Bay Harbor Post Acute Healthcare Center

Inspectors wroteBased on medical record review and interviews, it was determined that the facility staff failed to enter medication orders into a resident's electronic health record (EHR). This deficient practice was evidenced in 1 (R #238) of 5 resident records reviewed for medication administration during the recertification survey. The deficient practice resulted in harm to R#238. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/13/2026.

Inspectors wroteBased on observations, resident interview, and record review, and staff interview, it was determined that the facility failed to: 1.) supervise and identify residents needing assistance with smoking and 2.) ensure adequate supervision of residents in wheelchairs. This was evident for 4 (Resident #83, # 8, #47, #68) out of 32 residents reviewed during the recertification survey. 1. The survey team made several observations of residents sharing cigarettes in the designated smoking area from 4/12/26 - 4/15/26. The survey team requested the smoking policy on 4/12/26 at 1:00pm. Review of the smoking policy on 4/15/26 at 10:00am revealed residents are not permitted to share smoking items including cigarettes with another resident. The survey team interviewed smoking aide #14 on 4/16/26 at 12:30pm regarding smoking policy and his/her responsibilities as a smoking aide. [...]

Inspectors wroteBased on interviews and observations, it was determined that the facility failed to ensure that the smoking designated area was safe for residents who used wheelchairs. This was evident during a tour of the smoking designated area.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a homelike environment. This was evident for 1 (Resident #83) out of 57 residents reviewed for environment.

Inspectors wroteBased on review of facility investigation, resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of verbal abuse. This was evident for 1 (Residents #57) of 6 residents reviewed for abuse.

Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to ensure a resident's belongings were secured until the family was able to acquire them. This deficient practice was evidenced in 1 (#239) of 1 record reviewed for misappropriation of property during the recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide the resident or representative with the required discharge documentation. This was evident for 1 (Resident #230) out of 2 residents reviewed for hospitalizations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to complete Minimum Data Set Assessments accurately. This was evident for 2 (Resident #15 and #28) out of 8 residents reviewed in the Resident Assessment task.

Inspectors wroteBased on medical record review and interview, facility nursing staff failed 1.) to provide nursing services that did not meet professional standards by failing to correctly identify a resident (resident # 237) prior to medication administration leading to the resident being administered medication prescribed for another resident (resident #244), and 2.) to adhere to nursing care standards of practice as evidenced by a nurse failed to write a verbal order Glucagon after the medication was administered and 3.) failed to document a resident's ostomy care. This deficient practice was evidenced in 4 (# 237, #244, #234, & #236) of 13 medical records reviewed during the recertification survey. [...]

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to provide showers to dependent residents. This was evident for 2 (Resident #243 and #56) out of 10 residents reviewed for activities of daily living during the recertification survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to administer medications to residents in accordance with minimum standards of care. This was evident for 3 Resident (Resident #237, #244, and #242) of 3 reviewed for insulin medication administration during the annual survey 1.) Surveyor review of a complaint (2797325) on 4/13/26 at 9:00am alleging that a member of the facility's nursing staff erroneously administered medications to resident #237 that were prescribed for the resident's former roommate that had discharged earlier in the day. Review of resident # 237's medical records on 4/13/26 at 9:30am revealed a change in condition progress note dated 3/4/26 at 11:30pm stating that the resident was given his/her roommates night-time medication. The resident had no abnormal signs or symptoms from the incorrect medication administration. [...]

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to change a resident's foley catheter as ordered. This was evident for 1 (Resident #71) out of 3 residents reviewed for urinary tract infection during the recertification survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure complete and accurate dialysis orders were present for residents receiving dialysis services. This was evident for 1 (Resident #223) out of 1 residents reviewed for dialysis.

Inspectors wroteBased on review of Geriatric Nursing Assistant personnel files and interviews it was determined that the facility failed to conduct yearly performance reviews at least every 12 months on 1 (Staff #24) out of 5 personnel files reviewed.

