Baptist Homes, Tri-County

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety. The facility census was 58. Review of the facility policy, Sanitization, revised November 2022, showed the following:-The food service area is maintained in a clean and sanitary manner;-All kitchens, kitchen areas and dining areas are kept clean;-All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 1. Observations in the kitchen on 3/2/26 between 10:45 A.M. and 3:30 P.M., and on 3/3/26 between 8:30 A.M. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund petty cash account and by not reconciling each month. The facility managed funds for 37 residents. The facility census was 58. Review of the facility's monthly bank statements and resident trust fund records for December 2025, January 2026 and February 2026, showed no documentation the facility reconciled the monthly bank statements with the month ending resident trust fund records, to include outstanding checks and petty cash, to ensure an accurate accounting of all resident finds. During an interview on 3/5/26 at 1:00 P.M., the Business Office Manager (BOM), said the following: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service (USPS), including Saturdays. The facility census was 58. Review of the facility's undated admission Packet showed a Patient [NAME] of Rights (page 33), which included the right of each resident to send and receive unopened mail. Review of the facility policy, Mail and Electronic Communication, revised May 2017, showed the following: -Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email, and other electronic forms of communication confidentially; -Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. The facility census was 58. Review of the facility's undated admission packet, Resident Rights, showed the following: -Each resident shall be encouraged and assisted throughout his/her stay to exercise their rights as a resident and citizen and may voice grievances and recommend changes in policies and services to the facility staff or outside representatives of his/her choice; -A staff person shall be designated to receive grievances and residents may voice their complaints and recommendations to staff designee, an ombudsman, or any person outside the facility; -Residents shall be informed of and provided with a viable format for recommending changes in policy and services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services that met professional standards of practice for two residents (Resident #10 and #56), in a review of 19 sampled residents. The facility failed to administer bolus tube feedings according to physician orders and per manufacturer guidelines and failed to properly administer medications via a feeding tube for Resident #10. The facility failed to obtain a lithium level (a laboratory test to monitor the concentration of lithium in the blood - a mood stabilizing medication to treat mental illness) for Resident #56. The facility census was 58. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%), when staff made two medications errors out of a total of 30 opportunities for error, resulting in a 6.67% error rate. Staff did not ensure Resident #2 received the full dose of ordered insulin and did not administer the ordered dose of Tramadol (a narcotic pain medication) to Resident #44. The facility census was 58. Review of the facility policy, Administering Medications, revised April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure stock medications (a limited supply of non-prescription, over-the-counter [OTC] or emergency drugs stored on-site for immediate use) were labeled with the date they were opened and removed and/or replaced when expired. This had the potential to affect all residents. The facility census was 58. Review of the facility policy, Storage of Medications, last revised November 2020, showed the following: -The facility stores all drugs and biologicals (specialized medications used to treat specific conditions) in a safe, secure, and orderly manner; -Discontinued, outdated, or deteriorated drugs or biologicals are destroyed; -OTC medication will be available for use until the manufacturer expiration date unless there are signs of deterioration; -OTC will have an open date label when the container is opened; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served food that was palatable and served at a safe and appetizing temperature. The facility census was 58. Review of the facility policy, Food Preparation and Services, revised November 2022, showed the following:-Proper hot and cold temperatures are maintained during food distribution and service; -Food and nutrition services staff are to monitor the temperatures of foods held in the steam tables throughout the meal service. 1. Review of the Resident Council Minutes, dated 01/08/26, showed the following:-The vegetables were cooked too long;-The food on the west hall was cold. Staff explained to the residents the plate warmer broke, and they were working on getting a new one. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for two residents (Resident #01 and Resident #03), in a review of 18 sampled residents, and for two additional residents, (Resident #32 and Resident #39), who participated in a group interview and reported bedtime snacks were not offered on a routine basis at the facility. The facility census was 58. Review of the facility policy Frequency of Meals, dated July 2017, showed the following:-Nourishing snacks will be available for residents who need or desire additional food between meals;-Evening snacks will be offered routinely to all residents;-Residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast excessed 14 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) the Infection Preventionist attended QAPI meetings as required. The facility census was 58. Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Plan, dated 06/23/25, showed the following:-QAPI Committee Members:-Administrator;-Medical Director;-Director of Nursing;-Pharmacy Consultant;-Infection Preventionist (IP);-MDS Coordinator;-Social Services Director;-The QAPI Committee meets quarterly. 1. Review of the Quarterly QAPI Meeting Attendance, dated 04/29/25, showed documentation the IP was absent. Review of the Quarterly QAPI Meeting Attendance, dated 07/24/25, showed documentation the IP was absent. Review of the Quarterly QAPI Meeting Attendance, dated 10/27/25, showed documentation the IP was absent. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate infection control practices for six residents (Resident #59, #47, #1, #2, #9 and #36), in a review of 19 sampled residents, and for four additional residents (Residents #46, #60, #48 and #44). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an adequate audible system for residents to signal nursing staff for assistance and failed to ensure staff responded to call lights timely for two residents (Resident #19 and Resident #2) in a review of 19 sampled residents and two additional residents (Resident #39 and Resident #32). The facility census was 58. Review of the facility policy titled Resident Call System dated [DATE] showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation;-Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor;-Call system communication may be audible or visual. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately address strong and pervasive urine odor at its source. The facility census was 58. No policy regarding addressing odors was received from the facility upon request. 1. Observation on 03/02/26 at 11:50 A.M. showed the following: A strong, urine odor in the hallway outside of Resident #28's room and adjoining resident rooms on the hall; -Resident #28's door was partially open; -The resident appeared to be sleeping and lay on his/her bed, unclothed, with his/her private area covered by a towel;-The fitted sheet beneath the resident had a dark, circular ring just beneath the resident's buttocks that appeared wet. Observation on 03/02/26 at 4:15 P.M. showed the following: -A strong urine odor noted in the hallway outside of the resident's room, and adjoining resident rooms in the hall; [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor the drug regimen for unnecessary medications by not ensuring the as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #19 and #14), in a review of 19 sampled residents. The facility census was 58. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan that included services to maintain the residents' highest practicable physical, mental, and psychosocial well-being, when the facility failed to include skin breakdown and pressure ulcers for one resident (Resident #9), and the use of a nebulizer due to chronic health conditions for one resident (Resident #36), in a review of 19 sampled residents. The facility census was 58. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff transferred one resident (Resident #59), in a review of 19 sampled residents, using appropriate technique, consistent with the resident's abilities and condition, to ensure the resident's safety. The facility census was 58. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews for two Certified Nurse Aides (CNA F and CNA G), in a review of two CNA employee files. The facility census was 58. Review of the Facility Assessment, revised 04/01/2025, showed the following:-The facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for the resident population;-Required in-service training for nurse aides. In-service training must:-Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician provided his/her rationale for not making a medication change as recommended by the pharmacist during the monthly drug regimen review for one resident (Resident #9), in a review of 19 sampled residents. The facility census was 58. Review of the facility policy, Antipsychotic Medication Use, revised July 2022, showed the following:-All antipsychotic medications will be used within the clinically recommended dosage guidelines or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours;-The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two residents (Resident #2 and #8) in a review of nine residents when staff failed to provide incontinence care timely and maintain good personal hygiene and failed to ensure resident clinical assessments were completed and documented for Resident #2. The facility failed to provide sufficient staff on the memory care unit to ensure supervision of Resident #8. The facility also and failed to consistently have Certified Nurse Assistant (CNA) staff as identified in the facility assessment. The facility census was 54. Review of the facility policy Staffing, Sufficient and Competent Nursing, dated 8/2022 showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #2), who staff identified as incontinent and required staff assistance with toileting and incontinence care, in a review of nine residents, was provided incontinence care timely and maintained good personal hygiene. The facility census was 54. Review of the facility policy, Urinary Continence and Incontinence, Assessment and Management, dated 8/2022 showed the following: -As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence; -Staff will check the resident for incontinence and change the resident at regular intervals using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #2) in a review of nine residents, was provided treatment and care in accordance with professional standards of practice when staff failed to assess the resident's clinical condition, failed to ensure a heart monitor was in place and functioning as ordered by the physician, failed to ensure the resident received therapy services following a hospitalization, and failed to ensure the resident's Care