) establish dialysis specific infection control policy, and 3.) assess and document care of peritoneal catheter access site. This deficient practice was evident for 2 (#17, #55) of 2 residents reviewed for dialysis during the annual survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility staff failed to conduct annual nursing aide performance reviews. This deficient practice was evident for 2 out of 5 nursing aide annual performance reviews, reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that staff failed to ensure that a resident did not have unnecessary medications. This was evident for 1 (#111) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review and interviews, it was determined that the facility failed to serve residents meals based on their meal tickets. This was evidence for 3 residents (Resident #6, #40, and #14) out of 8 residents observed during dining.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to 1) maintain medical records on residents that are complete and accurately documented and 2) validate the signature on a bed hold policy form and included conflicting information regarding the resident's ability to sign the document. This was evident for 1 resident (Resident #3) out of 2 residents reviewed for hospitalization and 1 (Resident #111) of 6 residents reviewed for unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility failed to provide the required Quality Assurance and Performance Improvement (QAPI) training to staff. This deficient practice was evident in 5 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility failed to provide the required Infection Control training to staff. This deficient practice was evident in 3 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility failed to provide the required Compliance and Ethics training to staff. This deficient practice was evident in 3 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility failed to provide geriatric nursing assistants (GNA) with the required minimum of 12 hours of annual in-service training. This deficient practice was evident in 5 out of 5 GNA employee files reviewed during the annual survey.

Inspectors wroteBased on interviews and administrative record reviews, it was determined that the facility failed to provide the required Dementia training to staff. This deficient practice was evident in 4 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on complaint, observations, staff interview, and record review, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for when individual room air conditioning systems failed to cool resident rooms. Residents were exposed to ambient temperatures above 81 degrees Fahrenheit. This was evident for 4 (Residents #1, #2, #3, #4) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that resident room hand sanitizing dispensers were functioning properly. This was evident for 8 of 56 rooms reviewed during a complaint survey.

Inspectors wroteBased on observations, resident interview, staff interview, family interview and clinical record reviews, it was determined that the facility staff failed to ensure that wound care was provided to a resident (#274) as ordered, that a resident (#2) received the size catheter that was ordered, that a resident (#225) was provided transportation for an appointment, that a resident (#227) was administered medications on time, that consultant recommendations were followed for a resident (#45), that a resident (#16) received insulin on time as per physician order, and that vital signs were discontinued as ordered for a hospice resident (#57). These deficient practices were evident for 7 (#274, #2, #225, #227, #45, #16, #57) of 43 residents reviewed during the recertification process.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to provide showers per a resident's request (Resident #223). This was evident for 1 of 43 residents reviewed during an annual survey.

Inspectors wroteBased on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #19). This was evident for 1 of 43 residents reviewed during an annual survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to hold a care plan meeting to include the interdisciplinary team, resident and resident's representative quarterly (Resident #45). This was evident for 1 out of 43 residents reviewed during an annual survey.

Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that dependent residents were provided with the necessary services to maintain clean and trimmed fingernails. This was evident for 1 (#14) of 6 residents reviewed for activities of daily living (ADL). ADLs are tasks of everyday life. Examples of ADLs include dressing, bathing, grooming, and toileting. Nail care would fall under this category.

Inspectors wroteBased on medical record review and interview, the facility staff failed to obtain ophthalmology services for a resident (Resident #45). This was evident for 1 of 43 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #15, #45 and #324). This is evident for 3 of 5 residents reviewed for pressure ulcers during an annual survey.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure that a dietary consult was obtained after a significant weight loss. This was evident for 1 (#10) of 8 residents reviewed for nutritional status.

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined that the facility staff failed to ensure that a tube feeding container was labeled. This was evident for 1 (#2) of 3 residents reviewed for tube feedings.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to provide dialysis care consistent with professional standards of practice and ordered by the physician (Resident #231). This was evident of 1 of 3 residents reviewed for dialysis during the annual survey.

Inspectors wroteBased on interview and record review, it was determined that the Physician failed to provide timely visit notes to the electronic record system following each visit. This was evident for 1 (Resident #40) out of 5 residents reviewed for urinary catheter care.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility staff failed to ensure Resident # 16's preferences were honored and to provide appropriate foods to meet his/hers needs. This was evident for 1 (Resident #16) out of 2 resident reviewed for food preferences and serving proper food.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#324). This was evident for 1 of 43 residents selected for review during the survey process.

