Baisch Nursing Center

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the HVAC (heating, ventililation, and air conditioning) system in working order to provide comfortable and safe temperatures for residents residing on the 100 hallway. During an Extreme Heat Warning, multiple resident rooms exceeded the acceptable indoor temperature range, resulting in residents being unable to consistemtly maintain a comfortable living environment. This deficient practice had the potential to affect all 15 residents who live on the 100 hall. The facility census was 51. Review of the facility's Extreme Heat Policy, revised 11/01/13, showed staff were to monitor temperatures and humidity between 1:00 p.m. and 7:00 p.m.; obtain temperatures in resident rooms and common areas; relocate residents when individual rooms exceeded 80 degrees; contact maintenance to repair the HVAC system; [...]

Inspectors wroteBased on interview and record review, the facility failed to allow residents access to resident funds on an ongoing basis for one resident (Resident #34) out of 13 sampled residents and two residents (Residents #7 and #39) outside the sample. This had the potential to affect all residents for whom the facility managed funds. The facility census was 51. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the environment in a safe and well-maintained condition by failing to repair damaged flooring, tiles, handrails, corridors, door frames, grout, showers and faucets, and failing to maintain a functioning door closer on the exterior door. The deficient practice had the potential to affect all residents. The facility census was 51. Review of the facility policy titled, Policy and Procedure Environment/Homelike, dated 01/01/26, showed:- The facility will remain clean and sanitary;- Equipment will be kept in good repair. Observation on 06/02/26 at 7:41 P.M., of the men's shower room on [NAME] Wing 2 showed:- Water leaked from the left shower faucet in the back shower when the water was turned on;- Water leaked from the top of the faucet and down the shower hose when water was turned on. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the statement of appeal rights, and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices, and failed to notify the ombudsman of the transfer or discharge for two residents (Residents #2 and #34) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy titled, Written Notice Before Transfer/Discharge, dated 02/01/26, showed: - The facility will notify the resident and/or resident representative of transfer in writing before transfer or discharge; - Notice will be sent to the Office of the Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) for two residents (Residents #18 and #26) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy, MDS Resident Assessment, dated 01/01/26, showed: - The purpose is to provide guidance to conduct initially and periodically a comprehensive, accurate and standardized reproducible assessment of each resident's functional capacity; - The Interdisciplinary Team (IDT) is expected to complete an assessment, coordinated by a Registered Nurse (RN), using the Resident Assessment Instrument (RAI) specified by the state in compliance with the RAI guidelines; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and document a treatment as ordered for one resident (Resident #13) and failed to obtain a physician order for one resident (Resident #18) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy titled, Physician Orders, dated 01/01/26, showed: - The purpose is to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; - A physician's order must be documented clearly in the medical record including the required components of a complete order: date and time of receipt of order; name of practitioner providing the order; name and strength of product; quantity or specific duration; dosage and frequency of administration; route of administration; indication/diagnosis for which the product is given; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident and/or the resident's representative for two residents (Residents #9 and #18) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Bed Rails - Intended Purpose and Potential Risks, dated 05/08/12, showed: - Intended Purpose of Bed Rails: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent the development and transmission of infection during blood glucose monitoring for two residents (Residents #30 and #42) and during insulin and medication administration for three residents (Residents #28, #30, and #45) out of six sampled residents. The facility census was 51. Review of the facility's policy titled, Policy and Procedure-Use of Gloves, dated 04/01/19, showed:- Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment and services to the resident and when cleaning contaminated surfaces;- Gloves should only be used once and discarded in an approved container located in the room in which the procedure is performed;- Once gloves are removed, the next step should be hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for two residents (Residents #9 and #18) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Bed Rails - Intended Purpose and Potential Risks, dated 05/08/12, showed: - Intended Purpose of Bed Rails: One of several methods utilized to prevent resident from falling out of bed, reminds resident not to get out of bed when medically contraindicated and/or medical equipment is attached to the resident, defines the bed edge, helps to protect resident from falling out of bed during transport, and may assist resident with movement within the bed and getting in and out of bed; - Potential Risks of Bed Rails: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This had the potential to affect all residents in the facility. The facility's census was 48. Review of the facility's policy, Environment/Homelike, undated, showed: - It is the policy of this facility to provide a safe, clean, comfortable and homelike environment. Including allowing residents to use personal belongings to the extent possible; - The facility will remain clean and sanitary; - The facility will be odor free; - The facility will maintain clutter and remove it if it poses a hazard; - Equipment will be kept in good repair; - The safety of the residents and staff will take precedence over resident choice. 