Beauvais Rehab and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to protect one resident from misappropriation of property when Certified Nurse Aide (CNA) A took the resident's debit card to obtain vending machine snacks for the resident and then started to Cash App themself money over a period of two months. The resident (Resident #4) had only given the CNA permission to get him/her snacks. CNA A removed a total of $483.40 from the resident's bank account and then credited the resident $29.40 for a total withdrawal amount of $454.00. The sample was 8. The census was 137. The facility was notified of past non-compliance on 9/10/25. The resident's bank notified the Administrator on 9/8/25 of the suspicious charges. The Administrator, contacted the police and suspended the employee. The facility reimbursed the resident for the full amount on 9/10/25. The employee was terminated. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's right (Resident #2) to be free from physical abuse when his/her roommate (Resident #3), who had a history of aggressive behaviors, punched him/her in the face, then displayed a sharp knife and threatened to kill him/her. The sample was 7. The census was 140. The facility was notified of past non-compliance on 6/6/25. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 5/23/25. Review of the facility's abuse prevention and prohibition program revised 10/24/22, showed: -Each resident has the right to be free from mistreatment, neglect and abuse. The facility has zero-tolerance for abuse and neglect. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up with the facility's primary care physician and/or the resident's Veteran's Affairs (VA) physician to get medication orders after finding filled prescription bottles in the resident's room after he/she returned from an appointment for one out of three sampled residents (Resident #6). Additionally, the facility failed to provide care consistent with professional standards of practice when staff sat in the hallway, outside the residents' room, with the door closed during one-to-one observation. The residents (Resident #2 and Resident #3) had a physical altercation inside their room and Resident #3 displayed a knife and threatened to kill Resident #2. The sample was 7. The census was 140. Review of the facility's Physician Order policy, dated 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened residents and staff members, and used illicit substances. The resident's behaviors escalated, and he/she punched his/her roommate in the face, displayed a knife and threatened to kill him/her. Additionally, staff did not complete a Pre-admission admission Screening and Resident Review (PASRR) (a federally mandated screening process for individuals with serious mental illness (SMI), intellectual disability/developmental disability (IDD/DD), and/or related condition who apply for or reside in a Medicaid Certified bed in a nursing facility regardless of payment source) when it was determined the resident would be admitted to the facility for long-term care. The sample was 7. The census was 140. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure competencies were completed for Certified Medication Technician (CMT) staff to safely administer medications to residents for 10 (CMT2, CMT3, CMT4, CMT6, CMT8, CMT9, CMT10, CMT11, CMT12, and CMT14) of 10 CMT personnel reviewed. The facility census was 136.

Inspectors wroteBased on record review, and interview, the facility failed to ensure binding arbitration agreements were explained in a form and manner that residents understood and that the resident or their representative acknowledged that they understood the agreement for three of three residents (Resident (R) 92, R95, and R189) reviewed for binding arbitration agreements out of a total sample of 48. The facility census was 136.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible to 27 of 27 residents and/or visitors who resided on the secure unit. This failure had the potential to allow inappropriate access to resident records. The facility census was 136.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure adequate staffing on the fifth floor for four of 18 residents (Resident (R) 138, R97, R75, and R89) reviewed for staffing concerns out of a total sample of 48. This failure had the potential to affect quality resident care. The facility census was 136.

Inspectors wroteBased on interview, facility documentation, and facility policy review, the facility failed to ensure eight hours of Registered Nurse (RN) coverage every day of the week for 136 of 136 census residents. This failure had the potential to affect the safety of resident care. The facility census was 136.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, and expired medications were disposed of and not made available on the medication cart for 4 of 4 medication carts reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications. The facility census was 136.

Inspectors wroteBased on observation, interview, and sampling of a meal test tray, the facility failed to ensure food prepared by the facility was palatable for seven of seven residents (Resident (R) 42, R129, R77, R99, R109, R96, and R132) reviewed for palatability out of a total sample of 48. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. The facility census was 136.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to deliver meal trays in a manner to prevent cross-contamination for seven of 48 sampled residents (Resident (R) 5, R8, R80, R117, R76, R93, and R91) reviewed for infection control, and administer medications in a manner to prevent cross-contamination for four of four residents (R41, R24, R92, and R106) observed during the medication pass observation. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. The facility census was 136.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the fifth-floor shower room was cleaned as required for one of one resident (Resident (R) 109) reviewed for the environment out of a total sample of 48. This failure had the potential to affect the resident's health and ability to utilize the shower area. The facility census was 136.