Inspectors wroteBased on staff interviews and record review, it was determined that the facility staff failed to ensure that the infection line listing was updated and that residents that required further review for antibiotic use were reviewed. This was evident for 6 (#66, #273, #223, #63, #276, #45) of 7 residents reviewed for antibiotic use.

Inspectors wroteBased on review of resident medical records, it was found that the facility failed to prepare baseline care plans for residents within 48 hours of a resident's admission. This was evident for 7 (#24, #38, #341, #80, #76, #33, #52) of 7 recently admitted residents. This practice had the potential to affect all newly admitted or readmitted residents. A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on resident and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 17 (#86, #35, #63, #72, #45, #47, #58, #341, #64, #70, #24, #78, #189, #74, #76, #33, #52) of 35 residents reviewed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 1/2/19 at 12:21 PM, an interview was conducted with Resident #86. The resident was asked if he/she had any problems with hearing and the resident stated, I am hard of hearing and I do not wear hearing aids and I would like to know why I can't hear out of the left ear and see what can be done about it. [...]

Inspectors wrote6) Resident #71 was interviewed on 1/2/19 at 9:50 AM. During interview, the resident expressed that he/she was uncertain that s/he wasinvited to attend care plan meetings. Resident #71's medical record was reviewed on 1/10/19. The resident was admitted in December of 2017. Information in the medical record related to care plan meetings was sparse. There was not any quarterly care plan meeting documentation for 2/18, 5/18, and 8/18. There was a care plan meeting sign in sheet with three staff and the resident's surrogate decision maker for 11/18. An interview was conducted with the Unit Manager (staff # 5) at 12:54 PM on 1/10/18. Upon discussion and review of the care plan meeting sign in sheets, staff #5 indicated that there was not/or staff #5 did not know of any more documentation or additional information as to what was discussed in the care plan meeting held in November of 2018. [...]

Inspectors wroteBased on interview with facility staff, it was determined that the facility failed to ensure that the individual designated as the director of food and nutrition services was nationally certified for food service management and safety. This had the potential to affect all residents.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and that kitchen equipment was cleaned and in a sanitary manner. This was evident for 2 of 2 tours of the kitchen performed during the survey.

Inspectors wroteBased on review of facility records, it was determined the facility staff failed to accurately assess the resources necessary to care for its residents during both day-to-day operations and emergencies by failing to accurately assess 1) resident acuity, 2) staffing plan and 3) staff competencies necessary to provide the level and types of care needed for the resident population. This was evident during Sufficient and Competent Nurse Staffing review.

Inspectors wroteBased on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement effective plans of action to correct quality deficiencies identified during the prior annual quality indicator survey.

Inspectors wroteBased on review of facility documentation and interview with staff, it was determined that the facility failed to ensure staff competency by failing to provide required in-service training for nurse aides for no less than 12 hours per year including dementia management, cognitive impairment and resident abuse training. This was evident during Sufficient and Competent Nurse Staffing review.

Inspectors wrote2) Observation was made on 1/8/19 at 2:00 PM of Staff #3 standing to feed Resident #34 in the resident's room. Resident #34 was lying in bed and Staff #3 was standing to the right side of the bed feeding the resident lunch. 3) Observation was made on 1/8/19 at 4:00 PM of Resident #72 sitting in a geriatric chair on the second floor nursing unit. Staff #1 was observed pulling Resident #72 down the first hallway backwards, turned the corner around the nurse's station and then continued pulling Resident #72 down the next hallway backwards until Staff #1 got to the resident's room. 4) Observation was made on 1/10/18 at 10:06 AM of Staff #14 pulling Resident #17 down the hallway backwards. Resident #17 was sitting in a geriatric chair and Staff #14 was taking the resident outside to smoke. [...]

Inspectors wroteBased on surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 2 of 2 nursing units.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 11 (#35, #58, #72, #86, #41, #70, #24, #74, #76, #33, #52) of 35 residents reviewed. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.

Inspectors wroteBased on family and staff interview, observation and medical record review, it was determined the facility failed to provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 2 (#35, #63, #74) of 7 residents reviewed for activities of daily living and for 1 of 2 dining observations.