Inspectors wroteBased on record reviews and interviews it was determined that the facility administered medication to a resident without clinical indication. This was evident for 1 (Resident #54) out of 9 residents reviewed for medication administration.

Inspectors wroteBased on interviews, observations and review of records, it was determined that the facility failed to provide routine dental services to residents. This was evident for 2 (Resident #56 and #9) out of 3 residents reviewed for dental services during the annual survey.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to serve residents meals based on their menu tickets. This was evident for 2 residents (Resident #137 and #81) out of 4 residents observed during dining.

Inspectors wroteBased on medical record review and interview, facility nursing staff falsely documented medication administration to a resident (resident #244) when the medication was given to another resident (resident #237). This was evident in 1 of 8 residents reviewed; and failed to document when a resident who had wounds was repositioned to offload pressure. This was evidenced in 1 (#236) of 2 resident records reviewed with wounds during the recertification survey.

Inspectors wroteBased on observations, record review, and staff interview, it was determined that the facility failed to follow appropriate infection control practices while providing care. This was evident in 4 (Resident #14, #83, #240, and #196) out of 61 residents reviewed for infection control. Enhanced Barrier Precautions (EBP) are an infection control strategy for nursing homes, requiring gowns and gloves during high-contact resident care to prevent the spread of multidrug-resistant organisms. 1.) On 4/13/2026 at 6:47 AM, an observation of Resident #14 was made. The resident had a tracheostomy and an Enhanced Barrier precaution sign outside their door. On 4/13/2026 at 8:51 AM an observation of care provided to Resident #14 by Staff #37 was conducted. Staff #37 performed trach care with gloves but did not use an isolation gown. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure four (Resident #41, Resident #11, Resident #22, and Resident #33) of 23 residents reviewed for abuse were reported/timely reported to the Administrator and State Survey Agency (SSA) and failed to ensure the results of investigations were submitted to the SSA/submitted within five working days of the incident for four (Resident #11, #2, 22, and 34 of 23 reviewed for abuse. Specifically, the failed to report/timely report the following: 1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to report the allegation to the SSA.2. Resident #11 reported that Housekeeper #28 pushed them. [...]

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure 4 (Residents #41, #11, #33, and #34) of 23 residents reviewed for abuse had thorough investigations completed. Specifically, the facility failed to conduct thorough investigations regarding the following:1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to conduct a thorough investigation and failed to suspend RN #20 placing Resident #41 and additional residents at risk for abuse.2. Resident #11 reported that Housekeeper #28 pushed them. The facility failed to conduct a skin audit or trauma assessment from Resident #11 and failed to obtain a witness statement from Resident #11 and additional residents.3. [...]

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to address Resident Council concerns regarding staffing and call lights for 9 of 9 months reviewed. Specifically, the Resident Council expressed repeated concerns related to call light response times and staffing, but at the time of the survey, the issues were still ongoing, indicating the facility had not sufficiently addressed them.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure prompt and consistent efforts were made to resolve grievances. Specifically, the facility failed to:- thoroughly investigate a grievance related to failure to provide incontinence care and inform the resident and family member who filed the grievance of the facility's efforts to resolve the grievance for 1 (Resident #47) of 3 sampled residents reviewed for grievances.- effectively and on an ongoing basis, address and make reasonable effort to follow up on and resolve repeated grievances and concerns related to staff response to call bells, as submitted by multiple residents and by the Resident Council over the past 9 of 9 months reviewed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to implement its abuse prohibition and prevention policies for 9 (Residents #6, #11, #14, #18, #22, #24, #30, #34, and #35) of 21 residents reviewed for abuse. Specifically, the facility failed to report allegations of abuse/neglect/injuries of unknown origin to local law enforcement and/or the ombudsman and failed to follow the facility's policy related to conducting and documenting thorough investigations of allegations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff consistently and correctly implemented infection control practices. Specifically, the facility failed to:- ensure enhanced barrier precautions were followed during wound care for 1 (Resident #28) of 2 residents observed during wound care.- ensure catheter care and hand hygiene were performed in accordance with professional standards of practice and facility policy for 2 (Resident #44 and Resident #45) of 2 residents observed during catheter care.

