Avenue at Lyndhurst

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and/or promote pressure ulcer healing for Resident #29, #83 and #100. This affected three residents (Resident #29, #83 and #100) of six residents reviewed for pressure ulcers. The facility census was 88. Actual harm occurred on 03/26/26 (13 days after admission) when Resident #100 who was severely cognitively impaired and high risk for pressure ulcer development with a history of pressure ulcers and skin disorders developed pressure ulcer, first identified to be Stage III (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible) to the right groin. [...]

Inspectors wroteBased on medical record review, staff and resident interviews, review of the facility investigation, review of staff witness statements, review of hospital documents, review of the manufacturers recommendations, and policy review, the facility failed to ensure Resident #99's was safely transferred in a Hoyer lift, failed to implement effective fall preventive measures to prevent multiple falls for Resident #82, failed to ensure fall interventions were implemented for Resident #10, and failed to ensure thorough fall investigations were completed to determine root cause of falls and proper fall interventions to implement. This affected four residents (Resident #65, #76, #82, and #99) of eight residents reviewed for falls. The facility census was 88. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide necessary nutritional and hydration care and services for Residents #25, #46, #76, #77, #83, #99, and #100). This affected seven residents (Resident #25, #46, #76, #77, #83, #99, #100) out of 12 residents reviewed for nutrition. The facility census was 88. Actual harm occurred on 05/07/26 after Resident #83, who had cognitive impairment with a history of malnutrition, nutrition and hydration status was not properly monitored and poor oral intakes were not treated, resulting in the resident experiencing weight loss, significant dehydration and acute kidney injury. Resident #83 required hospitalization, intravenous (IV) fluids, and treatment for a urinary tract infection.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to employ staff free of disqualifying offenses. This had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of time punch details, daily staffing sheets and schedules, review of the facility assessment, and facility policy review, the facility failed to ensure adequate staffing levels to meet the needs of the residents. This affected all 88 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had routine performance evaluations completed as required. This affected five CNAs (#309, #328, #364, #369 and #388) of six CNA personnel files reviewed and had the potential to affect all 88 residents in the facility.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were stored and administered in accordance with professional standards of practice and facility policy. This affected Resident #16, Resident #43, and Resident #97 and had the potential to affect all residents within the facility, The facility census was 88.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure a sanitary kitchen environment was maintained. This had the potential to affect 88 residents receiving food from the facility's kitchen. The facility indicated no residents received nothing by mouth. The facility census was 88.

Inspectors wroteBased on observation, record review, review of facility job descriptions, and interview, the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence, and attain or maintain the highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate facility assessment. This had the potential to affect all 88 residents residing in the facility. The facility census was 88.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee was in place to identify and address concerns timely and effectively. This had the potential to affect all 88 residents in the facility.

Inspectors wroteBased on review of personnel files and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had 12 hours of annual in-servicing as required. This affected four CNAs (#309, #364, #369 and #388) of six CNA personnel files reviewed and had the potential to affect all 88 residents in the facility.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to provide care conferences quarterly and upon request. This affected seven residents (#10, #14, #17, #34, #46, #65 and #87) of seven residents reviewed for care planning. Facility census was 88.

Inspectors wroteBased on record reviews and interviews, the facility failed to complete initial comprehensive Minimum Data Set (MDS) 3.0 assessments as required on new admissions. This affected five residents (Residents #83, #85, #99, #100, and #102) residents of 45 residents reviewed for MDS 3.0 assessments. The facility census was 88.

Inspectors wroteBased on resident record reviews, resident interviews, staff interviews, and facility policy review, the facility failed to provide routine activities of daily living (ADLs) for 12 residents (Residents #10, #17, #20, #34, #46, #66, #77, #82, #87, #99, #100 and #108) of 21 residents reviewed for ADLs. The facility census was 88.

