Ballard Center

Inspectors wroteBased on interview and record review the facility failed to ensure risks and benefits associated with a health care/treatment plan change was offered to a resident who had the capability to make that decision for 1 of 3 residents (Resident 1), reviewed for resident rights. This failure placed the resident at risk for emotional distress, not having health care coverage, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physicians orders for referrals to audiology (healthcare focused on hearing and their related disorders) were followed for 2 of 3 residents (Resident 2 and Resident 3), reviewed for hearing devices. This failure placed the residents at risk for poor communication, low self-esteem, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice for 4 of 4 residents (Residents 1, 2, 3, & 4) and failed to provide a written transfer/discharge notice to the residents and/or their representative for 1 of 4 residents (Resident 4), reviewed for discharge process. These failures placed the residents at risk of not having opportunities to make informed decisions about transfer/discharge.

Inspectors wroteBased on record review and interview, the facility failed to ensure annual Minimum Data Set (MDS - an assessment tool) were completed within 14 days of the ARD (Assessment Reference Date) for 3 of 26 residents (Residents 18, 100 & 2), reviewed for comprehensive assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) for 3 of 6 residents (Residents 10, 9 & 7), reviewed for SCSA. This failure placed the residents 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 complete quarterly Minimum Data Set (MDS- an assessment tool) timely within 14 days from the Assessment Reference Date (ARD) for 3 of 21 residents (Residents 14, 10 & 7), reviewed for resident assessments. This failure placed the residents 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 ensure resident assessments were completed accurately for 9 of 32 residents (Residents 49, 100, 14, 13, 66,19, 3, 10 & 71), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessment was marked on the MDS regarding weights, PASRR [Preadmission Screen and Resident Review], insulin injections (medication used to manage blood sugar levels), Serious Mental Illness (SMI), diagnosis, weight loss, medication, and Bilevel Positive Airway Pressure (BiPAP - a noninvasive ventilator that helps people breathe easier by delivering pressurized air through a mask) 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 ensure smoking materials were safely stored for 8 of 10 residents (Residents 66, 54, 63, 61, 75, 13, 2 & 85), reviewed for smoking. This failure placed the residents at risk for accidents, injury and a diminished quality of life.:

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess and evaluate the need for bed rails for 3 of 6 residents (Residents 9, 74 & 103), reviewed for bed rail use. This failure placed the residents at risk for entrapment, injury, and a diminished quality of life.

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 licensed and unlicensed nursing staff directly responsible for resident care per shift for 9 of 10 days (04/01/2026 to 04/08/2026 & 04/10/2026), reviewed for posted nurse staffing information. In addition, the facility failed to post the current nurse staffing information for 1 of 8 days (04/09/2026). The failure to post a complete and current nurse staffing 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 a system was in place for tracking and accounting of controlled drugs, and failed to store controlled drugs in a locked, permanently affixed compartments in 1 of 2 medication rooms (Medication room [ROOM NUMBER]'s E-Kit [emergency medication box]), reviewed for controlled drugs management. This failure placed the facility at risk for potential loss and/or drug diversion of controlled drugs.

Inspectors wroteBased on interview and record review, the facility failed to ensure adverse side effects and target behaviors were monitored for medication use and/or physician's orders were followed when administering medication for 3 of 6 residents (Residents 30, 13 & 7), reviewed for unnecessary medications. These failures placed residents at risk for adverse side effects, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were properly labeled and stored in accordance with current accepted professional standards for 3 of 3 medication carts (Medication Cart 3, Medication Cart 4 & Medication Cart 2), and for 1 of 2 medication rooms (Medication room [ROOM NUMBER]), reviewed for medication storage and labeling. These failures placed the residents at risk of receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. In addition, the facility failed to ensure hand hygiene was performed after removal of Personal Protective Equipment (PPE - gloves and gown), disinfect shared medical equipment after resident use, ensure proper PPE and/or Enhanced Barrier Precautions [EBP-specialized infection control measures used to prevent the spread of specific infections) were followed for 3 of 8 staff (Staff P, Staff L & Staff M), reviewed for infection control. These failures placed residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was evaluated, and a physician order was obtained for safe administration of medication for 1 of 1 resident (Resident 25), reviewed for self-administration of medication. This failure placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications.