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 (Residents #47, #30, and #48) of 3 residents reviewed for dignity were treated with dignity and respect. Specifically, facility staff failed to promptly assist Resident #47 with incontinence care, which resulted in the resident attending church services in a soiled brief. Additionally, a staff member failed to knock or announce herself prior to entering the shared room of Resident #30 and Resident #48).

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to protect Resident #16's right to be free from physical abuse by another resident (Resident #49). This affected 1 (Resident #16) of 23 sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure therapy services were provided in accordance with physician orders for 1 (Resident #31) of 4 residents sampled for therapy services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record for 3 (Residents #32, #31, and #30) of 48 sampled residents.

Inspectors wrote3) On 1/17/2025 at approximately 9:25 AM, the Surveyor observed the Medication room at nursing station #1. There were 2 small black refrigerators sitting one on top of the other in the medication room. The inside of the bottom refrigerator door and interior shelves were dirty, covered with multiple areas of brown dried food stains and sticky cream-colored stains. The Surveyor observed a clear cup of cream-colored pudding covered with plastic wrap and labeled 1/11. 4) On 1/17/2025 at approximately 9:50 AM, the Surveyor observed the Clean Utility room. There was a Standard size refrigerator located in the corner of the room. Licensed Practical Nurse (LPN) #5 informed the Surveyor that was where resident stored personal foods. The Surveyor observed a January 2025 temperature log with no freezer or refrigerator temperature documentation. [...]

Inspectors wroteBased on observation and interviews with facility staff it was determined the facility failed to ensure a resident's dignity was maintained for residents. This was found to be evident for 6 (Resident #210, #130, #56, #91, #152, and #179) ) of 7 residents reviewed for dignity during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to verify each resident on Unit 4 had their call bells readily available if assistance were needed and ensure a resident's needs were accommodated by scheduling a follow-up appointment in a timely manner. This was evident for 4 (Resident #119, #179, #210, and # 178) out of 5 residents reviewed for accommodation of needs during the survey.

Inspectors wroteBased on resident and staff interviews and record review, it was determined the facility failed to act promptly upon the recommendations of the resident council concerning issues of resident care and life in the facility. This was evident for 4 of 4 months of resident council meeting minutes reviewed.

Inspectors wroteBased on medical record reviews and interviews, it was determined that facility staff failed to assess the resident for an advance directive and did not offer assistance with creating an advance directive. This deficient practice was evident for 6 (#98, #76, #133 #185, #107, #547) out of 6 residents reviewed during the survey.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to provide adequate lighting, housekeeping and maintenance services to keep the residents' environment clean and in good repair. This was evident in 3 of 4 unit units observed during tours of the facility and resident rooms during the survey.

Inspectors wroteBased on record reviews and resident interviews conducted during the resident council meeting, it was determined the facility failed to ensure the residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal and failed to promptly assist a resident in filing a grievance of missing personal property. This deficient practice was evident for 1 (#76) out of 1 resident reviewed during the annual survey.

Inspectors wroteBased on resident interviews, staff interviews, and record reviews, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding activity needs for residents, a resident with weight loss and a resident with communication deficit. This was evident for 3 (#150, 116 & #179) of 5 residents reviewed for careplans during the survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to provide nursing care within professional standards of practice. This was found to be evident for 5 (Resident #178, #297, #447, #150, and #158) out of 74 residents reviewed during the annual and complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure that physician's orders were implemented and completed, ensure a residents' weight was monitored and ensure professional standards of nursing practice were followed when administering medications to residents. This practice was noted for 7 ( Resident #178, #297 #150, #116, #193, #188, #107) out of 74 residents reviewed during the survey.