Inspectors wroteBased on medical record review, observation, interview, review of dietary tray tickets, and facility policy review, the facility failed to ensure resident preferences and religious preferences were honored as required. This affected four residents (#25, #76, #99 and #100) of six reviewed for dietary preferences. This had the potential to affect all residents residing at the facility. The facility census was 88.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to dispense medications in a manner to prevent the spread of infection. This affected three residents (#11, #34 and #53) of four residents observed for medication administration. Additionally, the facility also failed to ensure enhanced barrier precautions (an infection control measure used to prevent the spread of multi-drug resistant organisms) were followed for three residents (#27, #90 and #96) of 26 residents identified as being on enhanced barrier precautions. The facility census was 88.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Resident #12 and Resident #27 were treated in a dignified manner at all times. This affected two residents (Resident #12 and Resident #27) of 11 residents reviewed for dignity. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach at all times to accommodate resident needs. This affected three residents (Resident #34, Resident #93, and Resident #100) out of 11 residents reviewed for resident rights.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure advanced directives were addressed in resident records. This affected two residents (#22 and #90) of three residents reviewed for advance directives. Facility census was 88.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure a comfortable, homelike environment with equipment that was in good repair. This affected two residents (Residents #34 and #77) of 10 residents reviewed for environment and had the potential to affect all residents within the facility. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #100 was free from neglect of necessary care and services to allow the resident to reach the highest practicable, physical and emotional well-being. This affected one resident (Resident #100) of five residents reviewed for abuse and neglect. The facility census was 88.

Inspectors wroteBased on record review, review of the facility self-reported incident (SRI), policy review, and interviews, the facility failed to prevent the diversion of narcotics by staff. This affected one resident (Resident #73) of one resident reviewed for misappropriation. The facility census was 88.

Inspectors wroteBased on resident record reviews, staff interviews, and facility policy review, facility failed to implement person centered fall prevention interventions as outlined in the comprehensive care plans for Residents #10 and #82. This affected two residents (Residents #10 and #82) of 45 residents reviewed for care plans. The facility census was 88.

Inspectors wroteBased on medical record review, interviews, and policy review, the facility failed to ensure required care conferences were conducted and failed to verify resident and/or representative participation for Resident #77. This affected one resident (Resident #77) of 45 residents reviewed for care plans. The facility census was 88.

Inspectors wroteBased on observations, resident record review, staff interviews, and facility policy review, the facility failed to implement adequate communication for non-English speaking residents. This affected two residents (Residents #50 and #65) of two residents reviewed for communication. The facility census was 88.

Inspectors wroteBased on resident record review, staff interviews, and facility policy review, the facility failed to honor resident preferences related to activities for Resident #50. This affected one of one resident. The facility census was 88.

Inspectors wroteBased on interview and record review, the facility failed to administer medications to treat Parkinson's disease in a timely manner for Resident #87, and failed to ensure a timely orthopedic follow-up appointment was scheduled for Resident #99. This affected two residents (Resident #87 and Resident #99) of four residents reviewed for quality of care. The facility census was 88.

Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to provide timely and appropriate incontinence care for Residents #22 and #31. This affected two residents (Residents #22 and #31) of seven residents reviewed for incontinence care. The facility census was 88.

Inspectors wroteBased on medical record review, interviews, review of email and photographs provided by family, and policy review, the facility failed to ensure enteral tube feeding was provided as physician ordered for Resident #100 of two residents reviewed for enteral feedings. The affected one resident (Resident #100) of two residents reviewed for enteral feedings. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to change a nebulizer mask (a mask used to distribute breathing medications by machine) in a timely manner for infection prevention measures. This affected one resident (Resident #85) of one resident reviewed for respiratory care. The facility identified 17 residents as utilizing nebulizers (#1, #7, #19, #22, #30, #33, #34, #35, #46, #47, #53, #66, #75, #77, #85, #94, and #107). The facility census was 88.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to provide comprehensive pre and post dialysis monitoring. This affected one resident (#41) of two residents receiving dialysis at the facility. Facility census was 88.

Inspectors wroteBased on record review, interviews, review of hospital records, and policy review, the facility failed to ensure the attending physician monitored Resident #83 for significant weight loss, poor nutritional intake, and change in condition. This affected one resident (Resident #83) of one resident reviewed for physician oversight. The facility census was 88.

Inspectors wroteBased on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure adaptive equipment was provided for Resident #34. This affected one resident (#34) of one resident reviewed for adaptive equipment. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure coordination of care with hospice services for residents to ensure safe and person-centered care. This affected one resident (#3) of one resident reviewed for hospice services. Facility census was 88.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to ensure adequate hand hygiene supplies were routinely available. This affected two residents (#14 and #27) of ten rooms observed. Facility census was 88.

Inspectors wroteBased on observation and interview, the facility failed to ensure survey results were up to date and accessible for visitor/family review. This had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure posted staffing was accurate. This had the potential to affect all 88 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure outside trash was stored and secured as required. This had the potential to affect all 88 residents residing at the facility. The facility census was 88.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to ensure clean food service areas including opened food that was not labeled or dated. This had the potential to affect all residents who received meals from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86.