Inspectors wroteBased on record review, staff interview, and facility policy, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of change for one of 10 residents (Resident (R) 23) reviewed for significant change assessments out of a total sample of 48. R10 showed a severe weight loss of 11.28% in six months and declined in mobility status that impacted more than one area of the resident's health status. This failure had the potential to cause further decline in the resident's status without further intervention by staff, interdisciplinary review, or revision of the care plan. The facility census was 136.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two of 48 residents (Resident (R) R23 and R136) whose records were reviewed. This had the potential to cause unmet care needs for the residents. The facility census was 136.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) level one was updated with a new diagnosis after admission for one of two residents (Resident (R) 91) reviewed for PASARR out of a total sample of 48. This failure had the potential to affect the resident's need for any potential additional services. The facility census was 136.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a care plan for a resident's hospice services for one of one resident (Resident (R) 57) reviewed for hospice out of a total sample of 48. This had the potential to cause unmet care needs. The facility census was 136.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed physician orders for the use of a helmet related to fall safety for one of one resident (Resident (R) 2) reviewed for Helmet use out of a total sample of 48. This had the potential to increase R2's risk of injury with any fall. The facility census was 136.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure vision services related to cataract surgery provided for one of two residents (Resident (R) R16) reviewed for vision and hearing services out of a total sample of 48. R16 had a failed appointment for cataract surgery in May of 2024 and the facility failed to reschedule the appointment. This failure had the potential to prevent R16 from living in the highest practicable physical well-being. The facility census was 136.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) R2) reviewed for smoking out of a total sample of 48 did not smoke inside the facility. R2, who was assessed to need supervision while smoking locked himself in his bathroom and smoked. The facility census was 136.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one of one resident (Resident (R)51), reviewed for oxygen administration out of a total sample of 48, received oxygen per nasal cannula according to the physician's order. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.) The facility census was 136.

Inspectors wroteBased on interview and record review, the facility failed to monitor target behaviors for the use of psychotropic medications for one of five residents (Resident (R) 42) reviewed for unnecessary medications out of a total sample of 48. This had the potential to cause R42 to receive unnecessary medications. The facility census was 136.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to offer pneumococcal vaccines for two of seven residents (Resident (R) 92 and R95) reviewed for pneumonia vaccinations out of a total sample of 48. This practice had the potential to increase the risk for these residents to contract pneumonia. The facility census was 136.

Inspectors wroteBased on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for two of seven sampled residents (Residents #2 and #1). One resident's resistance to repositioning and transfers due to a stiff painful knee from osteoarthritis (a degenerative joint disease which causes tissues in the joint to break down over time) experienced recurring issues with moisture associated skin damage (MASD, inflammation and erosion of the skin). Nursing staff also failed to consistently carry out physician's orders to get the resident out of bed for meals to improve intake as well as a need for pressure relief (Resident #2). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately address the pain of one of seven sampled residents (Resident #3). The facility failed to assess, monitor and implement interventions to adequately address breakthrough pain (a sudden and brief flare-up of pain from a chronic condition like arthritis which breaks through doses of administered pain medication) which impacted the provision of rehabilitation services and assistance with activities of daily living (ADLs). Nursing staff also failed to consistently carry out physician's orders for a neurological assessment to secure Botox treatments to relax the resident's tightly contracted joints. The census was 137. Review of the facility policy titled, Pain Management, revised 10/24/22, showed the purpose of the policy was to ensure accurate assessment and management of a resident's pain. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for 123 of 125 residents who received nourishment from the kitchen.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to keep the area surrounding the dumpsters free of debris for 2 (dumpsters) of 2 dumpsters observed.

Inspectors wroteBased on observations, interviews, facility document and policy review, the facility failed to maintain an effective pest control program, as evidenced by mice sightings on 3 (Unit 100, 200, and 500) of 5 units.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter to maintain dignity for 1 (Resident #90) of 3 sampled residents reviewed for urinary catheter management.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to invite the resident or resident RP to participate in the care planning process for 1 (Resident #79) of 25 residents whose care plans were reviewed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to notify the physician when there was a need to alter treatment for 1 (Resident #100) of 3 residents reviewed for skin concerns.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure resident care plans were comprehensive for 1 (Resident #128) of 3 residents reviewed for care plans.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide services necessary to maintain good grooming and personal hygiene for 1 (Resident #111) of 9 sampled residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's needs, interests, and preferences as identified in the resident's assessment to enhance quality of life for 1 (Resident #43) of 3 residents reviewed for activities.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a rash for 1 (Resident #100) of 3 residents reviewed for skin concerns were assessed and received treatment.

