Avamere Rehabilitation of Shoreline

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for 1 of 3 residents (Resident 1), reviewed for significant medication errors. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report a missing resident within the required reporting timeframe for 1 of 4 residents (Resident 2), reviewed for abuse reporting. The failure to notify law enforcement, the state agency and the failure to follow its policy requirement of immediate notification of the Administrator, Director of Nursing Services, the resident's legal representative, and the attending physician when a resident is missing placed the resident at risk for unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 3 residents (Resident 1) reviewed for Activities of Daily Living (ADLs). The failure to provide bathing care for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident taking a diuretic (used to help remove extra fluid from the body) medication and failed to notify the provider of weight gain for 1 of 4 residents (Resident 1), reviewed for quality of care. These failures placed residents at risk for unrecognized weight gain, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain and implement physician orders for Continuous Positive Airway Pressure (CPAP - a machine that helps a person breathe more easily while they sleep) treatment in a timely manner for 1 of 4 residents (Resident 1), reviewed for respiratory care. This failure placed the resident at risk for poor sleep quality, related medical complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within the required timeframe for 3 of 7 residents (Residents 1, 2 & 3), reviewed for abuse reporting. This failure placed the residents at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated for 3 of 7 residents (Residents 1, 2 & 3), reviewed for abuse investigation. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement care plans for 1 of 2 residents (Resident 1), reviewed for comprehensive care plans. The failure to develop/implement care plans for Activities of Daily Living (ADL) and prosthesis (an artificial device that replaces a missing body part) care placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 1 of 3 residents (Resident 1), reviewed for ADLs. The failure to provide assistance with personal hygiene placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 4 residents (Residents 1 and 2) reviewed for resident-to-resident altercations. Resident 1 sustained skin injuries (a skin tear & bruises) when their arm was grabbed by another resident in the facility (Resident 3). The facility also failed to ensure Resident 2 was free from physical abuse when their hair was pulled by another resident in the facility (Resident 3). These failures had the potential to cause more than minimal physical harm, psychological harm, mental anguish and fear.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions (RC) are not inappropriately placed in nursing homes for long-term care) screening form was completed, for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 3 residents (Resident 3) reviewed for PASARR screening. This failure placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and interventions were implemented to manage aggressive behaviors for 1 of 3 residents (Resident 3) reviewed for resident-to-resident altercations. This failure had the potential to cause substantial injuries to residents, fear and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification about medication changes was provided to 1 of 3 residents (Resident 1), reviewed for changes in medication. The failure to notify Resident 1 that the medication Potassium Chloride (medication used to prevent and treat low potassium levels in the blood) would not be administered for thirteen days placed Resident 1 at risk for lack of knowledge about their medical condition and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and failed to ensure staff documented treatments in accordance with professional standards for 1 of 1 resident (Resident 1), reviewed for treatment administration. These failures placed the residents at risk for unmet care needs, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Licensed Practical Nurse (LPN) had the appropriate competencies, skills set and proficiencies to assess/evaluate wound care for 1 of 1 nursing staff (Staff E), reviewed for competent nurse staffing. This failure placed the residents at risk for unmet care needs, inaccurate wound assessments, and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation and to take appropriate corrective action for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice to ensure a clinical assessment was completed timely for a change of condition (a sign that something might be wrong and needs attention) for 1 of 3 residents (Resident 3), reviewed for assessment of care services. This failure placed the resident at risk of receiving delayed care and for potential negative outcomes. Review of the facility's policy titled, admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed that The following information should be recorded in the resident's medical record: 1. The date and time of the assessment was performed and showed that reporting included report