Inspectors wroteBased on record review, observations, interviews and facility policy review, the facility failed to ensure all call lights were within reach for residents who were dependent for activities of daily living. This affected four (Residents #5, #54, #89, #102) of 17 residents observed for accommodation of needs. In addition, the facility failed to ensure Resident #14 's tray table was in reach. This affected one (Resident #14) of 17 residents reviewed for accommodation of needs. The facility census was 86.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to develop and implement comprehensive care plans. This affected four (Residents #1, #6, #7, and #39) of 38 residents reviewed for care plans. The facility census was 86.

Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to provide timely incontinence care for dependent residents. This affected five (Residents #9, #15, #41, #69 and #84) of ten residents observed for incontinence care. The facility census was 86.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure residents at risk for falls were safe by implementing interventions written in the plan of care, appropriate call light response, and timely intermittent observations of residents. This affected one (Resident #65) of five residents reviewed for falls. The facility failed to ensure all residents requiring a mechanical lift for transfers were transferred safely. This affected one (Resident #65) of 34 residents who required a mechanical lift for transfers. The facility failed to provide care and services to prevent falls related to level of assistance. This affected two (Residents #18 and #39) of five residents reviewed for falls. The facility failed to ensure Resident #99 had a fall assessment and a pain assessment after a fall with minor injury. [...]

Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to ensure all insulin pens were documented with resident name, opened and expired dates. The facility also failed to remove expired insulin pens in a timely manner. This affected eight (Residents #10, #24, #33, #40, #73, #78, #81, and #82) of 19 residents who required insulin. The facility census was 86.

Inspectors wroteBased on observation, review of the meal spreadsheet, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 22 (Residents #10, #14, #18, #29, #30, #37, #41, #42, #45, #46, #47, #51, #54, #56, #59, #66, #69, #73, #74, #78, #79, and #103) in the main dining room who were not on a pureed diet. The facility identified four (Residents #1, #48, #65, and #90) in the main dining room who received a pureed diet. This had the potential to affect all residents who received meals from the facility. The facility identified four (Residents #4, #19, #49, and #60) who received nothing by mouth (NPO). The facility census was 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This affected three (Residents #37, #666, and #103) and had the potential to affect all resident receiving food from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86.

Inspectors wroteBased on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training upon hire and/or annually to all staff who were employed at the facility. This had the potential to affect all 86 residents in the facility.

Inspectors wroteBased on medical record request review, email review, staff interview and facility policy review, the facility failed to fulfill a request for medical records in a timely manner. This affected one (Resident #100) of three residents reviewed for medical records requests. The facility census was 86.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman was notified of transfers for Residents #10 and #93, and the facility failed to ensure a transfer notice was issued for Resident #98. This affected three (Residents #10, #93, and #98) of three residents reviewed for hospitalization. The facility census was 86.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure medications were available for administration. This affected two (Residents #20 and #99) out of ten residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure proper infection control with Resident #69 during incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care and had the potential to affect six additional (Residents #1, #22, #42, #55, #59, and #77) whom required incontinence care on the Certified Nursing Assistant's (CNA) #365's assignment. The facility census was 86.

Inspectors wroteBased on observation, medical record review, hospital record review, facility policy review and staff and resident interview, the facility failed to develop and implement a comprehensive, individualized and effective pain management program for Resident #77 who was admitted with acute pain and difficulty with moving due to pain to the left foot and a vascular wound. Actual Harm occurred beginning on 01/18/25 when Resident #77 did not receive ordered pain medication, Tramadol (an opioid pain reliever). The resident was admitted to the facility (on 01/18/25) with a physician order for Tramadol 25 milligram (mg) every 12 hours as needed for pain for up to seven days; however, the medication was not administered until 01/21/25 (three days after admission). During this time, Resident #77 had complaints of severe and unrelieved pain. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure chart room that contained residents private information were secured. This had the potential to affect all residents residing in facility. The facility census was 100.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of time punch details, daily staffing sheets and schedules, review of the facility assessment, and facility policy review, the facility failed to ensure adequate staffing levels to meet the needs of the residents. This affected all residents residing in the facility. The facility census was 100.

Inspectors wroteBased on observation, resident interviews, staff interviews, facility policy review, and return demonstration of a test tray, the facility failed to serve hot, palatable meals. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO).

Inspectors wroteBased on observation, resident interviews, staff interviews, and review of facility mealtimes, revealed the facility failed to ensure meals were served in a timely manner. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO). The facility census was 100.

