Bella Terra St. George (black Rock Health and Rehab

Inspectors wroteBased on interview and record review, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record; and PRN orders for psychotropic drugs were limited to 14 days. Specifically, for 1 out of 32 sampled residents, a resident taking a PRN psychotropic did not have that psychotropic limited to 14 days and the prescribing practitioner did not document their rationale in the resident's medical record for the PRN order to be extended beyond the 14 days. Resident identifier: 8.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, for 2 out of 32 sampled residents, a resident's insulin was administered when it should have been held per the physician ordered parameters, and a resident's Midodrine was administered when it should have been held per the physician ordered parameters. Resident identifiers: 4 and 42.

Inspectors wroteBased on interview and record review, it was determined for 7 out of 65 sampled residents that the facility did not ensure that each resident had the right to be free from abuse and neglect. Specifically, residents were not assessed for the capacity to consent to a sexual relationship. This was cited at an immediate jeopardy level, Another resident experienced unwanted sexual contact from another resident. In addition, a resident without capacity was able to leave the facility against medical advice and was charged with trespassing. The last 2 examples were cited at a harm level. Resident identifiers: 6, 49, 54, 67, 121, 319, 419.

Inspectors wroteBased on interview, observation and record review it was determined, for 7 of 65 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, a resident was soiled and calling for help, incontinence cares were not being completed every 2 hours, showers were not provided to residents, there were complaints of staff not answering call lights and resident council minutes revealed complaints of not enough staff. Resident identifiers: [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, inadequate oversight by the Director of Nursing resulted in multiple system failures in resident care areas which placed residents at harm. Resident identifiers: 1, 3, 4, 5, 9, 10, 13, 15, 16, 20, 26, 27, 28, 29, 32, 34, 38, 45, 46, 49, 51, 52, 53, 55, 57, 61, 65, 120, 269, and 371.

Inspectors wroteBased on observation, interview and record review it was determined, for 45 out of 65 sampled residents, that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, deficient practice identified during the survey regarding abuse was found to have occurred at an Immediate Jeopardy level. Additionally, deficient practice identified during the survey regarding involuntary seclusion, pressure ulcers, accident hazards, bowel and bladder incontinence, sufficient staffing, competent nursing staff, behavioral health services and sufficient dietary personnel were found to have occurred at a harm level. Resident identifiers: [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 1, 3, 4, 5, 6, 9,10, 13, 14, 15, 16, 18, 20, 22, 24, 26, 27, 28, 29, 30, 32, 34, 36, 38, 44, 45, 46, 49, 50, 51, 52, 53, 54, 55, 57, 60, 61, 65, 67, 120, 121, 269, 319, 371, and 419.

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, that the facility failed to ensure the resident was free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, a resident was relocated to the locked memory care unit for not following the smoking policy. Resident identifier: 46.

Inspectors wroteBased on record review and interview it was determined, for 1 of 65 sampled residents, based on the comprehensive assessment of a resident the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically a resident's wound Vacuum-Assisted Closure (VAC) was not working for approximately 24 hours and the physician was not notified until the resident was somnolent. Resident identifier: 371.

Inspectors wroteBased on observation, interview, and record review, it was determined for 5 of 65 sampled residents that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell as a result of the use of damaged medical equipment; no updated interventions were implemented after resident falls, with one resident having sustained a major injury; neurological assessments were not completed after falls and a call light was not within reach. Resident identifiers: 1, 5, 13, 18, 51, 52 and 60.

Inspectors wroteBased on observation, interview and record review, for 3 of 65 sampled residents, the facility did not ensure a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or became such that continence was not possible to maintained. Specifically, a resident had a urine analysis (UA) obtained and 12 days later staff obtained the results and treatment was started for a urinary tract infection (UTI). The resident complained of flank pain during the 12 days and was administered Tylenol. Another resident was occasionally incontinent of bladder upon admission was not provided a bladder retraining program. In addition, the same resident was observed to have a call light on for 8 minutes, yelling for help, and another resident found staff to clean him up after having a bowel movement. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideation's had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57.

Inspectors wroteBased on observation, interview and record review it was determined, for 17 of 65 sampled residents, that the facility did not employ sufficient staff with the appropriate competencies and skills set to carry out the function of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, meals were observed to be served over an hour later than the posted meal times, a resident was observed to be yelling he was hungry, residents were in the hallways waiting for food, residents were upset in the dining room waiting for meals and residents council minutes revealed complaints of late meals. Resident 16 will be cited at a harm level. Resident identifiers: [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 30 of 65 sampled residents, that the facility did not provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, meals were served late, menus were not meeting nutritional needs, portion sizes were not appropriate, food was not palatable, resident food allergies and preferences were not honored, beverages were not offered between meals, therapeutic diets were not followed, snacks were not provided, adaptive equipment was not provided, and the kitchen was not sanitary. In addition, weights and nutritional assessments were not being completed. Resident identifiers: [...]