Plan was up to date and reflected the resident's current condition and care needs. The facility census was 54. Review of the facility policy admission Notes, dated 9/2012, showed the following: -Preliminary resident information shall be documented upon a resident's admission to the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures were followed when staff failed to utilize proper handwashing and gloving techniques while providing wound care and failed to utilize Enhanced Barrier Precautions (EBP, an infection control intervention that utilizes personal protective equipment to reduce the spread of multi drug-resistant organisms) during wound care for two residents (Resident #3 and #7) in a review of nine residents. The facility census was 54. Review of the facility policy, Handwashing/Hand hygiene, dated 8/2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitation and food storage practices were maintained in the main facility kitchen and the activity kitchen. The facility census was 47. Review of the facility policy, Food Storage (Dry, Refrigerated and Frozen), dated 2020, showed the following: -Food shall be stored on shelves in a clean, dry area free from contaminants; -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 41 residents. The facility census was 47. 1. Record review of the facility maintained bank statements for months 01/2023 through 12/2023 showed no documentation of reconciliations. Record review of the facility maintained reconciliation forms, dated 01/2023 through 12/2023, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required pre-employment screenings for three of seven sampled employees hired since the previous survey. The facility failed to request a criminal background check for three employees and complete an Employee Disqualification List (EDL) check for one employee, prior to hire. The facility census was 47. Review of the facility policy, Background Screening Investigations, revised March 2019, showed the following: - For purposes of this policy ''direct access employee'' means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on a pureed diet and residents on a dental soft (mechanical soft) diet received food in the proper form in accordance with their physician's orders. The facility census was 47. Review of the facility policy, Pureed Diet, dated 2022, showed the following: -The pureed diet is designed for individuals who cannot chew foods of the dental soft (mechanical soft) consistency and/or difficulty swallowing; -All foods are prepared in a food processor or blender, with the exception of those foods which are normally in a soft, moist and smooth state; -Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve the appropriate consistency (puddings, smooth mashed potatoes); -Process hot or cold items until they are smooth and homogenous in texture; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for four staff members in a review of seven sampled employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. The facility census was 47. Review of the facility's policy, Employee Screening for Tuberculosis, revised March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Residents #32, #33 and #15), in a review of 12 sampled residents, and for one additional resident (Resident #5). The facility census was 47. Review of the undated facility policy, Bed Safety and Bed Rails, showed the following: -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the Food and Drug Administration (FDA). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for four residents (Resident #35, #39, #100 and #101). The facility census was 47. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 02/08/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #35 $1,455.70 #39 $2,540.75 #100 $92.40 #101 $57.60 Total $4,146.45 During email correspondence on 02/09/24 at 9:59 A.M., the Business Office Manager said he/she did not realize there could be no resident credits in the operating account.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, after two residents (Resident #1 and #39), in a review of 12 sampled residents, were admitted to hospice. The census was 47. Review of the facility's Change in a Resident's Condition or Status Operational Policy, revised February 2021, showed a significant change in condition is a major decline or improvement in the resident's status that: -a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); -limpets more than one area of the resident's health status; -creatures interdisciplinary review and/or revision to the care plan; and -d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks for two residents (Residents #39 and #40), in a review of 12 sampled residents. The facility census was 47. Review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised [DATE], showed the following: -The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications through a gastrostomy tube (g-tube; a tube placed through the abdomen directly into the stomach for nutrition and medications) in accordance with facility policy for one resident (Resident #3), in a review of 12 sampled residents. The census was 47. Review of the facility policy, A Stepwise Approach: Selecting Medications for Feeding Tube Administration, dated 2020, showed giving medications through an enteral feeding tube can be complicated. Clogging can be a major complication with feeding tubes. Inappropriate medication administration and inadequate flushing can lead to clogging. Generally, do NOT mix medications with tube feedings, mix medications together, or give multiple medications at the same time. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders and ensure one resident (Resident #11), in a review of 12 sampled residents, was free from a significant medication error, when staff failed to discontinue a medication for 34 days after the resident's physician ordered to discontinue the medication. The facility also failed to properly transcribe the physician's orders received upon the resident's readmission to the facility from the hospital to show the previously discontinued medication was to be given as needed (PRN). Staff administered the medication as scheduled and not PRN. The facility census was 47. Review of the facility policy for administering medications, last revised April 2019, showed the following: -Medications were administered in a safe and timely manner, and as prescribed; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to four residents (Residents #3, #11, #33, and #40), in a review of 12 sampled residents, and/or their representative upon transfer to the hospital. The census was 47. Review of the facility policy, Facility-Initiated Transfer or Discharge, dated October 2022, showed once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. -When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three residents (Residents #3, #11, and #40), in a review of 12 sampled residents, and/or their representative of the facility's bed hold policy at the time of transfer to the hospital. The facility census was 47. Review of the facility undated policy, Bed Hold Policy Guidelines, showed the facility will notify all residents and/or representatives of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of the transfer to the hospital or leave; and at the time of the non-covered therapeutic leave. 1. Review of Resident #3's medical record showed his/her family member was his/her responsible party. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their policy and failed to initiate cardiopulmonary resuscitation (CPR) (process of providing rescue ventilation and chest compressions to maintain circulation of blood) and call 911 for two residents (Resident #105 and #106) identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the residents unresponsive and without a pulse. The facility census was 55. The administrator was notified on [DATE] at 2:30 P.M. of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the undated facility policy CPR showed the following: Standard: -Residents who have Full Code status will be given CPR in the absence of vital signs; Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate accurate and consistent information related to Resident #42's condition to the resident's physician, including the resident's variations in level of alertness and expressions of thirst. The facility failed to include hospice and the resident's family in an effective plan of care, to address the resident's needs after the facility received an order for the resident to be given nothing by mouth (NPO) following an episode of difficulty in swallowing. The resident had periods of fluctuating levels of alertness both before and after 2/8/22 when the NPO order began. Following the NPO order the resident verbalized thirst. The facility failed to ensure the resident was assessed and received appropriate interventions to address thirst, hydration and nutrition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident, Resident #27, in a review of 19 sampled residents. The facility staff failed to implement fall prevention interventions as indicated on the resident's care plan, failed to provide safe transfers as directed by the resident's plan of care. Resident #27 had multiple falls with injuries including a subdural hematoma (pool of blood between the brain and its outermost covering). The facility census was 55. Review of the undated facility policy, Fall Assessment policy and procedures, showed the following: Fall assessment is completed up on admission to identify residents, who are at high risk for falls order to implement interventions and reduce the incidence of falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess pain twice daily as directed in the facility policy, report pain during care to the charge nurse, provide medications in anticipation of cares that caused pain, for one resident (Resident #43), in a review of 19 sampled residents, who yelled out in pain during care. The facility census was 55. Review of the facility undated Pain Management Policy showed the following: -Each resident who experiences pain will have an assessment of that pain and will have a treatment plan established to treat his/her pain; -To effectively prevent or reduce the limits pain causes on the activities of daily living for our residents. And, assist in maintaining their dignity, self-respect and quality of life they are entitled to; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide/designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis, and provide an RN eight consecutive hours a day, seven days a week. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Nursing services are provided 24 hours a day, seven days a week; -At least one registered nurse (RN) is on duty eight hours a day, seven day a week. (Due to recent staffing shortages, if a RN is unavailable for eight hours a day, seven days a week, a licensed practical nurse (LPN) will be utilized); -When staffing falls below normal numbers, attempts will be made to call in help; -Nursing staff will be scheduled extended shifts and not be allowed to leave their unit until the proper personnel relief including: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 55. Observations in the kitchen on 2/15/22 between 10:30 A.M. and 2:00 P.M. showed the following: -The four-plex outlet, located above the food preparation table by the food processor, was soiled with food debris; -Brown debris was splattered along the wall above this food preparation table, behind the food processor, blender and wall-mounted knife rack; -Dusty and black debris on the vent cover for the ceiling mounted HVAC units throughout the kitchen; -A buildup of black debris on the fan cover and inside the fan in the reach-in double refrigerator unit; [...]