other information in accordance with facility policy and professional standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a therapeutic diet was provided as ordered for 2 of 3 residents (Residents 1 & 2), reviewed for therapeutic diets. This failure had the potential to cause unwanted weight gain, a decline in medical conditions, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired foods were discarded for 1 of 1 refrigerator (Solarium Room Residents' Refrigerator), and failed to ensure dishwasher temperatures were maintained within the required ranges for 1 of 1 dishwasher, reviewed for food service safety. In addition, the facility failed to follow reheating food requirements for 1 of 1 (Staff L). These failures placed all residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were evaluated and assessed, and/or physician orders were obtained for safe administration of medication for 5 of 19 residents (Residents 30, 34, 38, 10 & 5), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were maintained for 4 of 19 residents (Residents 29, 13, 269 & 31), reviewed for environment. The failure to ensure resident rooms were free from broken light switches and soiled privacy curtains placed residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS - an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 4 of 6 residents (Residents 53, 25, 42 & 59), reviewed for transmitting MDS assessments. This failure placed the residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 8 of 21 residents (Residents 26, 65, 51, 30, 21, 2, 48 & 39), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual/developmental disabilities [ID/DD]), discharge status, bowel (gut) continence, oxygen, medication, urinary catheter (a flexible tube inserted into the bladder to drain urine), and bowel patterns, placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement care plans for 5 of 15 residents (Residents 3, 4, 29, 51 & 39), reviewed for comprehensive care plans. The failure to develop/implement care plans for Activities of Daily Living (ADL) and urinary catheter (a flexible tube inserted into the bladder to drain urine) care placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 9 residents (Residents 26, 2, 30 & 32), reviewed for care plan revision. The failure to revise the care plan that included interventions for Level II Preadmission Screen and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions), use of opioid (narcotic pain medication), self-administration of medication, oxygen use, and range of motion, placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 3 of 4 residents (Residents 3, 29 & 51), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with personal hygiene placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 4 of 5 residents (Residents 10, 38, 30 & 271), reviewed for respiratory care. The failure to label/date oxygen tubing, properly store oxygen tank, and obtain oxygen orders placed the residents at risk of respiratory infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff, and the hours worked for each shift for 4 of 4 days (05/12/2025, 05/13/2025, 05/14/2025 & 05/16/2025), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided in accordance with professional standards of practice to meet the needs of 4 of 6 residents (Resident 4, 30, 21 & 38), reviewed for medication management. The failure to follow physicians order and medication instruction placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications with adverse side effects were adequately monitored and/or non-pharmacological interventions were provided prior to administering pain medications for 3 of 5 residents (Residents 2, 39 & 271), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications and biologicals were discarded for 1 of 1 medication room (Medication Room) and for 2 of 2 crash carts (300 Hall & 400 Hall Crash Carts), reviewed for medication storage and labeling. In addition, the facility failed to properly store medications for 5 of 19 residents (Residents 30, 38, 34, 10 & 5). These failures placed the residents at risk for receiving compromised and/or ineffective biological and medical supplies.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were properly completed for 4 of 7 residents (Residents 36, 25, 2 & 30), reviewed for resident records. The failure to fill out resident forms accurately placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases by: 1. Not ensuring the Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually, as required. 2. Not monitoring the expiration for eyewash station solutions for 3 of 4 eyewash stations (300 Hall Nurse's Station, 500 Hall Resident Care Manager [RCM] Office, Laundry Room), reviewed for water management. 3. Not ensuring Enhanced Barrier Precautions (EBP - precautions to protect the spread of infectious organisms) were followed for 1 of 9 residents (Residents 1). 4. Not performing hand hygiene during care and treatments for 4 of 11 residents (Residents 4, 7, 23 & 38). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) were provided with privacy for 2 of 6 residents (Residents 30 & 8), reviewed for dignity. This failure placed the residents at risk for decreased self-worth and a diminished quality of life