1. Observation on 02/25/25 at 9:05 A.M. of the hallway near the front nurses' station showed a strong urine smell. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for six residents (Resident #11, #21, #22, #33, #37, and #202) out of 12 sampled residents. The facility's census was 48. Review of the facility's Discharge/Transfer Policy, revised 06/25/20, showed: - Explain transfer and reason to resident and/or representative, give copy of signed transfer or discharge notice to resident and/or representative. If an emergency, the transfer or discharge notice should be given to ambulance personnel; - Explain and give copy of bed hold form to the resident and/or representative. If an emergency transfer, may be completed later, but as soon as possible; - Complete transfer form, copy any portion of the medical record necessary for care of the resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for six residents (Resident #11, #21, #22, #33, #37 and #202) out of 12 sampled residents. The facility's census was 48. Review of the facility's Bed Hold Policy Notice, undated, showed: - It is the facility's policy to notify all residents and/or residents' representatives of the facility bed hold policy; - If the resident discharges to the hospital, the bed may be held by paying the room rate that is in effect at the time the reservation is made; - If the resident and/or representative wants to hold bed, a signed authorization must be obtained with each discharge; [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for two residents (Resident #38 and #202) out of 12 sampled residents. The facility's census was 48. The facility did not provide a policy. 1. Review of Resident #38's medical record showed: - admission date of 08/23/23; - Diagnoses of chronic pain, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Review of the resident's care plan, revised 12/19/24, showed the resident is a smoker. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that five nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 48. Review of the facility's policy, Nurse Aide Training, dated 05/01/23, showed the policy did not address the requirement that nurse aides should be certified within four months of employment. 1. Review of Nurse Aide H's personnel file and schedule showed: - Hire date of 01/03/23; - Not currently enrolled in a Certified Nursing Assistant (CNA) class; - Scheduled to work day shift on 02/04/25, 02/05/25, 02/08/25, 02/09/25,02/13/25, 02/14/25, 02/18/25, 02/20/25, 02/22/25, 02/27/25, and 02/28/25; - The facility failed to ensure the NA was certified within four months of their employment. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for four of four narcotic count books checked. The facility's census was 48. Review of the facility's policy titled, Narcotic Count, revised 04/30/20, showed: - Purpose is to complete a physical inventory of narcotics at change of each shift by two licensed nurses, two Certified Medication Technicians (CMTs), or (any combination of) to identify discrepancies and need for reconciliation and accountability; to assure controlled drugs are handled, stored, and disposed of properly; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent, when medications were administered. There were 29 opportunities with three errors made, for an error rate of 10.34%. This affected three residents (Resident #1, #9, and #31) outside of the 12 sampled residents, and had the potential to affect all residents. The facility's census was 48. The facility did not provide a policy. 1. Review of insulin aspart pen (insulin in a pen-type device) directions showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button to make sure drop of insulin appears; - Select dose; - Give injection; - After dose counter reaches zero, count to six; - After injection, remove needle and place in sharps container. 2. Review of Fiasp insulin pen directions showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This deficient practice affected one resident (Resident #202) out of 12 sampled residents and two residents (Resident #9 and #13) outside the sample and had the potential to affect all residents. The facility's census was 48. Review of the facility's policy titled, Medication Expiration Dates, dated 05/01/23, showed: - Purpose is to identify medication expiration dates and provide recommendations for disposal in accordance with manufacturer recommendations; - Medications and supplies that have reached their expiration date will be disposed of in accordance with facility policy; - The date of the opening should be noted on the medication package or container at the time of opening; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 48. Review of the facility's policy titled Quality Assurance and Improvement Program (QAPI), dated 05/31/24, showed: - The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; - Members of facility management are accountable for QAPI efforts; - The QAPI Committee will include at minimum: the Administrator, Director of Nursing; Medical Director; Activities Director; Social Services Director; Dietary Manager; Housekeeping and Laundry Supervisor; Maintenance Director; additional facility staff; and contracted staff including Pharmacy Consultant, Dietician, and Rehab Director; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection when proper surveillance was not done. The facility failed to use a blood glucose monitor that could be disinfected and shared between residents for six residents (Resident #1, #9, #10, #13, #31, and # 202) out of six sampled residents. The facility's census was 48. 