Inspectors wrote2. Resident 26 was admitted to the facility on [DATE] with diagnoses which include, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. On 11/3/24 at 3:20 PM, an interview was conducted with resident 26. Resident 26 stated that the kitchen used to clean the mugs that residents used on a daily basis. Resident 26 stated that mugs were not getting clean and she began to wash the mugs she received with hand soap prior to using them. Resident 26 stated that washing the mugs in her bathroom sink was difficult due to size and that she purchased her own smaller mugs to use. Resident 26 stated that she purchased dish soap and washed the mugs in her bathroom sink because clean mugs were not provided to her. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff not performing hand hygiene during meal service and medication pass, food was delivered to resident rooms uncovered, and the facility did not have a Legionella prevention and monitoring plan in their water management program. Resident identifiers: 20, 46.

Inspectors wroteBased on observation, interview, and record review it was determined, for 13 out of 65 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, residents complained of cold temperatures in their rooms, resident rooms were not cleaned, resident toilets leaked and a toilet seat was loose, a resident sink leaked water, resident showers flooded rooms, holes were found in a residents door, a brown substance was observed on a resident's wall, and resident personal belongings were lost. Resident identifiers: 3, 13, 20, 22, 26, 27, 29, 30, 32, 51, 53, 55, and 120. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 out of 65 sampled residents, that the facility did not make prompt efforts to resolve grievances. Specifically, residents expressed grievances about missing personal property to staff and there was no resolution to the grievances. Resident identifiers: 29, 51.

Inspectors wroteBased on interview and record review it was determined for 5 out of 65 sampled residents, that the facility did not develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, facility staff did not conduct capacity to consent to sexual relationships for residents prior to residents engaging in sexual relationships. Resident identifiers: 6, 49, 54, 121 and 319.

Inspectors wroteBased on interview and record review, it was determined for 6 out of 65 sampled residents, that in response to an allegation of abuse, neglect, exploitation, or mistreatment, the facility failed to report immediately, but not later than 2 hours to the other officials including the State Survey Agency (SSA). Specifically, sexual abuse, a fall with a major injury, a fall from a hoyer lift, exploitation of a resident, involuntary seclusion, and an elopment were not reported to the SSA. Resident Identifiers: 5,13, 46, 54, 121, 419 Findings Include: The facility's Abuse Policy and Procedures were reviewed. The following was documented in the policy: [...]

Inspectors wroteBased on interview and record review it was determined, for 3 out of 65 sampled residents, that the facility did not provide written information to the resident or resident representative the duration of the state bed hold policy, during which the resident was permitted to return and resume residence in the nursing facility. Specifically, residents were transported to the hospital and were not informed of the facility bed hold policy. Resident identifiers: 5, 8, 123.

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not accurately assess residents. Specifically, one resident's Minimum Data Set (MDS) assessment did not reflect a discharge to home. Resident identifier: 68.

Inspectors wroteBased on interview and record review it was determined, for 4 out of 65 sampled residents, that the facility did not ensure that baseline care plans were developed and implemented within 48 hours of the resident's admission and contained the minimum information necessary to care for the resident including, but not limited to, initial goals, physician orders, dietary orders, therapy services, social services and Preadmission Screening and Resident Review (PASRR). Specifically, baseline care plans were not completed for residents timely and they did not contain the minimum healthcare information. Resident identifier: 38, 51, 65, and 66.

Inspectors wrote4. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabtes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:40 AM, an interview was conducted with resident 55. Resident 55 stated he had pain in his back, that radiated down his right side to his groin and left hip. Resident 55 stated he thought it was a pinched nerve but the nurse got a urine sample on 10/28/24. Resident 55 stated he had not heard about the results from his urine and was not sure if he was taking antibiotics. Resident 55 stated the pain from his back to his groin was new. Resident 55 stated that his catheter was removed about a month ago. Resident 55's medcal record was reviwed 11/5/24 thought 11/13/24. [...]

Inspectors wroteBased on interview and record review it was determined, for 4 of 65 residents sampled, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, resident's were not provided bathing/shower assistance, nail care, and incontience care for over 3 hours. Resident identifier: 15, 49, 51 and 60.

Inspectors wroteBased on observation, interview and record review, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65.

Inspectors wroteBased on interview and record review, it was determined for 5 out of 65 sampled residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, as needed (PRN) orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, and should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a resident was prescribed an antipsychotic without a supporting diagnosis and no gradual dose reduction was initiated. [...]