Inspectors wroteBased on interviews, record reviews, and facility document and policy review, the facility failed to ensure 1 (Resident #538) of 3 residents reviewed for pain management received pain medication as ordered by the physician.

Inspectors wroteBased on interviews, record reviews, facility document and policy review, the facility failed to ensure a resident receiving antipsychotic medication had an appropriate diagnosis for continued use for 1 (Resident #128) of 6 residents reviewed for antipsychotic medications:

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records that were complete and readily accessible for 1 (Resident #70) of 2 residents reviewed for hospitalizations.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure two staff members wore appropriate personal protective equipment (PPE) to prevent the spread of infection when caring for 1 resident who was COVID-19 positive (Resident #187) of 4 residents sampled for infection control.

Inspectors wroteBased on observations, interviews, facility document and policy review, the facility failed to post nurse staffing information in an area highly visible to residents and visitors within two hours of the start of shift on 3 of 4 days of the survey.

Inspectors wroteSee Event ID LTWZ12. Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards and followed their Wound Management-Nursing Care policy to identify, document, monitor, notify physicians and promptly initiate physician's orders to treat pressure injuries/ulcers (injury to the skin and underlying tissue caused by pressure or friction) for two of six residents sampled with actual pressure injuries and/or at risk of developing pressure injuries (Residents #21 and #22). The census was 133. Review of the facility Wound Management-Nursing Care policy, last revised 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury; -Policy: [...]

Inspectors wroteSee Event ID LTWZ12 Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The residents' feet were extremely dry with large areas of skin that flaked and peeled (Residents #21 and #22). The census was 133. 1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/23, showed the following: -Short/Long term memory loss; -Required extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene; -Required total staff assistance for toilet use and bathing; -Diagnoses of malnutrition, arthritis and anemia; -No foot problems documented. Review of the resident's care plan, dated 8/10/23, showed the following: -Problem: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for four residents (#138, #141, #135, and #143), of six residents investigated for non-pressure wounds and wound care when the facility failed to assess and treat wounds per facility policy and standards of practice. Resident #138 had a delay in treatment orders after admission. The facility failed to routinely apply the ordered treatments and assess the wounds. The resident had a change in level of swelling and wound drainage and the facility failed to timely notify the physician after identifying the change. The resident had a change in mental status after several days of increased swelling, drainage and pain; and was sent to the hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulcers and ensure residents with pressure ulcers receive the necessary treatment and services to promote healing, for five of seven residents investigated for pressure ulcers (Residents #56, #135, #60, and #143). The facility failed to assess wounds per facility policy and standards of practice and provide treatments as ordered. Resident #56 had a delay in identification of a pressure ulcer. When first identified by the facility, the pressure ulcers was a stage III. This resulted in a delay of treatment. After identified, the facility failed to assess and monitor the wound and failed to provide treatments as ordered consistently, which resulted in the wound developing into a stage IV pressure ulcer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment accurately reflected the resident's status, for five of 29 sampled residents (Resident #141, #143, #56, #38 and #60). The census was 143. 1. Review of Resident #141's medical record, showed: -An incident note, dated 11/9/19, resident stated he/she had an area on his/her bottom that he/she wanted evaluated. Upon assessment, Non blanchable, red excoriation noted to left buttocks. Area approximately 3.3 x 1.0 centimeter (cm). Physician notified and new orders obtained; -An order dated 11/10/19, for skin prep wipes to left gluteal (buttocks) two times day; -An annual MDS, dated [DATE], showed: -Other ulcer, wounds and skin problems: No; -Moisture associated skin damage (MASD): Not marked; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan regarding infections, nutrition/weight loss, and pain management for eight of 29 sampled residents (Residents #138, #56, #38, #60, #85, #123, #62 and #127). The census was 143. 1. Review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: -admitted [DATE] from an acute hospital; -Diagnoses included septicemia (sepsis, systemic infection of the blood); -Infection of the foot; -Application of nonsurgical dressings other than to feet; -Applications of dressings to feet. Review of the resident's care plan, in use while a resident at the facility, showed: -Focus: The resident has infection of the (specify): -Goal: Be free from complications related to infection; -Interventions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a discharge planning process was in place which addressed discharge goals and needs, including an updated care plan, caregiver support and referrals to local contact agencies as appropriate, that involved the resident and interdisciplinary team in developing a discharge plan for four of 29 sampled residents (Residents #139, #398, #2, and #1). The census was 143. 1. Review of Resident #139's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/20, showed the following: -admitted to the facility on [DATE]; -Ability to understand others and to make him/herself understood; -Always continent of bowel and bladder; -Adequate speech, hearing and vision; [...]