1. Review of the facility's Infection Control Policy, dated 04/10/19, showed: - Policies and procedures will be utilized as the standards of the Infection Prevention and Control Program (IPCP); - The IPCP will be driven by coordination, oversight, surveillance, data analysis, outbreak management, prevention of infection, immunization and monitoring; - The IPCP will be coordinated and overseen by the Director of Nursing (DON); [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility's census was 48. Review of the facility's Infection Control Policy, dated 04/10/19, showed: - Policies and procedures will be utilized as the standards of the IPCP; - The IPCP will be driven by coordination, oversight, surveillance, data analysis, outbreak management, prevention of infection, immunization, and monitoring; - The IPCP will be coordinated and overseen by the Director of Nursing (DON); - The IPCP committee will review surveillance data, and reporting data to determine potential issues or trends; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) was complete and reviewed annually. The facility census was 56. Review of the Facility Assessment policy, dated 04/01/19, showed: - A facility assessment will be conducted annually to determine and update our capacity to competently care for and meet the needs of our residents during day-to-day operations including during an emergency; - Once a year and as needed, a designated team will conduct a facility wide assessment to ensure that the resources are available to meet the specific needs of the residents; - The team responsible for conducting, reviewing, and updating the facility assessment includes the following: the Administrator; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's QAPI Principles and Plan, undated, showed: - QAPI will be incorporated into the culture of the facility. We will use data gathered to make decisions and to drive improvement in all areas of our business. The underlying message to everyone working or living in our facility will be that we will take steps to identify, implement, and sustain continuous improvements in all departments. The method for approaching decision-making and problem solving will involve all members of our facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's census was 56. Review of the facility's policy, Quality Assurance and Improvement Program (QAPI), dated 04/10/19, showed: - The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; - The QAPI Committee will include at minimum: the Administrator; Director of Nursing; Medical Director; Activities Director; Social Service Director; Dietary Manager; Housekeeping and Laundry Supervisor; Maintenance Director; Additional Facility Staff; and contracted staff including but not limited to Pharmacy Consultant, Dietician, and Rehab Director; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's Antibiotic Stewardship policy, dated 03/26/20, showed: - The purpose is to reduce the use of antibiotics to make sure residents aren't receiving antibiotics unnecessarily; to educate resident, family, and staff on the use of receiving antibiotics unnecessarily; and to track antibiotic use and to make sure that the correct antibiotic is being prescribed; - The nurse will complete the criteria form specific to each individual's clinical symptoms and notify the doctor if it meets those specific criteria for an antibiotic order. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 56. The facility did not provide a policy regarding required primary professional training for the Infection Preventionist. During an interview on 01/25/24 at 2:49 P.M., the Director of Nurses (DON) said she is the IP. She has taken the classes, but hasn't taken the certification test. The facility doesn't have a certified IP. During an interview on 01/26/24 at 6:45 P.M., the Administrator said she would expect the facility to have a certified IP. During an interview on 01/30/24 at 3:45 P.M., the Administrator said the DON has been in the IP role for about two years.

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond (a purchased bond for security of resident's personal funds) sufficient to ensure the protection of resident funds. The facility census was 56. Review of the residents' personal funds account for the period January 2023 through December 2023 showed an average monthly balance of $84,050.48. An average monthly balance of $84,050.48 rounded to the nearest thousand equaled $84,000.00, at one and one half times will equal the required bond amount of at least $126,000.00. Review of the facility's current surety bond, effective 05/08/23, showed the facility held a bond in the amount of $87,000.00, which was insufficient by $39,000.00. During an interview on 01/26/24 at 5:28 P.M., the Business Office Manager (BOM) said the surety bond should be one and one half times the average ledger balance. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) prior to hire for five out of ten sampled new staff. This deficient practice had the potential to affect all residents, staff and visitors. The facility census was 56. Review of the facility's policy, Abuse and Neglect Reporting Policy, undated, showed: - The purpose is to ensure the safety and comfort of all the residents residing within this facility and to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion, and misappropriation of property for all residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and document an advance directive (a written legal statement of a person's wishes in regards to medical treatment) or code status (the type of treatment a person would or would not receive if their heart or breathing were to stop) for two residents (Resident #114 and #115) out of 14 sampled residents. The facility census was 56. Review of the facility's policy, Advance Directive, revised [DATE], showed: - Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct an assessment for the use of a shoulder strap (straps over both shoulders that buckle in the center of chest while in a wheelchair) as a restraint for one resident (Resident #5) out of one sampled resident with a restraint, who was unable to easily and intentionally remove the strap. The facility failed to identify a medical symptom that supported the use of the shoulder strap and failed to develop a care plan that included documentation of the medical symptom being treated, attempted alternatives or interventions nor was there any documentation of ongoing monitoring or re-evaluation of the device. The facility census was 56. Review of the facility's policy, Acknowledgement Facility Restraint Philosophy and Policy, not dated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Resident #15 and #34) out of 14 sampled residents transferred to the hospital. The facility's census was 56. Review of the facility's Admission, Transfer & Discharge Rights policy, undated, showed: - The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Before a resident is transferred, the facility will notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge. This notice shall be in a language and manner they understand. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #15 and #34) out of 14 sampled residents. The facility census was 56. Review of the facility's Admission, Transfer & Discharge Rights policy, undated, showed: - The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Before a resident is transferred to a hospital, the facility will provide written information to the resident and a family member or legal representative specifying the duration of the bed hold policy during which the resident is permitted to return and resume residence in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit two annual Minimum Data Sets (MDS, a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for two residents (Resident #1 and #5) out of 14 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual showed the ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment. Review of the facility's policy, MDS Resident Assessment, dated 02/20/20, showed assessments will be completed per RAI guidelines. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit a discharge or death in facility Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for five residents (Resident #2, #24, #32, #44, and #46) outside of the 14 sampled residents. The facility census was 56. Review of the Resident Assessment Instrument (RAI) Manual showed: - Discharge assessment to be completed no later than 14 days after the discharge date (Z0500B + 14 days) and transmitted no later than the MDS completion date + 14 calendar days; - Death in Facility tracking record to be completed no later than seven calendar days after the discharge (death) date (Z0500B + seven days) and transmitted no later than discharge (death) date + 14 calendar days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for oxygen use and orders for oxygen tubing (a small, flexible tube that contains two open prongs that sit in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for two residents (Resident #34 and #114) out of two sampled residents with oxygen. The facility census was 56. Review of the facility's policy, Physician Medication Orders, revised April 2010, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for dialysis (a process for removing waste and excess water from the blood) treatments for one resident (Resident #15) out of one sampled resident receiving dialysis. The facility census was 56. The facility did not provide a policy. Review of Resident #15's medical record showed: - admission date 06/12/23; - Diagnoses including type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), chronic kidney disease, and dependence on renal dialysis. Review of the resident's care plan, last revised 11/04/23, showed: - Resident will receive hemodialysis related to diagnosis of chronic kidney disease on Monday, Wednesday and Friday. Nursing sends communication forms with resident to dialysis and dialysis center faxes copy back to facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a as needed (PRN) psychotropic medication's (a medication that changes brain function and changes perception, mood, consciousness, or behavior) order was limited to 14 days for one resident (Resident #1) out of 14 residents sampled. The facility census was 56. Review of the facility's policy, Psychotropic Drug Use, dated 02/20/20, showed any PRN antipsychotic shall be ordered for 14 days or less. The effectiveness and need for the PRN antipsychotic will then be reevaluated by the nurse and physician. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool), dated 12/15/23, showed: - No cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were two errors out of 31 opportunities for errors, resulting in an error rate of 6.45%. Out of the six residents observed, this affected two residents (Resident #12 and #14), outside of the 14 sampled residents. The facility census was 56. Review of NovoLog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised February 2015, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing; - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button and make sure drop of insulin appears; - Select dose; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize proper technique during incontinent care for one resident (Resident #16) out of 14 sampled residents and one resident (Resident #27) outside the sample, when staff removed multiple clean disposable wipes from the package with soiled gloves and did not perform appropriate hand hygiene or glove changes. The facility failed to use proper hygienic practices in the dining room for two residents (Resident #5 and #33) out of the 14 sampled residents, when staff touched the resident's food with bare hands, and touched a resident's hair, clothing, and wheelchair with bare hands and assisted the resident to eat. The facility failed to develop and implement a water management program to prevent Legionella infection. The facility's census was 56. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected three out of four sampled Certified Nurse Assistants (CNAs). The facility census was 56. Review of the facility's policy, In-Service Training Program, Nurse Aide, revised December 2011, showed: - All nurse aide personnel shall participate in regularly scheduled in-service training classes; - Annual in-services must be no less than 12 hours per employment year; - Enhance the skills of the nurse aides in providing care for residents with dementia and preventing resident abuse. 1. Review of the in-service record for CNA K showed: - A hire date of 02/23/21; - A total of seven hours of annual in-service training for February 2022 through February 2023; - Less than twelve hours of in-service education for February 2022 through February 2023; [...]

Inspectors wroteBased on observation and interview, the facility failed to make available the most recent survey and any abbreviated survey results, in a place that was readily accessible to residents, family members and legal representatives of the resident. The facility census was 56. The facility did not provide a policy for posting survey results. Observation of the facility on 01/26/24 at 01:22 P.M. showed no survey results posted. During a Resident Council interview on 01/25/24 at 2:07 P.M., seven residents collectively said they were not aware the survey results were available or where they were located. During an interview on 01/26/24 at 6:45 P.M., the Administrator said she would expect the most recent survey results to be posted where the residents have access to them.