Inspectors wroteBased on interview and record review, for 7 of 65 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, results from laboratory tests completed at outside facilities were not obtained and filed into resident's medical record. Resident identifiers: 1, 2, 13, 50, 52, 54, and 55.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 65 sampled residents, that the facility did not have menus that met the nutrition needs of residents in accordance with established nutritional guidelines. Specifically, menus were not followed and correct portion sizes were not provided to residents. Resident identifiers: 15, 16 and 55.

Inspectors wroteBased on observation, interview and record review it was determined, for 11 out of 65 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of food, there were multiple resident council complaints about the flavor of food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 9, 12, 16, 22, 26, 27, 28, 32, 50, 55, and 120.

Inspectors wroteBased on observation, interview and record review it was determined, for 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38.

Inspectors wroteBased on observation, interview and record review for 4 of 65 sampled residents, the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, water was not being provided to residents between meals, residents had to seek out staff to obtain fresh water and resident water mugs were not being cleaned regularly. Resident identifiers: 26, 27, 55 and 120.

Inspectors wroteBased on observation, interview and record review it was determined, for 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9,13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120.

Inspectors wroteBased on interview and record review, the facility did not ensure that, for 6 of 65 sample residents, medical records were complete and accurately documented. Specifically, neuro checks were not documented in the resident's medical record, records were not obtained after a resident went to and returned from the hospital, a resident's medical information was found in another resident's medical record, and a physician documented a progress note in the wrong resident's medical chart. Resident identifiers: 10, 13, 26, 220, 221 and 371.

Inspectors wroteBased on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the COVID-19 immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunization documentation in their medical records. Resident identifiers: 49, 61, and 269.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 65 residents sampled, that the facility did not adequately equip residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities. Specifically, resident's bedside and toilet call lights were not in working condition or were not present at all. Resident identifiers: 44, 51, and 55.

Inspectors wrote3. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On 11/4/24 at 8:16 AM, an observation was made of resident 27 eating cereal out of a small disposable cup. On 11/4/24 at 8:16 AM, an interview was conducted with resident 27. Resident 27 stated that she had received her cereal in a disposable container. Resident 27 stated the she would like to eat cereal out of a larger bowl and not a small disposable container. [...]

Inspectors wroteBased on interview and record review, for 1 of 65 sampled residents, the facility failed to provide the residents the right to participate in the development and implementation of a person-centered care plan, the right to attend meetings regarding the person-centered care plan, and the right to request revisions to the person-centered plan of care. Specifically, a resident who wished to participate in her plan of care was not included, and there was no documentation that care plan meetings were being held. Resident identifier: 3.

Inspectors wroteBased on observation and interview it was determined, for 2 of 65 sampled residents, that the facility did not ensure the resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, the resident call lights were out of reach. Resident identifiers: 1 and 30.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 65 sampled residents, the facility failed to ensure the resident had reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Specifically, a resident was not provided access to a phone in her room as requested. Resident identifier: 28.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 65 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, a resident had a signed Provider Order for Life-Sustaining treatment (POLST) form for a Do Not Resuscitate (DNR) but the electronic medical records banner documented that the resident wanted full treatment. Resident identifier: 22.

Inspectors wroteBased on interview and record review, for 1 of 65 sampled residents, the facility did not take all the necessary steps to prevent the exploitation of a resident for personal gain. Specifically, when the facility became aware of possible exploitation of a resident, the police were not notified, and no follow-up occurred to protect the resident. Resident identifier: 13.

Inspectors wroteBased on interview and record review, for 1 of 65 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency, within 5 working days of the incident. Specifically, after a resident sustained a fall resulting in a major injury, the facility did not investigate the incident and did not update the resident's care plan to initiate interventions to prevent additional falls. Additionally, the incident was not reported and investigative results were not submitted to the State Agency within 5 working days. Resident identifier: 13.

Inspectors wroteBased on interview and record review it was determined for 3 out of 65 sampled residents, that the facility did not ensure that the receiving health care institution had the resident's medical record information including: the contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan, and any other documentation to ensure a safe and effective transition of care. Specifically, the residents were transferred to the local area hospital emergency department (ED) without any accompanying medical records. Resident identifiers: 8, 123, and 371.

Inspectors wroteBased on interview and record review, the facility did not provide and document sufficient preparation to 1 of 65 sampled residents to ensure a safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment signed out of the facility against medical advice and was subsequently imprisoned and charged with criminal trespassing. Resident identifier: 419. Findings Included: Resident 419 was admitted to the facility on [DATE] and discharged on 3/25/24 with diagnoses of metabolic encephalopathy, schizophrenia, psychological and behavioral factors, and polydipsia. Resident 419's medical record was reviewed on 11/13/24. A hospital history and physical dated from 2/6/24 to 3/20/24 documented resident 419 was unable to care for themselves nor make medical decisions and lacked self-awareness. [...]