Inspectors wroteBased on record review and interviews it was determined that the facility leadership staff failed to ensure certified nursing assistants completed a state approved geriatric nursing assistant training program within four months of employment. This deficient practice was evident in 7 (#29, #61, #73, #74, #75, #76, #77) actively employed certified nursing assistants.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to ensure the pharmacist reports irregularities to the attending physician (Resident #133), and ensure that the Medication Regimen Review (MMR) of Residents #107 and # 150 was conducted at least once a month by a licensed pharmacist. This was evident for 3 of 7 residents reviewed.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to their menu ticket. This was evident for 6 (Resident #136, #97, #176, #600, #193, #83, #599) of 6 residents randomly observed during meals, and 1 of 1 meal tray line observed during the survey.

Inspectors wroteBased on resident interview and surveyor observation it was determined the facility failed to provide palatable food with an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray.

Inspectors wroteBased on an interview with resident council members, it was determined the facility staff failed to ensure that suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. This was evident for 10 out of 10 residents present at the resident council meeting with the surveyor.

Inspectors wroteBased facility record reviews and staff interviews, it was determined that the facility failed to provide documentation indicating that facility staff members received screening, education, offering, of the current COVID-19 vaccination. This was evident for 5 staff members (Geriatric Nursing Assistants #64, 65, 66, 67 and 68) out of 5 staff members reviewed during the survey.

Inspectors wroteBased on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 5 (Resident #48, #107, #160, #167, and #188) of 5 residents reviewed for accidents.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to keep a sanitary environment. This was evident for 3 of 4 units observed.

Inspectors wroteBased on medical record review and interview with facility staff and family, it was determined that the facility failed to notify the resident's responsible party (RP) when residents were had a change in condition/medical care. This was evident during a random observation for 2 of 2 residents (Resident #176 and #133) reviewed for notification during the survey.

Inspectors wroteBased on administrative review and interviews with facility staff it was determined the facility failed to prevent a resident from experiencing verbal abuse by an employee. This was found to be evident for 1 (Resident # 24) of 6 residents reviewed for abuse during the survey.

Inspectors wroteBased on resident interviews and staff interviews it was determined that the facility failed to protect the residents from misappropriation of personal property and investigate resident's report of missing personal property. This was evident for 2 (resident #38 and #76) out of 4 residents reviewed during survey.

Inspectors wroteBased on review of the facility reported incidents and interviews, it was determined that the facility failed to report an injury of unknown origin in a timely manner to the state agency. This was found to be evident for 1(Resident #154) of 6 residents reviewed for abuse during the survey.

Inspectors wroteBased on medical record review, facility investigation report review, and staff interview it was determined that the facility failed to retain documentation related to the delayed reporting of a resident fall. This was evident for 1 out of 4 (#124) residents reviewed for falls during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to code a resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #188) of 40 sampled residents reviewed during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to have a care plan meeting with the interdisciplinary care team and failed to provide residents with a quarterly care plan meeting prepared and revised by the entire interdisciplinary team after the quarterly review assessment. This deficient practice was evidenced in 2 ( Resident #116 and Resident #150) of two records reviewed for care plan meetings during the survey.

Inspectors wroteBased on clinical record review, staff interviews, and observations it was determined that the facility failed to offer alternative equipment for a resident whose electric wheelchair was broken in order to maintain the resident's mobility and opportunities to be out of bed and failed to provide basic activities of daily needs to a resident. This was evident for 2 (Resident #130 and # 116 ) out of 4 residents reviewed for activities of daily living during the survey.

Inspectors wroteBased on staff interviews, observations, administrative records reviews,and medical record reviews it was determined that the facility failed to document that a dependent resident consistently received activities of daily care such as showering and bathing or assistance with meals. This was evident for 1 out of 4 residents (#130) reviewed during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that one-on-one activities were provided for a resident. This was found to be evident for 1 (Resident #24) of 3 residents reviewed for activities during the facility's survey.