Inspectors wroteBased on observation and interview the facility failed to ensure adequate amounts of supplies were available to provide resident care. This had the potential to affect all residents residing in the facility. The facility census was 100.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents.

Inspectors wroteBased on employee file review and interview, the facility failed to ensure staff were trained as required. This had the potential to affect all 100 residents residing at the facility.

Inspectors wroteBased on observation, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#50, #59, #70, and #71) of four residents reviewed for dignity and respect. The facility census was 100.

Inspectors wroteBased on observations, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the resident environment was maintained in a clean and sanitary manner, and failed to ensure water temperatures were at a comfortable level. This affected seven residents (#6, #29, #42, #49, #70, #82, and #83) of seven reviewed for physical environment. The facility census was 100.

Inspectors wroteBased on interview, policy review, grievance log review, and personnel file review the facility failed to ensure resident concerns were addressed. This affected four residents (Resident #9, Resident #27, Resident #61, and Resident #73) and had the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on resident record review, staff interview, and facility policy review, the facility failed to ensure resident care plans were up-to-date and reviewed on a quarterly basis as required. This affected four residents (#9, #26, #44, #54) of four residents reviewed for care planning. The facility census was 100.

Inspectors wroteBased on observation, interview, medical record review, review of hospital records, and facility policy review, the facility failed to timely implement a physician-ordered treatment to a vascular wound upon admission. This affected one (Resident #77) of three residents reviewed for wound care management. Additionally, the facility failed to ensure resident call lights were answered and care provided in a timely manner. This affected four (Residents #17, #25, #26, and #44) of four residents reviewed for call lights. The facility census was 100.

Inspectors wroteBased on record review, interview, facility policy review, the facility failed to adequately monitor resident nutritional status by not obtaining consistent weights per physician orders. This affected four residents (Resident #26, #54, #66, and #101) of eight residents reviewed for weights. This had the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure residents' were timely administered medications and were free from significant medication errors. This affected five (Residents #26, #27, #61, #77, and #115) of five resident records reviewed for medication administration. The facility census was 100.

Inspectors wroteBased on observations, resident record review, staff interview, and facility policy review, the facility failed to ensure resident dietary preferences were maintained. This affected five residents (#25, #26, #28, #33, and #82) of five reviewed for dietary preferences. The facility census was 100.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident records were maintained in an accurate manner and contained the assessments and services provided. This affected seven residents (#6, #9, #49, #54, #77, #82, #83) of seven reviewed for accurate medical records. The facility census was 100.

Inspectors wroteBased on observations, resident interviews, staff interviews, and facility policy review, the facility failed to ensure the resident environment was kept in a clean and sanitary manner. This had the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on review of camera footage, medical record review, interview, and review of facility policy, the facility failed to ensure call lights were within reach of residents. This affected one resident (#61) out of five observed for call lights. The facility census was 100.

Inspectors wroteBased on interview, record review, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), and review of facility policy, the facility failed to timely report an injury of unknown origin to the State Agency as required. This affected one resident (#64) of three residents reviewed for self reported incidents. The facility census was 100.

Inspectors wroteBased on observations, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were provided assistance with meals. This affected two residents (#26 and #71) of three residents reviewed for meal assistance. The facility census was 100.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #17's newly-identified pressure ulcer was timely assessed and had a treatment implemented. This affected one (Resident #17) of three residents reviewed for wounds. The facility census was 100.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a hand splint was re-ordered and applied as requested. This affected one (Resident #26) of three residents reviewed for range of motion. The facility census was 100.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure Resident #97 and #110 had accurate and thorough fall investigations completed, and failed to ensure admission nursing care plans with individualized fall prevention interventions were implemented. This affected two (Residents #110 and #97) of three residents reviewed for falls. Additionally, the facility failed to ensure only clinical and trained staff members provided assistance with transfers. This affected one (Resident #115) of three residents observed for safe transfers. The facility census was 100.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provided timely and appropriate incontinence care for dependent residents. This affected three residents (#26, #49 and #54) of three residents reviewed for incontinence care. The facility census was 100.

Inspectors wroteBased on interview, review of photographs, and review of the facility policy, the facility failed to ensure medications were not left unattended in residents' room. This affected three residents (#27, #61 and #115) of five residents reviewed for . The facility census was 100.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #64's diagnostic test for a suspected injury was ordered, reported, and treatment was initiated timely. This affected one resident (Resident #64) out of three residents reviewed for diagnostic testing. The facility census was 100.