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 1 of 32 residents (Resident 94), reviewed for resident assessments. 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 ensure the Preadmission Screen and Resident Review (PASRR or PASARR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 2 of 10 residents (Residents 6 & 30), reviewed for PASRR coordination. This failure placed the residents at risk of not receiving the necessary behavioral health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a new Level I Preadmission Screening and Resident Review (PASARR or PASRR-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) was completed for an exempted hospital discharge resident who remained in the facility for more than 30 days and/or a Level I PASARR was completed accurately for 2 of 10 residents (Residents 99 &19), reviewed for PASARR screening. These failures placed residents at risk of not receiving the appropriate care, limited access to necessary specialized services, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator and complete a new Level I PASARR after a significant change in status occurred for 1 of 1 resident (Resident 7), reviewed for PASARR. 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 develop and/or implement a care plan for 2 of 26 residents (Residents 1 & 19), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for psychotropic (medications that change how the brain works to affect mood, thoughts, feelings, or behavior) and Post Traumatic Stress Disorder (PTSD - a mental health condition that can develop after a traumatic event) 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 ensure the care plan was revised accurately to reflect changes related to use of hearing devices for 1 of 2 resident (Resident 66), reviewed for care planning. This failure placed resident at risk for unidentified and unmet care needs, and a diminished quality of life.:

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing activities/programs for 1 of 1 resident (Resident 91), reviewed for activities. This failure placed the resident at risk for unmet leisure interests, poor psychosocial well-being, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care and communication with medical providers were consistently followed timely in accordance with professional standards of practice and ensure neurological/neuro assessments (used to establish a baseline or identify acute changes in condition) were consistently conducted following an unwitnessed fall for 1 of 1 resident (Resident 106), reviewed for change of condition. These failures placed residents at risk for potential harm, poor clinical outcomes, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory services in accordance with accepted professional standards of practice for 2 of 2 residents (Residents 71 & 25), reviewed for respiratory care. The failure to properly store the Bilevel Positive Airway Pressure (BiPAP - a noninvasive ventilator that helps people breathe easier by delivering pressurized air through a mask) mask and oxygen (O2) nasal cannula (flexible tube used to deliver O2) when not in use, ensure to label/date O2 tubing, and to change AIRVO 2 (a humidifier with an integrated flow generator that delivers warmed, humidified, high-flow air and/or oxygen) water bag, 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 consistently monitor weights before and after hemodialysis (a procedure that removes waste from the blood via a machine when the kidneys can no longer function properly) and include transportation information in the care plan per professional standards of practice for 1 of 3 residents (Resident 19), reviewed for dialysis. This failure placed the resident at risk for unmet care needs, related complications, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene before putting on new gloves for 2 of 6 staff (Staff Z and Staff AA), reviewed for food services. This failure placed the residents at risk for food-borne illnesses (caused by the ingestion of contaminated food or beverages), cross-contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was administered for 1 of 5 residents (Resident 19), reviewed for pneumococcal immunization. This failure placed the resident at risk for acquiring, transmitting, and/or experiencing potential complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to complete thorough and timely investigations for 3 of 5 residents (Residents 1, 3 & 4), reviewed for abuse/incident investigations. This failure placed the residents at risk for unidentified abuse, repeated incidents and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to log an allegation of unprofessional conduct on the facility's reporting log for 1 of 5 residents (Resident 3), reviewed for incident investigations. This failure placed the residents at risk of unidentified abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 5 residents (Residents 1, 2 and 3), reviewed for discharge care plans. The failure to develop a care plan to address necessary care and services for planned discharges placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate discharge instructions including a discharge summary or recapitulation of stay for 3 of 4 residents (Residents 2, 3 & 4), reviewed for discharge process. This failure placed the residents at risk for lack of knowledge regarding their medical status and medications at the time of discharge, a break in communication and continuity of care, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to verify and follow the code status (medical care elected by a person in the event their heart or breathing stops) for 1 of 3 residents (Resident 1), and failed to ensure licensed nursing staff had current cardiopulmonary resuscitation (CPR-an emergency procedure consisting of chest compressions combined with giving breaths of air) certification for 2 of 6 staff (Staff E & F), reviewed for CPR. The failure to follow advance directive (written document of a person's expressed emergency care) and timely CPR training for staff placed the residents at risk for unwanted CPR, avoidable trauma and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse for 2 of 3 residents (Resident 1 & Resident 2), reviewed for abuse reporting. The facility's failure to report an allegation of sexual abuse to law enforcement placed the residents at risk for repeated incidents and unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective pest control system was in place for 2 of 3 residents (Residents 1 & 2), reviewed for pest control. This failure placed the residents at risk for unsafe living conditions, emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely initiate and/or investigate an allegation of neglect for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigation. This failure placed the resident at risk for potential unidentified neglect and lack of protection from abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to timely develop a care plan for lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) infestation for 1 of 1 resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk for further infestation, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contact precautions (set of safeguards used to prevent the spread of infection transmitted through direct or indirect contact with a resident or their environment) signage was placed on the outside of the room for 1 of 1 Resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk of further infestation of lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) and related complications.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure by not ensuring reference checks were conducted prior to hire for 4 of 5 staff (Staff Y, Z, AA & BB), reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to complete the required annual performance evaluations for 5 of 5 staff (Staff M, N, O, P & Q), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. The failure to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately store drugs and/or biologics (diverse group of medicines made from natural sources) for 2 of 3 medication carts (Medication Carts 2 & 3), reviewed for medication storage. This failure placed the residents at risk for receiving compromised/ineffective medications and potential adverse outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received current food menus and/or alternative menus that meets their needs including daily fresh fruits and vegetables for 5 of 6 residents (Residents 14, 309, 89, 55 & 52), reviewed for dining services. This failure placed the residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 4 of 4 residents (Residents 51, 27, 64 & 93), reviewed for infection control. In addition, the facility failed to ensure hand hygiene, proper glove use, and infection control practices were followed for 3 of 13 staff (Staff DD, Staff II & Staff V). These failures placed the residents, staff, and visitors at an increased risk for infection and related complications.