Inspectors wroteBased on observation and interviews with facility staff it was determined the facility staff failed to use appropriate safety measures while transferring a resident with a Hoyer lift and keep a resident environment safe. This was found to be evident for 2 (Resident # 210 and # 154) of 6 residents reviewed for accidents during the survey.

Inspectors wroteBased on medical record reviews, and interviews, it was determined that facility staff failed to monitor and address the nutritional needs of a resident who had a known significant weight loss. This deficient practice was evident for 1 (#107) of 1 resident reviewed during the survey.

Inspectors wroteBased on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the initiation of bed rails. This was evident for 5 (Resident #48, #107, #160, #167, and #188) of 5 residents reviewed for physical restraints.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility staff failed to ensure that the physician provided supervision of a resident with significant weight loss. This deficient practice was evident for 1 (#107) resident reviewed during the survey.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that facility staff failed to ensure adequate nursing staff to properly monitor residents. This deficient practice was evident for 1 (#133) out of 1 resident reviewed during the survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to post the required staffing data on the whiteboard and/or on the daily staffing board. The facility also failed to post the daily staffing schedule in a prominent place, readily accessible visually to visitors and residents. This was evident on three out of three nursing units.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure that an account of all controlled drugs was complete and accurate and failed to provide the correct dosage of medication for a resident. This was found to be evident for 2 out of 2 narcotic lock boxes located in the narcotic medication carts and for 1 (Resident # 158) of 3 medication administration records reviewed for accuracy during the facility's survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed (PRN), had an end date that was limited to 14 days. This was evident for 1 (Resident #59) of 5 residents reviewed for medications.

Inspectors wroteBased on observation, record review, and interviews with staff, it was determined that the facility failed to ensure that all medications and biologicals were stored and labeled properly. This was evident for 3 out of 3 medication carts reviewed during the medication storage facility task completed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the facility's kitchen had an eating assistive device for a resident. This was evident for 1 (Resident #23) of 223 resident meal tickets observed during the kitchen meal tray line.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that residents' records are accurate, complete and protected. This was found to be evident for 3 (Resident # 41 and # 105) of 40 sampled residents reviewed during the facility's survey.

Inspectors wroteBased on review of the facility documentation and staff interviews it was determined the facility failed to ensure that the Quality Assurance Committee met on a quarterly basis for the past year. This was found to be evident during the facility's survey.

Inspectors wrote3. On 01/13/25 at 8:12 AM, Licensed Practical Nurse staff #9 was interviewed. During the interview, Licensed Practical Nurse staff #9 stated that Resident #447 was on droplet precautions for respiratory syncytial virus. Also, Licensed Practical Nurse staff #9 stated that the facility's policy and procedure is that residents diagnosed with respiratory syncytial virus should have droplet precaution signage on the outside of his/her room door. During observation rounds on 01/13/25 at 8:23 AM, Resident #447's room was found to not have droplet precaution signage posted on the outside of his/her room. On 01/17/25 at 11:28 AM, Resident's #447's medical record was reviewed. The medical record review revealed that Resident #447 was diagnosed with respiratory syncytial virus on 1/9/25. [...]

Inspectors wroteBased upon medical record review, facility documentation review and staff interview it was determined that facility staff failed to safely secure a resident during a Hoyer Lift transfer resulting in the resident's subsequent injury and a hospital emergency visit. This was evident for 1 of 1 residents reviewed (Resident #50) during the Complaint survey investigation.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for 5 of 8 nursing units observed during a complaint survey.

Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate injuries of unknown origin and allegations of abuse, neglect, and misappropriation of resident property. This was evident for 6 (#7, #32, #38, #45, #53, #55) of 28 facility reported incidents reviewed during a complaint survey

Inspectors wroteBased on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (Resident #12, #15, #20, #35, #38, #41, #43 and #47). This was evident for 8 of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to evaluate and document the condition of a resident's skin wound weekly (Resident #12). This is evident for 1 of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. This was evident during meal service, in the kitchen and infection control supplies on 4 of 8 nursing units.