Inspectors wroteBased on interview and record review, the facility failed to ensure an updated guardianship letter was readily available in medical records and accessible to staff for 1 of 4 residents (Resident 29), reviewed for Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care). This failure placed the resident and/or their representative at risk of losing their right to have their preferences honored to receive care according to their choice.

Inspectors wroteBased on interview and record review, the facility failed to issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 1 of 3 residents (Resident 56), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk for not being fully informed and losing their right to an appeals process.

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological interventions were in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 2 of 5 residents (Residents 64 & 57), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 2 residents (Resident 2), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) for Level II services (a process to determine what mental health services residents required after a Level I PASARR determined mental health services were necessary) for 1 of 2 residents (Resident 26), reviewed for PASARR. This failure placed the resident at risk of not receiving the necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 1 of 6 residents (Resident 36), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 2 residents (Resident 57). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for 2 of 4 residents (Residents 51 & 39), reviewed for quality of care. The failure to consistently conduct skin evaluations to include care planning, monitoring and necessary treatment for Resident 51, and the failure to consistently monitor and manage constipation (passing fewer than three stools a week or having a difficult time passing stool) for Resident 39, placed the residents and other residents at risk for unmet care needs, pain/discomfort, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 3 residents (Resident 10), reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase and/or to prevent decrease Range of Motion (ROM) for 2 of 3 residents (Residents 32 & 34), reviewed for restorative services. This failure placed the residents at risk for a decline in ROM, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 8 residents (Residents 4 & 39), reviewed for catheter care. The failure to empty urinary catheter bag and/or ensure other urinary catheter care were provided placed the residents at risk for infections, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who require ostomy (a surgical procedure creating an opening in the body for the discharge of body waste into a collection bag) care received services consistent with professional standards for 1 of 1 resident (Resident 17), reviewed for ostomy care. This failure placed the resident at risk for unmet care needs, skin breakdown, related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received trauma informed care, trigger assessment, and trauma-informed care assessment in accordance with professional standards of practice for 1 of 1 resident (Resident 48), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse for 1 of 3 residents (Resident 1), reviewed for abuse reporting. The facility's failure to report an allegation of sexual abuse to the state agency and to law enforcement placed Resident 1 and other residents at risk for repeated incidents and unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of sexual abuse was investigated timely for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Abuse-Sexual, means any form of non-consensual conduct, including but not limited to, unwanted or inappropriate touching. It further showed that sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages, cueing, or encouraging a resident to perform sexual acts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier Precautions (EBP- precautions to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) signage was in place and/or use of appropriate Personal Protective Equipment (PPE-gown) were followed during medication administration for 1 of 2 residents (Resident 1), reviewed for infection control. This failure placed the residents, staff, and visitors at an increased risk of infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the primary care physician was notified when medications were not administered for 1 of 3 residents (Resident 1) reviewed for medications. The failure to notify the primary care physician when the medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder was not administered placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 3 residents (Resident 1) was free from a significant medication error. The failure to administer a medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and failed to ensure a summary or copy of the baseline care plan were provided to the residents and/or their representatives for 3 of 4 residents (Residents 1, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary assistance for shower/bathing for 2 of 5 residents (Residents 1 & 2), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, poor hygiene, skin impairment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency within the required timeframe for 1 of 1 resident (Resident 1), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated and/or completed/documented on the incident report log within five days for 1 of 1 resident (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for unidentified abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 13 residents (Residents 4, 49, 53 & 45), reviewed for care plan revision. The failure to revise care plans for bed placed against the wall, refusal of showers, discharge planning, and involve resident in their care plan meetings, placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify a physician's order for 1 of 8 residents (Resident 20) and failed to ensure staff documented residents' medications in accordance with professional standards for 5 of 8 residents (Residents 5, 20, 9, 361 & 52), reviewed for medication administration. This failure placed the residents at risk for medication errors and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 2 of 6 days reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 3 of 4 freezers (Kitchen Freezer, Kitchen Walk-In Freezer and Downstairs Storage Freezer), 1 of 2 refrigerators (Cellarium Refrigerator), and 1 of 1 seasoning shelf (Kitchen Shelf) reviewed for food services. The failure to date and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a comprehensive water management program that assessed, measured, and/or monitored potential risk for exposure to Legionnaire's disease (Legionella - a potentially dangerous bacteria that grows in water, which could cause a serious lung infection) or other waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease). In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during resident care for 2 of 4 staff (Staff R & S), failed to appropriately disinfect medical equipment for 3 of 4 staff (Staff S, T & J), and failed to do hand hygiene during dining meal observations for 2 of 3 staff (Staff J & M), reviewed for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (a written instruction, such as a living will or durable power of attorney for health care) were obtained from the residents and/or their representatives and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 45 & 38), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive care according to their choice.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a required form that outlined the transfer of financial liability from the nursing facility to the Medicare [government health insurance program] beneficiary) for 3 of 5 residents (Residents 160, 30 & 161), reviewed for liability notices, who remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended. This failure placed the residents and/or their representatives at risk for not having adequate information to make financial decisions related to continued stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment for 1 of 1 room (room [ROOM NUMBER]), reviewed for environment. The failure to prevent excessive odor placed the resident at risk for feeling unclean, undignified, and a diminished self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, initiate, thoroughly investigate, and promptly resolve a grievance for 1 of 2 residents (Resident 15), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 49), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a baseline care plan for 1 of 4 residents (Resident 23), reviewed for baseline care plans. The failure to implement the baseline care plan for nutritional risk placed the resident at risk for health complications, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident 23), reviewed for accidents. The failure to provide necessary supervision placed the resident at risk for accidents, injury, and other negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain and monitor a resident weight for 1 of 2 residents (Resident 23), reviewed for nutrition. This failure placed the resident at risk for unrecognized weight loss, nutrition-related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respiratory equipment to include covering the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use, labeling the tubing, and ensure oxygen therapy was given according to standards of practice for 2 of 2 residents (Residents 23 & 26), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 of 30 days (02/25/2024), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a 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 (%). The failure to properly administer 9 of 53 medications for 2 of 8 residents (Residents 20 & 52), observed during medication pass resulted in a medication error rate of 16.98%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medication carts (Wing 1 Medication Cart), reviewed for medication storage. This failure placed the resident at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 26) reviewed for dental services was provided timely referral to a dentist and reimbursement for missing dentures. In addition, the facility failed to have a policy that identified when the loss of dentures was the facility's responsibility. These failures placed the resident at risk for difficulty chewing, oral pain, decreased self-image, financial burden, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner that the resident and/or representative understood for 1 of 3 residents (Resident 52), reviewed for arbitration agreement. This failure placed the resident at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 2 of 8 residents (Residents 52 & 4) related to pneumococcal vaccinations (vaccines used to prevent pneumonia [lung infection]). This failure placed the residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from pneumonia.