Inspectors wroteBased on interview and record review, the facility failed to properly monitor residents nutritional status to ensure early identification of residents with, or at risk for, impaired nutrition or hydration status. This would allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise. The facility failed to obtain weights as directed by the resident's care plan for one resident (Resident #56) and failed to ensure the dietician monitored residents nutritional status quarterly for four of eight residents reviewed for nutritional needs (Resident #56, #85, #123, and #144). The sample was 29. The census was 143. Review of the facility's Nutrition and Unplanned Weight Loss/Gain policy, dated 6/28/19, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services. The facility relied on staffing agencies to provide nursing services for the residents. The facility did not train the agency staff on facility policies and procedures. In addition, the facility staff failed to demonstrate competency in care provided to treat wounds. The census was 143. Review of the facility assessment, revised 12/9/19, showed: -Staff: -Registered Nurses (RN); -Licensed Practical Nurses (LPN); -Direct care staff; -Nurse educator; -(Agency staff not indicated as staff utilized) -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified 68 certified nursing assistants (CNAs) employed at the facility for more than a year. Seven CNAs were sampled and five of the seven did not have the required 12 hours of in-service training. The census was 143. Review of the facility assessment, revised 12/9/19, showed: -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are stored and labeled in accordance to current acceptable professional standards for two of three observed medication carts and two of three observed nurse treatment carts. The census was 143. 1. Observation on [DATE] at 6:36 A.M., of the second floor treatment cart, showed the following: -A tube of protective ointment cream labeled with a resident's name, the lid opened, and the tube lay directly in the drawer of the cart; -A tube of hydrogel wound cream (ointment used to keep wounds moist and promote healing) with vitamin E, the lid opened and the tube lay directly in the drawer of the cart. No resident name labeled on the tube; -A tube of itch relief cream, opened and lay directly in the drawer of the cart. No resident name labeled on the tube; [...]