Inspectors wroteBased on observation, resident record review, and staff interview, the facility failed to ensure resident meals were served in the proper, safe form. This affected one resident (#60) of one reviewed for therapeutic diets. The facility census was 100.

Inspectors wroteBased on observation, resident record review, and staff interview, the facility failed to ensure residents were provided with the appropriate assistive devices for meals. This affected one resident (#60) of one reviewed for assistive devices. The facility census was 100.

Inspectors wroteBased on observations, record review, staff interviews, and facility policy review, the facility failed to ensure facility staff followed infection control policies, protocols, and failed to ensure residents were care planned for infection control. This affected two residents (#9 and #44) of three reviewed for infection control. The facility census was 100.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure residents were regularly screened for risk of falls. This affected three residents (#15, #57, and #61) of four residents reviewed for falls. The facility census was 83.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound care was ordered and documented according to nurse practitioner orders. This affected one resident (#15) of three residents reviewed for wound care. The facility census was 83.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide condiments or an alternative for breakfast on 06/03/24. This had the potential to affect all residents who receive food from the kitchen, other than Residents #9 and #40 who the facility identified as receiving nothing by mouth. The facility census was 78.

Inspectors wroteBased on record review, interview, review of court documents, review of the Statement of Expert Evaluation, review of a police report, and facility policy review, the facility failed to prevent an unauthorized leave of absence (LOA) and subsequent discharge of Resident #78 who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS). This affected one resident (#78) of three residents who were reviewed for discharge. The facility census was 76. Findings Include: Review of the medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of a sworn affidavit in Resident #78 medical records dated 01/09/24 completed by an APS social worker revealed Resident #78 suffers from dementia and is frail and unsteady on her feet. [...]

Inspectors wroteBased on record review, interview, review of hospital records, review of a police report, and facility policy review, the facility failed to permit Resident #78, who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS), to return to the facility after an unauthorized leave of absence (LOA) with family. This affected one resident (#78) of three residents reviewed for discharge. The facility census was 76. Findings Include: A review of medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of hospital record reviews revealed an emergency room record dated 01/19/24 revealed Resident #78 was there for evaluation and guardianship. There were social and financial concerns. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food was served in a sanitary manner and food was stored and dated properly. This had the potential to affect 67 of 69 residents receiving food from the kitchen. The facility identified Residents #63 and #73 as not receiving food from the kitchen. The facility census was 69.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure temperatures in the main dining room were kept at a comfortable level. This had the potential to affect seventeen residents (#5, #7, #15, #18, #19, #22, #23, #24, #27, #31, #33, #37, #39, #41, #47, #48, #377) the facility identified as residents who ate meals in the main dining room. The facility census was 69.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure mechanically altered diets were prepared to a proper consistency to ensure safe consumption. This had the potential to affect eleven Residents (#3, #9, #19, #30, #33, #34, #35, #37, #49, #327, #379) who were identified by the facility to have a minced and moist mechanically altered diet order. The facility census was 69.

Inspectors wroteBased on observation and interview, the facility failed to ensure a urinary catheter bag had a privacy cover over it to maintain privacy and dignity for Resident #49. This affected one Resident (#49) of two residents (#49 and #64) who had urinary catheters. The census was 69.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline nursing care plan for Resident #75 according to the regulation requirement. This affected one Resident (#75) of 20 residents reviewed for care plans. The facility census was 69.

Inspectors wroteBased on record review, observation, resident, family and staff interviews, and review of facility policy, the facility failed to ensure nail care was provided for Resident #23 and timely incontinence care was provided for Resident #35. This affected two residents (#23 and #35) of three residents reviewed for activities of daily livings (ADL). The facility census was 69.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure adequate supervision of Resident #46 to prevent a fall. This affected one resident (46) of two residents reviewed for falls. The facility census was 69.

Inspectors wroteBased on observations and interview the facility failed to date insulin pens when opened. This affected four (Resident #4, #5, #36, and Resident #51) of five residents reviewed for medication storage. The facility census was 69.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff removed gloves after emptying a catheter and before proceeding to touch Resident #49's personal items. This affected one resident (#49) of 20 residents reviewed for infection control. The census was 69.

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure call lights and resident telephones were within reach. This affected four (Residents #25, #34, #45 and #54) of 10 residents observed for call light placement. The census was 65.

Inspectors wroteBased on record review, observations, and interview the facility failed to allow residents to have personal items in their rooms. This affected one (Resident #65) of three residents reviewed for access to personal items. The census was 65.