Inspectors wroteBased on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to ensure facility staff washed their hands after each direct resident contact when indicated by professional standards for one resident (Resident #207) in a sample of 19 residents and one additional resident (Resident #1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure staff carried functioning pagers to alert them to residents' calls for staff assistance. The facility census was 55. Review of the facility policy, Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -The system will allow each charge nurse or Special Care Unit (SCU) supervisor to carry beepers with them while on duty during their shift; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity for three residents (Residents #43, #28, and #41), in a review of 19 sampled residents. Facility staff also failed to cover two residents' (Resident #2 and #30) urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bags with a dignity/privacy cover. The facility census was 55. Review of the undated facility policy, Residents Rights Policy, showed the following: -These resident rights ensure that at least, each resident admitted to this facility is/has: -Fully informed, as evidenced by the resident's written acknowledgement, prior to or at this time of admission and during stay, of these rights and of all rules and regulations governing residents conduct and responsibilities; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for two residents (Resident #41 and Resident #45), in a review of nineteen sampled residents, when Residents #41 and #45 yelled out for assistance periodically throughout the day because they did not have access to a call light. The facility census was 55. Review of the facility's Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; [...]

Inspectors wroteBased on record review and interview, facility staff failed to ensure resident funds were placed in an account separate from the facility operating account and did not allow the residents/guardian the right to manage his/her financial affairs. The facility did not provide residents access to their funds as soon as possible for 20 residents (Resident #17, #29, #34, #47, #50, #200, #201, #202, #205, #206, #208, #209, #210, #211, #212, #213, #214, #215, #217 and #218). The facility also failed to ensure negative balances were not maintained for one deceased resident (Resident #229). The facility refunded more funds to the resident's responsible party than the resident maintained in the resident trust fund at the time of death, which resulted in refunding funds that belonged to other residents. The facility census was 55. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to reconcile the resident trust fund bank balance and resident petty cash with the current balance of the resident trust fund ledgers. In addition, the facility failed to provide quarterly financial statements to one resident (Resident #21). The facility census was 55. 1. Review of the facility's reconciliation, dated January 2021, showed the reconciled balance (bank statement balance minus the outstanding deposits and withdrawals) was $30,310.76. Review showed no evidence the facility included the resident petty cash balance maintained in the facility in the monthly reconciliation. Review of the Resident Trust Fund Current Balance Report (report with each resident's account balance including funds in the checking account and resident petty cash), dated 1/31/21, showed the total balance in the resident trust fund was $30,173.45. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident or his/her designee when the resident's account reached $200 less than the Supplemental Security Income resource limit of $5,000 (prior to [DATE] or $5,035 after [DATE]), for three residents (Residents #18, #226, and #227) who received Medicaid Benefit. The facility failed to refund resident funds within 30 days of discharge for four residents (Residents #55, #61, #219, and #225). The facility failed to provide a final accounting of resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for seven residents (Residents #202, #217, #220, #221, #222, #223, and #224). The facility census was 55. 1. Review of the facility's Resident Trust Fund Current Balance Reports showed the following for Resident #226: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) to ensure protection of the resident funds. The facility census was 55. Record review of the facility's resident trust fund reconciled bank statement for the period of January 2021 through December 2021 showed an average monthly balance of $42,709.45. Calculation showed the facility required a bond amount of at least amount $64,500.00. (The facility was unable to provide a monthly accounting of the money maintained in the resident petty cash to include in the calculation.) Record review of the facility's current surety bond showed the facility held a bond in the amount of $20,000.00. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable and odor free environment by failing to ensure flooring and walls in resident rooms, furnishings, hallways, ceiling vents, and common areas were clean and in good repair. The facility census was 55. Review of the facility policy, Homelike Environment, revised February 2021, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary, and orderly environment; b. inviting colors and decor; c. personalized furniture and room arrangements; d. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident representative when four residents (Resident #2, #28, #42 and #48), in a review of 19 sampled residents, were transferred to the hospital. The facility census was 55. 1. During an interview on 2/16/22 at 4:25 P.M., the administrator said the facility did not have a policy regarding discharge notices for facility-initiated discharges. 