Inspectors wroteBased on observation it was determined that the facility failed to maintain kitchen equipment and showers rooms in safe operating condition.

Inspectors wroteBased on observation, resident and staff interviews and review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning roaches and mice.

Inspectors wroteBased on review of medical record, observation and interview, the facility staff failed to treat every resident with respect and dignity (Resident #10, #35, #44 and #64). This was evident for 4 of 67 residents during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to protect residents from abuse from another resident (resident #24) and abuse from a staff member (resident #46). This was evident for 2 of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to report alleged abuse of a resident (residents # 18, #26, #37, and #39) to law enforcement. This was evident for 4 out of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on the review of facility documentation, medical record review and interview, it was determined that the facility failed to implement an effective discharge planning process for a resident (Resident #12). This was evident 1 of 34 discharged residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to place a discharge summary on a resident's (resident #21 and #34) medical record after discharge. This was evident for 2 of 67 residents reviewed in a complaint survey.

Inspectors wroteBased on the medical record review and resident interviews it was determined the facility staff failed to ensure that dependent resident (resident #67) personal hygiene needs were adequately met by not providing hot water showers and baths as scheduled. This was evident for 1 of 67 residents reviewed during the complaint survey process.

Inspectors wroteBased on medical record review and interview, the facility staff failed to assess and document a resident's need for pain medication (Resident #14). This was evident for 1 of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #15) This was evident for 1 of 67 residents reviewed during a complaint survey.

Inspectors wroteBased on interview with facility staff, it was determined that the facility failed to have a full time CDM (Certified Dietary Manager) or certified licensed Dietician on staff and in the kitchen on a full time basis. This practice had the potential to affect all residents.

Inspectors wroteBased on medical record review and interview with facility staff, the facility failed to send the comprehensive care plan goals with the residents who were sent to the hospital. This was evident for 4 (Residents #81, #98, #124, and #179) out of 4 residents reviewed for hospitalization.

Inspectors wroteBased on observation of the kitchen, it was determined that the kitchen staff: 1) failed to label and date food that was cooked and put away in the refrigerator; 2) failed to date food placed in the dry storage room; and, 3) failed to monitor staff for hair net use in the kitchen.

Inspectors wroteBased on medical record review and staff and resident interview, it was determined the facility failed to ensure that staff documented a physician's order for a suprapubic catheter for Resident #474. This was evident for 1 (Resident #474) of 44 residents reviewed during the survey.

Inspectors wroteBased on observation and interview with the Director of Dietary and Supervisor of Maintenance, the facility failed to have the freezer in safe working conditions. This practice has the potential to impact all residents receiving nutrition from the facility's dietary services.

Inspectors wroteBased on observation, medical record and staff interview, the facility staff failed to develop a treatment plan for Resident #33 eyes that were watery and bright red along the bottom of both eyelids. This was evident for 1 out of 67 residents investigated during the survey process. The findings Include: On October 7, 2019 during a late entrance tour of the facility around 6:30 PM, Resident #33's eyes were observed to be bright red along the base of both eyelids. The resident was not able to explain the redness to the eyes. On October 9, 2019 around 10:29 AM, Resident #33's eyes remained bright red around the bottom of each lid. On October 11, 2019 around 10:39 AM while reviewing the residents medical record, it was noted that there was no treatment ordered for the resident's eyes. [...]

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure that orders for as-needed psychiatric medication were limited to 14 days. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensurethat Resident #204 was not served food that would trigger a known food allergy. This was evident for 1 (Resident #204) of 12 residents identified by the facility as having food allergies.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility failed to 1) ensure equipment used for personal hygiene was not left directly on the bathroom floor for Residents #199 and #475; and 2) ensure that a visitor of Resident #475 received education regarding why a gown and gloves needed to be worn when visiting the resident. This was evident for 2 (Residents #199 and #475) of 44 residents reviewed during the survey.