Inspectors wroteBased on observation of the resident, medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional stands of practice by failing to ensure a resident who was dependent on oxygen had accurate physician orders; failing to ensure a resident's respiratory care supplies were stored in a clean and sanitary manner; failing to ensure a resident's oxygen was administered as ordered, failing to ensure emergency respiratory equipment was maintained at a resident's bedside, failing to ensure a prescribed biological was properly stored, failing to ensure Activities of Daily Living care was provided for a dependent resident and failing to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. [...]

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to ensure that residents remained free from accident hazards and received adequate supervision. This was evidenced by the failure to ensure a resident at risk for elopement received adequate supervision. This was evident for 1 (#10) of 4 residents reviewed for accidents.

Inspectors wroteBased on observations, medical record review, and interviews with facility staff, it was determined that the facility failed to provide residents with respiratory care consistent with professional standards. This was evident for 5 (#24, #63,#74, #52, #189) of 5 residents reviewed for respiratory care during the investigation phase of the survey.

Inspectors wroteBased on review of training records and interview with facility staff, it was determined that the facility failed to ensure a system was in place to track the training that staff nurses received regarding peritoneal dialysis. This had the potential to affect all residents receiving peritoneal dialysis.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain sufficient staff to provide care to residents to maintain the highest practical physical, mental, and psychosocial well-being of each resident as evidenced by residents failing to receive sufficient help during dining. This was evident for 1 of 2 dining observations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that staff was properly trained to administer peritoneal dialysis. This had the potential to affect all residents on peritoneal dialysis.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to ensure that residents were administered medications that were not necessary by 1) not clarifying physician's orders when a resident had been ordered antihypertensive and anti-hypotensive medications, 2) not clarifying physician's orders when a resident was ordered two medications for pain management, 3) not questioning a medication that was given in excessive doses, and 4) not monitoring behaviors related to antipsychotic medications. This was evident with 3 (#78, #52, #72) of 6 residents reviewed for unnecessary medications.

Inspectors wrote5) Review of Resident #58's medical record on 1/3/19 revealed the resident received Risperdal 0.5 mg (antipsychotic medication) at bedtime and Risperdal 0.25 mg in the morning for dementia with behavioral disturbance. The resident also received Mirtazapine (antidepressant) for mood, Escitalopram (antidepressant) for depression and Trileptal (anti-seizure medication) for mood stabilization. Review of a physician's progress note, dated 11/21/18, documented that the resident was being followed for a diagnosis of dementia with behavioral disturbances and was aggressive at times. A psychiatric nurse practitioner's note of 10/3/18 documented the resident's mood was irritable, insight poor and judgement impaired. Behavioral goal was to keep mood neutral. Staff to provide structured socialization and ADL care. [...]

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to keep residents free from significant medication errors as evidenced by 1) failing to give ordered medications, 2) failing to give medications within 1 hour of the ordered time, 3) failing to recognize a resident was receiving too many doses of a medication and 4) failing to follow physician's orders to administer blood pressure medications within parameters. This was evident for 2 (#45, #47) of 5 residents observed during medication administration and 2 (#52, #78) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview and facility documentation review, it was determined the facility staff failed to 1) label medications when opened, 2) discard medications when expired 3) lock and secure an unattended medication cart and 4) ensure that medications were not left at the bedside. This was evident for 1 of 2 medication rooms observed, 4 of 8 medication carts observed, 2 random resident room observations and 1 random observation on 1 of 2 nursing units.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to have accurate medical record documentation. This was evident for 12 (#35, #45, #47, #63, #72, #86, #80, #70, #74, #33, #52, #24) of 35 residents reviewed.

Inspectors wroteBased on observation, record review and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines while performing duties and caring for residents and not verifying evidence of immunity when an employee stated that they never had or been vaccinated for measles, mumps, rubella or was ever tested for evidence of immunity. This deficient practice had the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on resident and staff interview and review of the medical record, it was determined that the facility failed to ensure that the resident/resident representative were given the opportunity to participate in his/her care planning process. This was evident for 1 (#86) of 4 residents reviewed for care plan.

Inspectors wroteBased on observation, resident and staff interview, and medical record review,, it was determined that the facility staff failed to ensure access to the nurse call bell, the over the bed tray table, and an ordered snack for a resident who was totally dependent on nursing staff for daily care due to impaired mobility. In addition, the facility failed to provide enough geriatric chairs to ensure that all residents that wanted to get up and out of bed could do this daily. This was evident for 2 (#63, #72) of 35 residents reviewed during the annual survey.