Inspectors wroteBased on interview and record review of room size measurements, seven single resident rooms (Rooms 405, 407, 501, 503, 505, 507 & 509) failed to meet the minimum room size requirement of at least 100 square feet (sq ft) for a single resident room. The failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated and/or logged and completed timely within five days for 3 of 3 residents (Residents 3, 4 & 5), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the abuse allegation was thoroughly investigated for 1 of 2 residents (Resident 1) reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unrecognized abuse, and inappropriate corrective actions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu met the nutritional needs of residents in accordance with the established national guidelines for well-balanced diet/menu. This failure placed the residents at risk for not having their food choices honored, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual comprehensive Minimum Data Set (MDS) assessments were completely timely as required for 5 of 21 residents (Residents 3, 22, 30, 10 & 35) reviewed for comprehensive assessments. The facility's failure to conduct annual comprehensive assessments placed the residents at risk of unidentified physical, psychological, functional changes, other unmet care needs and a diminished quality of life.

Inspectors wroteBased on staff interview and record review, facility failed to ensure Minimum Data Set (MDS) assessments were conducted timely for 11 of 21 residents (Residents 27, 66, 13, 39, 24, 46, 36, 14, 23, 12 and 37) reviewed for Quarterly MDS Assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for 6 of 6 residents (Residents 14, 42, 374, 35, 40 and 15) reviewed for palatability. This failure placed the residents at risk for weight change, less than adequate nutritional intake, and dissatisfaction with meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a water management program to reduce the potential for exposure to opportunistic waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease) including Legionnaire's disease, a potentially dangerous bacteria that grows in water, which could cause a serious lung infection (Pneumonia). This failure created a potential risk for the facility residents to be exposed to Legionella, other opportunistic water-borne pathogens, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hot water to the sink in the room of 1 of 47 residents (Resident 42) reviewed for accommodation of needs. The failure to have hot water and weak water pressure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of neglect or mistreatment that did not result in bodily harm, no later than 24 hours after the allegation was reported for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for neglect, mistreatment, and unreported allegations.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of neglect or mistreatment for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for unrecognized abuse or neglect, and a diminished quality of life.

Inspectors wroteBased on interview and review, the facility failed to consistently complete and/or transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 3 of 21 residents (Residents 27, 12 & 10) reviewed for timeliness in submitting Minimum Data Set (MDS) assessments and/or completing and transmitting death in facility tracking record. These failures placed the residents at risk for inaccurate/incomplete assessments, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 1 resident (Resident 3) with a tracheostomy stoma (an artificial opening in the neck for breathing and respiratory secretions). This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 6 residents (Resident 15) reviewed for nutritional status. The facility's failure to ensure Resident 15 received the appropriate diet texture and assess for needed changes in interventions resulted in significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the risks and benefits of side rails were completed and that the side rails were regularly evaluated for safety for 1 of 1 resident (Resident 11) who had two, one-fourth siderails on their bed. This failure placed the resident at risk for entrapment and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 47 residents (Resident 41) reviewed for mental health provision and services. This failure placed the residents at risk for unmet psycho-social needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper diet texture consistency for 1 of 1 resident (Resident 374) reviewed for nutrition and specialty diet. This failure placed the resident at risk for nutritional imbalance, weight changes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety for 1 of 1 dining room. This failure placed the resident at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and review of room size measurements, seven single resident rooms failed to meet the minimum room size requirement of at least 100 square feet for single resident room. These rooms were: 405, 407, 501, 503, 505, 507 and 509.