Inspectors wroteBased on observation and interview, the facility failed to keep items labeled and dated in the kitchen storage rooms, to ensure the deep fryer was free of debris, microwaves and cabinets were free of dirt and debris and the vents above the preparation areas were free of dust buildup. This had the potential to affect residents who received food from the facility kitchen. The census was 143. Observation of the kitchen on 3/11/20, showed the following: -At 6:45 A.M., three large containers of dry cereal in the storage room did not have a label or date; -At 6:46 A.M., grease and debris on the top and sides of the deep fryer. The vents above the food preparation area covered with dust; -At 6:50 A.M., the microwave in the kitchenette of the main dining room had dried food and debris on the inside. Three dead bugs in the cabinets next to the microwave in the kitchenette of the main dining room; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the quality assessment and assurance committee develop and implement appropriate plans of action to correct identified quality deficiencies. The facility received repeated deficiencies for the prior year's annual survey to the current year's annual survey. In addition, the facility failed to implement a performance improvement plan for an identified concern with pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) care that resulted in a citation at the isolated actual harm level, which is a higher grid level than the citation received the prior year for the same concern. The census was 143. Review of the facility's Quality Assurance Process Improvement and Compliance policy, last revised 4/30/18, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement procedures for the provision of infection prevention and control utilizing current standards of practice for three of four residents observed during wound care (Resident #135, #60 and #38). In addition, the facility failed to ensure employee purified protein derivative (PPD) test (a test that helps diagnose (TB) tuberculosis) results were documented completely for seven of 10 sampled employees. The sample was 29. The census was 143. Review of the facility's Skin Ulcer-Wound policy, dated 8/15/18, showed: -All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations; -Purpose: To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Skin ulceration prevention: Promotion of clean, dry and well moisturized skin; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a training program to provide training to agency staff tasked with the responsibility to care for residents to include abuse, neglect, exploitation, misappropriation of resident property, dementia management and resident abuse prevention. The census was 143. Review of the State Operations Manual, showed staff includes for the purposes of the training guidance, all facility staff, (direct and indirect care and auxiliary functions) contractors, and volunteers. Review of the facility assessment, revised 12/9/19, showed: -Staff: -Registered Nurses (RN); -Licensed Practical Nurses (LPN); -Direct care staff; -Nurse educator; -(Agency staff not indicated as staff utilized); -Staff training/education and competencies: -All employees participate in a series of competencies upon hire and again quarterly and as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to assess if a resident's bed/side rails posed a safety risk or if they could be used by the resident safely, providing independence with bed mobility and/or transfers in and out of the bed. The facility removed Resident #38's bed with bed/side rails and replaced it with a regular bed without bed/side rails, without assessing and providing the resident an alternate accommodation to allow the resident to maintain independence with bed mobility, for one of 29 residents sampled (Resident #38). The census was 143. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/19, showed: -Moderate cognitive impairment; -No behaviors; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that include screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property by failing to complete required background checks timely for three of 10 employees sampled. In addition, the facility policy failed to require the nurse aide registry check on employees. The census was 143. Review of the facility's Employment Screening policy, revised 12/2016, showed: -In accordance with state and federal regulations, this facility will not knowingly hire, contract or retain any individual that is ineligible to work in healthcare facility, that has been excluded from participation in the Medicare or Medicaid programs, or that has not met required licensure or certification requirements for the position being considered; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident for two of three sampled residents admitted within the past 30 days (Residents #143 and #498). The census was 143. 1. Review of Resident #143's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/20, showed: -admitted [DATE] from an acute care hospital; -Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene; -Diagnoses included high blood pressure and seizure disorder; -At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the comprehensive care plan within 7 days after completion of the comprehensive assessment, for one of three sampled residents admitted within the past 30 days (Resident #143). The census was 143. Review of Resident #143's admission MDS, dated [DATE], showed: -admitted [DATE] from an acute care hospital; -Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene; -Diagnoses included high blood pressure and seizure disorder; -Care area assessment summary (CAAS), showed the following care areas triggered and the facility indicated the areas were care planned: -Urinary incontinence and indwelling catheter (tube inserted into the bladder to drain urine); -Nutritional status; -Feeding tube; -Dehydration/fluid maintenance; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene per resident wishes and standards of practice for two residents (Residents #60 and #135). The sample was 29. The census was 143. 1. Review of Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/20, showed: -Cognitively intact; -Rejection of care: Behavior not exhibited; -Total dependence for bed mobility, dressing and personal hygiene; -Bathing: Total dependence; -Diagnoses included cerebral palsy (disorder that affect movement and muscle tone), anxiety and depression. Review of the resident's care plan, dated 7/9/18, showed: -Focus: Activities of daily living (ADL) self-care performance deficit related to limited mobility and quadriplegia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to routinely assess, monitor and document on two residents receiving dialysis (process for removing toxins from the blood for individuals with kidney failure). The facility identified 6 residents as receiving routine dialysis treatments, three were sampled and problems were found with all three. (Residents #123, #62 and #127). The census was 143. Review of the facility's End Stage Renal Disease Dialysis Policy, dated 1/4/20, showed the following: -Purpose: To ensure a resident with End Stage Renal Disease (ESRD), including dialysis care and treatment outside the facility, receive services by facility staff trained in the care and special needs of these residents; -Policy: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure hot foods were at least 120 degrees Fahrenheit (F) when served to residents for one of one test trays sampled on the 100 hall. The census was 143. Observation of the 100 hall meal service on 3/11/20, showed the following: -At 8:30 A.M., during an interview, Nurse A said breakfast trays had not arrived to the hall; -At 8:35 A.M., observation of the main dining room showed five trays covered. During an interview, the Assistant Dietary Supervisor (ADS) said the meal trays were for 101 to 116 hall trays; -At 8:50 A.M., observation showed hall trays delivered to the hall; -At 9:00 A.M., hall trays passed out by staff. A test tray of a hall tray, completed with ADS, showed eggs at 100 degrees F and sausage at 80 degrees F. The sausage was cold to taste. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for two resident (Residents #56 and #38). The sample was 29. The census was 143. 1. Review of Resident #56's hospital discharge transfer orders for the receiving facility, showed: -discharged to facility on 2/20/20; -Procedure site: Sacral/coccyx (buttocks/tailbone area): Wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to sacrum. Review of the resident's medical record, showed: -A readmission assessment, dated 2/20/20: admitted from hospital on 2/20/20 at approximately 5:45 P.M. Skin issues present; -An order dated, 2/21/20 for collagenase ointment (an enzyme that helps promote healthy tissue growth), apply to affected area topically daily; -An order dated 3/2/20: [...]