Inspectors wroteBased on interview and record review, for 1 of 65 sampled residents, the facility failed to obtain the written and/or verbal physician orders to provide essential care to the resident upon admission to the facility. Specifically, a resident who was admitted with an indwelling catheter did not have physician orders for catheter care. Resident identifier: 221.

Inspectors wroteBased on interview and record review it was determined, for 2 of 65 residents sampled, that the facility did not ensure the timely transmission and completion of the Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid (CMS) System. Specifically, two resident's MDS assessments were not encoded and transmitted within 14 days after the facility completed the resident assessment. Resident identifier: 13 and 32.

Inspectors wroteBased on observation, interview and record review it was determined, 3 out of 65 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, there was no activity calendar, there were no activities on the weekends, resident complained of not enough activities, activities were observed during meal times, and there were complaints in resident council minutes. Resident identifiers: 26, 38 and 49.

Inspectors wroteBased on interview and record review, for 1 of 65 sample residents, the facility did not ensure a resident who required colostomy services received care consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. Specifically, the facility ran out of colostomy supplies and when the supplies were ordered, the wrong item was ordered leaving the resident without colostomy supplies. Resident identifier: 3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurse, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 64 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, staff reported ignoring resident behaviors and were not able to identify person-centered interventions or non-pharmacological approaches to resident's dementia care. Resident identifier: 65.

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, Darbepoetin Alfa injection for anemia was not available from the pharmacy for administration and laboratory values were abnormal. Additional medications were not available for administration. Resident identifier: 55.

Inspectors wroteBased on interview and record review it was determined, for 2 of 65 sampled residents, that the facility did not provide or obtain laboratory services timely to meet the needs of its residents. Specifically, a resident's urinalysis (UA) with culture and sensitivity (C & S) was not followed up on timely resulting in a delay of treatment and another resident did not have weekly labs completed for an ordered Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP). Resident identifiers: 1 and 55.

Inspectors wroteBased on observation, interview and record review, it was determined for 1 of 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 65 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. On 11/4/24 at 10:06 AM, an observation was made of resident 5 feeding himself in his room. The resident was eating off of a flat plate, no lip or divided plate was observed. A meal ticket was observed on his tray and indicated, Adaptive Equip: Lip Plate.

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to individuals providing services in the facility, and to the timeliness of those services. Specifically, facility staff documented they were unable to contact hospice, the facility did not obtain from the hospice provider the nursing notes and there were no coordination of care notes. Resident identifier: 4.

Inspectors wroteBased on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident was treated for a urinary tract infection (UTI) with an antibiotic that the organism was resistant to. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined, for 3 of 5 sampled residents, that the facility did not ensure that residents were offered the influenza and pneumococcal immunizations and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunizations documentation in their medical records. Resident identifiers: 49, 61, and 269.

Inspectors wroteBased on interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 32 sampled residents, a resident that had uncontrolled anxiety and agitation for two months had a fall that resulted in a fracture. This resulted in a finding of harm. In addition, a resident had four falls, did not have preventative interventions in place, and/or adequate supervision to prevent falls. The falls resulted in the resident hitting their head and causing lacerations. Resident identifiers: 47 and 164.

Inspectors wroteBased on interview and record review, it was determined, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 32 sampled residents, a resident that was a fall risk did not have a baseline care plan developed within 48 hours of the admission. Resident identifier: 47.

Inspectors wroteBased on interview and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 1 out of 32 sampled residents, a resident that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have a care plan developed and implemented in a timely manner. In addition, the care plan was not updated with safety interventions after the resident had four falls. Resident identifier: 47.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 32 sampled residents, facility staff did not promptly respond with a resident presented with signs and symptoms of a UTI and they did not ensure the resident received an antibiotic susceptible to the organism causing the UTI. Resident identifier: 3.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 1 out of 32 sampled residents, the facility was unable to demonstrate implementation of interventions for managing a residents dementia with behavioral disturbances. The resident had uncontrolled anxiety and agitation for two months that resulted in a fall with a fracture. Resident identifier: 164.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 2 out of 32 sampled residents, a resident with a Urinary Tract Infection (UTI) was started on an antibiotic and the culture and sensitivity (C&S) was never received which indicated to repeat the culture. In addition, a resident with a UTI was started on an antibiotic and a C&S was not completed per physician's orders. Resident identifiers: 25 and 31.