Inspectors wroteBased on interview, and record review, the facility failed to initiate and resolve a grievance for 2 of 4 residents (Residents 44 & 36), reviewed for grievances. The failure to resolve grievances for missing personal items and discharge planning placed the residents at risk for frustration, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident to resident altercations were thoroughly investigated for 3 of 5 residents (Residents 44, 55 & 46), 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 accurately assess 1 of 26 residents (Resident 36), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding collecting information during the entire look-back period for MDS Section L (Oral/Dental Status), Section N (Medications), Section O (Special Treatments, Procedures, and Programs), Section P (Restraints and Alarms) and Section Q (Participation in Assessment and Goal Setting), placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 2 of 6 residents (Residents 103 & 22), reviewed for PASARR screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement care plans for 4 of 26 residents (Residents 39, 89, 17 & 99), reviewed for comprehensive care plans. The failure to implement care plans for edema (swelling caused by buildup of fluid in the body's tissues), nutrition, Range of Motion (ROM) and discharge planning placed the residents at risk for unmet care needs, complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plans for 3 of 26 residents (Residents 36, 87 and 91), reviewed for care plan timing and revision. The failure to develop comprehensive care plans for discharge planning, smoking behaviors and oxygen use, placed the residents at risk for unmet care needs, burns, injury, and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order in accordance with professional standards when administering medications for 3 of 11 residents (Resident 42, 43 & 46), reviewed for medication administration. These failures 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 an effective resident centered discharge plan was in place for 1 of 5 residents (Resident 36), reviewed for discharge planning. The failure to develop a discharge care plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-morale, sadness, 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 2 of 4 residents (Residents 8 & 65), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with getting out of bed, showers, and nail 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 ensure residents received care and services in accordance with professional standards of practice for 3 of 5 residents (Residents 39,89 & 46), reviewed for quality of care. The failure to follow treatment orders for edema (swelling) and bowel management and/or the failure to notify medical providers for a significant weight gain placed the 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 services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 1 of 3 resident (Resident 17), reviewed for ROM and mobility. This failure placed the resident at risk for unmet care needs, a decline in ROM, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement smoking assessment and care plan, and did not ensure smoking materials were securely maintained for 1 of 10 residents (Resident 91), and failed to ensure side rails were secured and maintained for 1 of 2 residents (Resident 34), reviewed for accident hazards. These failures placed the residents at risk of potential burns, injury, potential harm and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 2 of 3 residents (Residents 22 & 87), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy, and properly store oxygen equipment placed the residents at risk for respiratory infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to include plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure foods were served at proper temperature for 2 of 5 nursing units (500 and 200 Unit), and 6 of 6 residents (Residents 7, 3, 6, 4, 5 & 1), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a boiler that consistently supplied hot water to the kitchen sink for dishwashing for 1 of 1 kitchen, reviewed for essential equipment. This failed practice caused the meals to be served from plastic containers that did not keep the meals at proper temperatures when served to residents and had the potential to cause weight loss and a diminished quality of life.