2. Review of Resident #2's face sheet showed his/her admission to the facility on 1/13/21. Review of the resident's nurses notes, dated 1/11/22, showed the following: -The resident was being assisted by staff to stand and pull up his/her pants when he/she went limp, eyes rolled back in his/her head, and he/she stopped breathing; -Staff administered sternal rub and the resident started breathing again; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative for four residents (Resident #2, #28, #42, and #48) in a review of 19 sampled residents, when the facility initiated a transfer to the hospital. The facility census was 55. Review of the undated facility policy Bed Hold showed the following: -If facility beds are 95% occupied, there will be a bed hold charge and the resident will be billed the daily rate to reserve the same bed; -If occupancy is under 95% there will be no charge to hold the bed and it will be available when the resident returns; -All residents regardless of pay source will be treated equally. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's census report showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete comprehensive assessments timely for one resident (Resident #207) in a review of 19 sampled residents and for three additional residents (Residents #306, #208, and #355). The facility census was 55. Review of the facility policy, Comprehensive Assessments and the Care Delivery Process, revised December 2016, showed the following: -Comprehensive assessments will be conducted to assist in developing person-centered care plans; -Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions; -Comprehensive assessments are conducted and coordinated by a registered nurse (RN) with appropriate participation of other health professionals; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for three residents (Residents #11, #43 and #48), in a review of 19 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 55. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks to provide effective person-centered care that met professional standards of quality care, within 48 hours of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents, one closed record review (Resident #55), and one additional resident (Resident #208). The facility census was 55. Review of the facility's Baseline Care Plan Policy, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Resident #2, #28, and #41), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; 3-The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided bathing and hygiene needs for six residents (Residents #6, #28, #37, #41, #43, #44), in a review of 19 sampled residents who were unable to perform their own activities of daily living (ADL's). The facility census was 55. Review of the undated facility policy, Routine Resident Care/ADL's, showed the following: -Routine care rendered by all nursing staff includes attention to physical, emotional, social, spiritual, and life style preferences according to individual job descriptions; -Residents are given routine daily care by a certified nursing assistant (CNA) under the supervision of a licensed nurse; -Routine care by a nursing assistant includes the following: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to design and provide an activity program to meet the needs, interests, physical, mental, and psychosocial well-being for five residents (Residents #6, #11, #28, #43 and #48) in a review of 19 sampled residents. The facility census was 55. 1. Review of the Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, Chapter 3, revised October 2019, showed the following: -Most residents capable of communicating can answer questions about what they like; -Obtaining information about preferences directly from the resident, sometimes called hearing the resident's voice, is the most reliable and accurate way of identifying preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to assist three residents (Resident #41, #43, and #48), in a review of 19 sampled residents and one additional resident (Resident #21) in attaining or maintaining their highest level of functioning. The facility failed to prevent the development of limited range of motion for residents who were not admitted with a limited range of motion, or prevent further worsening of limited range of motion or development/worsening of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative plans with goals, frequency of task, number of repetitions, or length of time, or direction to staff to meet the resident's needs. The facility census was 55. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess and reassess the safety and effectiveness of bed rails in use for 11 residents (Residents #2, #207, #28, #11, #18, #48, #45, #47, #41, #43, and #6), in a review of 19 sampled residents. The facility census was 55. Review of the undated facility policy, Restraint Use and Use of Assist Handles, showed the following: -The need of each resident for restraint use is assessed on admission, quarterly (during care plan reviews), and as needed; -The Device Decision Guide will be used to determine whether or not a device is a restraint and if it should be used; -If it is determined not to be a restraint, it will be care planned for its purpose; -A side rail form should also be completed each time any change in side rail use is made; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for two residents (Resident #28, and #43) in a review of 19 sampled residents and three additional residents (Resident #14, #21 and #54). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors and failed to respond timely to call lights. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Consideration is given to the patients' and resident's needs when the composition of the nursing staff is determined; -Nursing services are provided 24 hours a day, seven days a week; -Sufficient personnel are assigned and on duty to assure safe, effective nursing care, including relief personnel during vacations, holidays, emergencies, and sick leaves; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses/behaviors to justify the implementation or continued used of antipsychotic medications for two residents with a diagnosis of dementia (Residents #28 and #42), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy Antipsychotic Medication Use, revised December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to remove and destroy expired medications for four residents (Residents #35, #36, #41 and #46) in a review of 19 sampled residents. The facility also failed to destroy expired stock supply of over the counter medications. The facility census was 55. Review of the facility policy, Storage of Medications, revised April 2007, showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, container or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three staff members (Feed Aide/Activity Aide BB, Feed Aide CC and Feed Aide DD) had successfully completed a State-approved training program for feeding assistants and failed to ensure these staff members were not providing feeding assistance to five residents (Residents #11, #18, #28, #44, and #48) in a sample of 19 residents with complicated feeding problems. The facility census was 55. Review of the undated facility policy, Paid Feeding Assistant, showed the following: -The regulation requires that paid feeding assistants must work under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN), and they must call the supervisory nurse in case of emergency; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's (Resident #500's) responsible party after the resident fell and re-opened a skin tear requiring treatment. The resident's responsible party learned of the resident's fall from another resident when he/she visited the facility. The facility census was 56. Review of the undated facility policy titled, Accident/Incident Event Report, showed the following: PROCEDURES: 1. Notify family; 8. The family should be notified immediately. Review of the facility policy titled, Assessing Falls and Their Causes, revised October 2010, showed the following: -Steps in the Procedure: -After a Fall: 4. Nursing staff will notify the resident's family in an appropriate time frame; -Reporting: 1. Notify the following individuals when a resident falls: a. The resident's family. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff who worked in the facility did not have a finding (Federal indicator) entered into the State certified nurse aide (CNA) registry concerning abuse, neglect, or misappropriation of property. Licensed Practical Nurse (LPN) PP, began work in the facility on 12/22/19 and had a Federal indicator preventing him/her from working in the facility. The facility failed to identify the LPN had a federal indicator. The facility census was 56. Review of the facility's undated Abuse Prevention Plan, showed the facility will not hire or maintain employment with a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities. This facility will not employ or otherwise engage individuals who: [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care within 21 days of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents and three additional residents (Resident #306, #355, and #208). The facility census was 55. Review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, showed the following: -The facility's Care Planning/Interdisciplinary Team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one resident (Resident #500), who had orders for lab work (blood and urine testing), out of seven sampled residents. The facility census was 56. 1. Review of Resident #500's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/13/22, showed the following: -Date of admission 4/6/22; -Brief Interview for Mental Status (BIMS) (brief screener that aids in detecting cognitive impairment) of 14 (BIMS scores range from 0-15, the higher the score, the lower the impairment to the cognitive response); -No problems recalling three words; -Could recall the year; -Could recall the week; -Missed the month by six days to one month; -Resident was usually understood; -Resident understands others; -Always continent of bowel and bladder; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a policy and procedure based on current standards of practice, to address the care of residents receiving dialysis services. The facility failed to consistently monitor the dialysis access site (fistula) according to the resident's physician's orders, and failed to complete post dialysis assessments to ensure no significant changes in the resident's condition following dialysis treatments for one resident (Resident #4), in a review of 19 sampled residents. The facility census was 55. Review of Nursing Management: The Journal of Excellence in Nursing Leadership, October 2010, Volume 41, Issue 10, Caring for a Patient's Vascular Access for Hemodialysis showed the following: -A patient in end-stage kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program when the facility did not have a director of nursing and no other nursing staff or nursing administration attended any QA/QAPI meetings. The facility census was 55. Review of the facility's undated Quality Assurance Process Improvement QAPI Program policy showed the following: Purpose: -To provide ongoing and comprehensive procedures that will guide the facility in monitoring resident care and services and will provide systems which facilitate the identification and correction of deficiencies and gaps in systems or processes; Goals: -The QAPI program will provide the structure for decision making and will guide our day to day operations; [...]