Inspectors wroteBased on observation, interview with facility staff, and record review, it was determined that facility staff failed to notify a resident's physician of a change in a residents' conditions. This was evident for 1 (#24) of 5 residents reviewed for respiratory status and 1 (#78) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident but not limited to for 2 (#29, #189) of 7 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to complete, within 14 days, a significant Minimum Data Set (MDS) comprehensive assessment. This was evident for 1 (#29) of 7 residents reviewed for hospitalization.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to meet professional standards of quality by 1) failing to check placement and residual for residents who received medications and nutrition through a feeding tube, 2) failing to administer all physician ordered medications, 3) failing to accurately document which medications were given or not available, 4) failing to follow physician's orders for the ordered amount of tube feeding flushes and 5) failing to administer medications and a scheduled tube feeding on time. This was evident for 2 (#45, #47) out of 5 residents observed during medication administration by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility staff 1) failed to provide an activities program to meet the needs and preferences of all residents and 2) failed to revise the care plan when a resident's health and ability to participate in activities declined. This was evident for 2 (#63, #341) of 2 residents reviewed for activities.

Inspectors wroteBased on resident and staff interview and medical record review, it was determined the facility failed to follow up with the resident to ensure the resident received the services necessary to maintain adequate hearing. This was evident for 1 (#86) resident reviewed for communication/sensory.

Inspectors wroteBased on observation, medical record review and staff interviews, it was determined that the facility staff failed to provide appropriate care for a resident that required total assistance with positioning and was assessed to have a pressure ulcer and continued to be at risk for development of pressure ulcers. This was evident for 1 (#63) of 4 residents reviewed for pressure ulcers.

Inspectors wroteBased on review of the medical record and interview with the resident and staff, it was determined the facility staff failed to provide services to increase or prevent decline in the resident's range of motion (ROM). This was evident for 1 (#70) of 4 residents reviewed for Position/Mobility.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined facility staff failed to provide the appropriate treatment and services to prevent complications of enteral feedings by not giving proper tube flushes and by not providing a tube feeding when ordered. This was evident for 2 (#45, #47) of 2 residents observed with tube feedings during medication pass observation.

Inspectors wroteBased on observation, family and staff interview and medical record review, it was determined the facility failed to provide coordinated interdisciplinary services for a resident to maintain his or her highest practicable physical, mental and psychosocial well-being. This was evident for 2 (#58, #33) of 2 residents reviewed for dementia care.

Inspectors wroteBased on observation, staff interview and medical record review, it was determined that the facility failed to provide residents' medications in a timely manner. This was evident for 2 (#18, #47) of 5 residents observed during medication administration.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to have a process in place to ensure that pharmacy recommendations were reviewed and acted upon as necessary. This was evident for 1 (#78, #70) out of 6 reviewed for unnecessary medications.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#45, #47) of 5 residents observed with 18 errors out of 37 medication administration opportunities which resulted in an error rate of 48.65% by 1 (Staff #2) of 2 registered nurses and 2 certified medicine aides observed.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to have quality laboratory supplies for resident diagnostic testing in 1 of 4 medication carts observed.

Inspectors wroteBased on review of facility records and interview with staff, it was determined that the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents, in a place where individuals wishing to examine the results do not have to ask to see them.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to give residents and their representatives written notice of hospital transfer when a resident was sent out via 911 for evaluation. This was evident for 7 of 7 residents (Residents #24, #38, #29, #58, #60, #64, and #189) reviewed for hospitalization.

Inspectors wrote6) Review of the medical record for Resident #29 on 1/9/19 revealed documentation that Resident #29 had an unplanned transfer to an acute care facility on 11/21/18. There was no written documentation that the resident or resident representative were notified in writing of the bed-hold policy. 3) Review of the medical record for Resident #58 on 1/9/19 revealed documentation in nursing notes which stated that the resident was sent to the emergency room. There was no written documentation that the bed hold policy was given to the resident or resident representative. 4) Resident #60's medical record was reviewed on 1/3/19 at 12:54 PM. The record revealed that the resident had been sent to the hospital 8 times in 2018. [...]