Inspectors wroteAMENDED ARE IN BOLD. Based on observation, interview, and record review, the facility failed to take timely action and/or document the reason for delayed dental treatment for 1 of 3 residents (Resident 1), reviewed for dental care services. The failure to provide timely dental care services placed the resident at risk for dental pain, decline in nutritional status, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide meals that accommodated resident food allergies and preferences for 1 of 2 residents (Resident 1), reviewed for food allergies/preferences. This failure placed the resident at risk for allergic reaction, dissatisfaction with food, weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff D) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances were initiated, logged, addressed, and resolved timely in response to concerns for 4 of 6 residents (Residents 9, 33, 19 & 22), reviewed for grievances. This failure placed the residents at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure food were served at proper temperature for 8 of 8 residents (Residents 58, 38, 83, 44, 73, 56, 74 & 54), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure damaged wheelchair armrests were repaired and/or replaced for 1 of 1 Resident (Resident 17), reviewed for comfortable/safe equipment use. This failure placed the resident at risk for unsafe equipment, potential injury, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notices to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents) describing the reason for transfer for 1 of 3 residents (Resident 42) reviewed for hospitalization. This failure placed the residents at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold notices were provided at the time of transfer for 3 of 3 residents (Residents 42, 59 and 86) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission assessments were completed within 14 days of admission for 2 of 15 residents (Residents 86 & 199), reviewed for comprehensive assessments. This failure placed the residents at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment was conducted after the determination that hospice (end of life care) services no longer required for 1 of 1 resident (Resident 38), reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days 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 complete and transmit resident assessment data according to the required timeframe for 1 of 3 residents (Resident 42), reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 24 residents (Residents 29, 38 & 77) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding participation of assessment/goal setting (Section Q) and Brief Interview for Mental Status (BIM - to assess cognitive patterns) placed the residents at risk for unidentified or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission and ensure a summary of the baseline was provided to the resident and/or their representative for 1 of 15 residents (Resident 199), reviewed for baseline care plan. 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 ensure care plans were developed for 1 of 24 residents (Resident 199), reviewed for comprehensive care plans. The failure to develop care plans for skin conditions and use of a Continuous Positive Airway Pressure (CPAP, a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing) machine 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 and/or their representatives were invited to participate in care plan meetings/care conferences for 3 of 6 residents (Residents 29, 45 and 50), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers/bathing were consistently provided for 2 of 4 residents (Residents 41 & 29), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a nutritional recommendation for Vitamin D (or Cholecalciferol, a supplement) was implemented for 1 of 1 resident (Resident 50), reviewed for nutritional management. In addition, the facility failed to ensure necessary care/treatment in accordance with professional standards of practice was followed for 1 of 1 resident (Resident 199), reviewed for skin condition. These failures placed the residents at risk for decline in health status, medical complication, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision was provided for a safe use of e-cigarette (electronic cigarette) 1 of 1 resident (Resident 30), reviewed for e-cigarette/smoking management. This failure placed the resident at risk for burns, and avoidable accidents or fire.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weekly weights were conducted for the first four weeks of admission to determine a baseline weight and failed to ensure nutritional supplements (health shake) at each meal was served for 1 of 1 resident (Resident 50) reviewed for nutritional management. This failure placed the resident at risk for significant weight loss, medical complications, and a diminished quality of life.