Beloved Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1), who was identified as at risk for elopement, in a review of six sampled residents, did not leave the facility without staff knowledge. Staff failed to ensure an interior, alarmed, coded double door, as well as the front entrance door alarms were activated and secured on 3/27/25. The resident exited the facility through the interior, alarmed, coded double doors, leading from the dining room to the facility front entrance and exited through the front entrance door without the alarm sounding and without staff knowledge. He/She walked one mile to a convenience store across four lanes of traffic and fell by the roadway. A passing car assisted the resident and called the police who returned the resident to the facility. [...]

Inspectors wroteRefer to 4RZT12. Based on observation, interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for three residents (Resident #10, #21, and #22), in a review of 23 sampled residents, who wished to have a snack offered. The facility census was 83.

Inspectors wroteRefer to 4RZT12. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 11/27/24. Based on observation, interview and record review, the facility failed to provide for a safe transfer for two residents (Resident #5 and Resident #12) in a review of 23 sampled residents. Facility staff failed to use a gait belt for the transfer of Resident #5 from his/her wheelchair to his/her bed, which resulted in a near-fall, and facility staff failed to use the appropriate size of a mechanical lift pad, based on resident weight, for the transfer of Resident #12 by a mechanical lift, causing the resident to complain of the sling hurting him/her during the transfer process. The facility census was 83.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent injuries/accidents for four residents (Residents #6, #7, and #20). Resident #6 had a history of self harm and swallowing batteries. The facility failed to ensure the resident did not have accessibility to batteries. The resident swallowing four triple A batteries and required treatment at the hospital. The facility also failed to ensure staff transported Resident #7, #15 and #20 in their wheelchairs with foot rests, failed to ensure two residents (Residents #243 and #250) did not smoke near hazardous items, and failed to ensure chemicals were kept secured and not accessible to residents. The facility census was 87. During an interview on 11/25/24 at 2:46 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently assess pain, document why pain medications were not administered when pain was identified, failed to medicate prior to treatment, failed to develop a care plan to implement appropriate pain interventions during and prior to care that elicited pain, and failed to address a sling causing pain for three residents (Resident #19, #36, and #80) in a review of 20 sampled residents, when the residents displayed signs of pain and some were not able to verbalize pain. Resident #19 had fractures and swelling of his/her right extremity, and the resident's sling was placed incorrectly. The resident verbalized distress with his/her limited speech and staff failed to use ordered interventions to assist the resident who showed facial grimacing, guarding, and expressed his/her arm hurt. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 87. Review of the facility maintained Resident Trust Bank Statements for the period 11/2023 through 10/2024, excluding 03/2024, showed an average monthly balance of $5,470.41. Review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 11/19/24, showed the facility held a balance of resident funds in the amount of $29,602.51. Review on 12/19/24 of the Department of Health and Senior Services approved bond list showed the facility had a $50,000 approved bond, making the bond insufficient by $2,500.00. During an interview on 11/25/24, at 5:40 P.M., Business Office Manager (BOM) #2 said she did not know the A/R amounts would increase the amount of the bond needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rights were posted on the 100 hall. Residents on the 100 Hall resided on a locked, secured unit. The facility also failed to ensure resident rights were reviewed with residents at least annually. The facility census was 87. Review of the facility's undated policy, admission Contract and Authorization for Treatment, showed the following: -The following is a statement of resident's rights under federal and state regulations; -The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibility during the stay in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (which would disqualify an individual from working in the facility) for nine of ten newly hired employees reviewed. The facility census was 87. Review of the facility's policy, Abuse and Neglect, dated 12/28/23, showed the facility would not employ individuals who have been convicted of abusing, neglecting or mistreating individuals. Potential employees are screened for a history of abuse, neglect or mistreating a resident. 1. Review of the Maintenance Director's employee file showed the following: -Date of hire 01/05/24; -No documentation the facility completed a Nurse Aide Registry check. 2. Review of Certified Nurse Assistant (CNA) K's employee file showed the following: -Date of hire 10/23/24; -No documentation the facility completed a Nurse Aide Registry check. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four nurse aides (NA) (NA U, NA Q, NA V and NA W) completed a nurse aide training program within four months of their employment as an NA in the facility. The facility also failed to ensure 16 hours of instructional training covering communication, infection control, safety/emergency procedures, residents' rights and promoting independence before any resident interaction for one NA (NA F) in a sample of five NA employee files reviewed. The facility census was 87. Review of the facility's policy, Nurse Assistants/Certified Nurse Assistants, undated, showed the following: -This policy defines the qualifications, roles and restrictions for Nursing Assistant (NA) Students and Certified Nursing Assistants (CNA) at the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff prepared and served the correct portion size of food items to residents with a physician's order for a pureed diet, failed to ensure staff prepared and served the correct portion size of food items to residents with a physician's order for a mechanical soft diet and failed to ensure staff prepared and served the correct food items to residents with a physician's order for a regular diet. The facility census was 87. 1. Review of the Diet Type Report, dated 11/18/24, showed two residents had a physician's order for a pureed diet. Review of the Diet Spreadsheet for lunch on 11/18/24 (Week 3, Day 16) showed residents on a pureed diet were to receive the following items: -Pureed smothered pork chop with gravy (#8 dip or ½ cup serving); -Pureed buttered cabbage (4-ounce or ½ cup serving); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in cooler fan shrouds were free of a buildup of debris; failed to ensure a chest freezer was maintained to keep food items frozen solid; failed to ensure food items were labeled, dated, and closed/sealed; failed to ensure dishware was not stacked and stored wet; and failed to ensure the ice machine was free of a buildup of black debris. The facility census was 87. 1. Observation on 11/18/24 at 10:24 A.M. showed two blue fan shrouds inside the walk-in cooler in the kitchen had a moderate buildup of fuzzy debris. 2. Observation on 11/18/24 at 10:38 A.M. of the thermometer inside the chest freezer, located inside the hot water heater/storage room in the kitchen, showed the temperature inside the freezer was 8 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and record review, the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 87. 1. Observation and review during the survey process from 11/18/24 through 11/21/24 and 11/25/24 showed the following: -No yearly staff education regarding care of residents with dementia; -No yearly staff education on abuse and neglect; -No yearly required training hours for certified nursing assistants; -No education calendar was completed; -No staff member was monitoring staff education hours; -Review of the staff training did not show required training was completed for all staff or nurse aides/certified nurse assistants; -The facility failed to ensure payroll based journal (PBJ) data was entered and submitted timely; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Tuberculin Skin Tests (TST) were completed and documented in accordance with the requirements for Tuberculosis (TB) (infectious bacterial disease that affects the lungs) testing for long-term care employees for six employees, in a review of ten employees, when the facility did not ensure the first-step TST was read on or prior to the employee's start date (first date of compensation). The facility failed to develop and implement a Legionella (bacteria found in water which can cause Legionnaires' disease, a serious type of pneumonia caused by Legionella bacteria that infect the lungs after being inhaled from water or soil.) Prevention Program. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate means of dining furniture/equipment for three residents (Resident #10, #36, and #80) of 20 sampled residents, in order to allow the residents to reach their food and drinks. The residents use a reclining chair on wheels and cannot sit up to the table. The residents sat parallel to the table and had to twist to reach items or place their plates on their laps to try to feed themselves. The facility census was 87. Through an email correspondence on 12/09/24 at 9:57 A.M., the Director of Nursing (DON) replied the facility had no policy for choices/self determination. 1. Review of Resident #36's care plan, revised 01/22/24, showed the resident needed supervision and touch assistance with eating. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for six residents (Resident #9, #27, #30, #69, #77 and #301). The facility census was 87. Record review of the facility maintained Accounts Receivable Aging Report, dated 11/19/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #9 $100.00 #27 $3,708.00 #30 $1,928.00 #69 $22,638.51 #77 $1,072.00 #301 $156.00 Total $29,602.51 During an interview on 11/25/24, at 5:40 P.M., Business Office Manager (BOM) #2 said she was not sure what the amounts on the A/R report were, she would have to check and get back to State Agency (SA) staff. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility also failed to provide quarterly statements to the residents. The facility managed funds for 27 residents. The facility census was 87. 1. Record review of the facility maintained attempted reconciliation forms, for the period 11/01/23 - 10/31/24, excluding 03/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to give appropriate Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMS-10055) and the CMS Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing with all required information to three residents (Residents #245, #391, and #246), reviewed in a sample of three residents, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 87. Through an email correspondence on 12/09/24 at 9:57 A.M., the Director of Nursing (DON) replied the facility had no policy for ABN and NOMNC notices. The facility followed the regulatory guidelines related to these areas. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was clean and the ceilings and walls were in good repair. The facility failed to ensure the facility was free of persistent strong urine odors and failed to ensure bathroom vents were free from a heavy accumulation of dust and debris. The facility census was 87. Review of the facility policy, Safe/Clean/Comfortable/Homelike Environment, dated 11/1/22, showed the following: -The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely; -The facility must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belongings to the extent possible; -Housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident money was free from misappropriation for ten residents (Resident #13, #25, #30, #31, #52, #67, #72, #85, #88 and #243) when Business Office Manager #1 removed and used resident funds in the amount of $6,117.21, for his/her personal use. The deficiency has the potential to affect any resident the facility managed funds for at the time of Business Office Manager #1's employment. The facility census was 87. Review of the facility policy Abuse and Neglect, dated 12/28/23, showed the following: -To outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for four sampled residents (Residents #30, #80, #19 and #65), in a review of 20 sampled residents. The facility census was 87. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. -The RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for three residents (Resident #241, #7, and #80), in a review of 20 sampled residents. The facility census was 87. During an interview the Director of Nurses (DON) said the facility did not have a policy for completing care plans. Review of the Resident Assessment Instrument (RAI) manual, dated [DATE], showed the following: -The admission Minimum Data Set (MDS) must be completed by the 14th day after admission, admission day being day one; -The comprehensive care plan must be completed no later than seven days after the completing of the admission MDS; -The overall care plan should be oriented towards: -Assisting the resident in achieving his/her goals, goals should be measurable. -Individualized interventions that honor the resident's preferences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided assistance with activities of daily Living (ADLs) to six residents (Resident #36, #80, #19, #67, #10, and #83), in a review of 20 sampled residents, to maintain proper grooming, nutrition, and personal and oral hygiene. The census was 87. Review of the facility policy Incontinence Care, dated 11/01/2022, showed the following: -Check the resident at least every two hours, and assist with toileting as needed, if the resident is not on a specified program. -Provide peri care after each incontinent episode. -Change briefs and pads promptly when they are wet or soiled. Review of the facility policy Personal Care, Hygiene, and Grooming, dated 11/01/22, showed the following: -The most important aspect of maintaining good health is good hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain foot health for three residents (Resident #19, #80, and #44) in a sample of 20 residents. The facility census was 87. Review of the facility policy Personal Care, Hygiene, and Grooming, dated 11/01/2022, showed the following: -Personal hygiene includes nail care; -Clean hands and well-groomed nails prevent infection; -Nail care includes keeping nails trimmed and file, no jagged or broken nails, cleaning underneath to remove debris, hangnails trimmed, no chipped or worn nail polish; -Nail care for residents with diabetes will be provided by the nurse; -Nail trimmers must be cleaned with an alcohol wipe between residents; -Change gloves and wash hands between every resident when providing nail care. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services to assist three residents (Resident #19, #80 and #4), in a review of 20 sampled residents, in attaining or maintaining their highest level of functioning. The facility failed to prevent further decline of limited range of motion or development/worsening of contractures (shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative plans with goals, frequency of task, number of repetitions, length of time, or direction to staff to meet resident needs. The facility census was 87. Review of the facility policy, Range of Motion, dated 08/15/22, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment prior to placement of bedrails, document alternatives attempted prior to bed rail placement, complete entrapment zone measurements, or obtain written consent from the residents and/or their guardians prior to use for two residents (Residents #19 and #20), who used side rails, in a review of 20 sampled residents. Resident #19 had quarter bed rails assessed but half-rails were present on his/her bed. The census was 87. During an interview on 11/25/24 at 2:00 P.M., the Director of Nursing (DON) said the facility did not have a policy for entrapment risks and bed rail use. 1. Review of Resident #20's Bed Measurement Device assessment form, dated 11/14/22, showed the following: -Zone one, quarter one = 4.25 inches (<4.75 inches within the rail); -Zone two, no measurements; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was sufficient and competent nursing staff to meet resident needs. The facility consistently had less nursing staff than indicated in the facility assessment. During a resident council meeting, three residents (Resident #4, #74 and #83), voiced concerns of call lights not being answered in a timely manner on night shift and on the weekends. The facility failed to provide restorative nursing to three residents (Resident #19, #80, and #4) in a sample of 20 residents who had contractures when the facility did not employee a restorative aide. The census was 87. Review of the facility's Facility Assessment, dated 11/26/24, showed the average daily facility staffing plan included: -One Hall Monitor; -Two Certified Nurse Assistants (CNA)'s; -Six Certified Medication Technicians (CMT)'s; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of a policy and procedure for monthly drug regimen reviews and failed to ensure the physicians for three residents (Residents #242, #50, and #33) provided a timely response to the pharmacist's recommendations to decrease the dosage of medications used to treat mental health disorders. The facility census was 87. The facility did not provide a policy to address the facility's system for the monthly drug regimen reviews, including time frames for different steps in the process, steps the pharmacist must take when he/she identifies an irregularity that requires urgent action, and expectations for the physicians to respond timely to identified irregularities/recommendations. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food to the residents that accommodated their preferences for three residents (Residents #83, #53, and #74), in a review of 20 sampled residents. The facility census was 87. 1. Review of Resident #83's Face Sheet showed he/she was his/her own responsible party. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She had a mechanically altered diet. Review of the resident's Physician Order Summary (POS), dated 10/01/23 through 11/30/24, showed the resident had a dietary order for mechanical soft texture. Review of the resident's Care Plan, revised on 11/12/24, showed the following: -The resident was at risk of aspiration; -Serve diet as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for three residents (Resident #10, #21, and #22), in a review of 23 sampled residents, who wished to have a snack offered. The facility census was 83. During an interview on 2/5/25 at 1:09 P.M., the Director of Nursing (DON) said the facility did not have a policy for bedtime snacks or following diet orders. Review of the undated facility Snack Schedule showed the following: -Monday: Fudge Rounds and animal crackers; -Tuesday: Fig Newtons and Honey Buns; -Wednesday: Oranges and animal crackers; -Thursday: Oreos and graham crackers; -Friday: Chips, brownies, and animal crackers; -Saturday: Fudge Rounds and Honey Buns; -Sunday: Oatmeal cookies and baked cookies from dietary. Observation on 2/4/25 at 4:40 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided education and offered, administered, or obtained the signed refusal for the pneumococcal immunization for four residents (Resident #7, #74, #18 and #44) and failed to track immunization history for at least one resident (Resident #7), in a review of 20 sampled residents. The census was 87. Review of the facility policy Pneumonia Vaccine - Pneumococcal Immunization - PPV, revised 12/20/22, showed the following: -PPV should be administered to all residents in the facility unless it is contraindicated or refused; -The Director of Nursing /Designee will maintain a log of all residents on the unit for a record of the immunization process that includes columns for: -Resident name and room number -That the resident/ family member was given information about the vaccine and its benefits and possible side effects; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were educated and offered or obtained consent or refusal of the COVID 19 immunization for two residents (Resident #7, #74) in a review of 20 sampled residents. The census was 87. Review of the facility Policy/ Procedure titled Influenza Immunization - Flu Vaccine- COVID Immunizations, last revised on 11/22/22 showed the following: -The Infection Control Nurse will give the Charge Nurse a log of all residents on the unit for a record of the immunization process that includes columns for: -Resident name and room number -That the resident/ family member was given information about the vaccine and its benefits and possible side effects; -Date vaccine administered; -Vaccine refused or contraindicated, and reason why; -The Charge Nurse will monitor the log daily to make sure it is being filled out correctly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a call light at each resident's bedside for the residents to call staff for assistance, affecting two resident (Residents #28 and #68), in a review of 20 sampled residents. The facility census was 87. Review of the facility policy, resident call system, dated 08/02/24, showed the following: -Each resident room will be provided with a call light in the event they require assistance from staff; -Each resident room should be equipped with at least two (four for the Quad rooms) call lights so that each resident can request staff assistance; -All call lights should be within reach of each resident; -All staff are expected to respond to call lights, or let the necessary personnel know the lights are going off and residents require assistance. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all employees completed communication training for three employees (Certified Medication Technician (CMT), CMT J, and CNA R) in a sample of four employee files reviewed. The facility identified specific training needs in the facility assessment, and did not have documentation or evidence the required training was completed. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; -Include staff certification requirements as applicable, testing policies, and your competency evaluations; -Training required - new hires: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all employees received training on resident rights. The facility identified specific training needs in the facility assessment, and did not have documentation or evidence the required training was completed for three of four employees reviewed (Certified Medication Technician (CMT) D, CMT J, and CNA R), or a current plan to ensure the training would be completed. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; -Include staff certification requirements as applicable, testing policies, and your competency evaluations; -Training required - new hires: [...]

Inspectors wroteBased on interview and record review the facility failed to provide training for abuse, neglect, exploitation, and misappropriation of resident property and the reporting and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property for three employees (Certified Medication Technician (CMT) D, CMT J, and Certified Nurse Assistant (CNA) R) of four employee records reviewed, as directed in the facility assessment and the facility's Abuse and Neglect policy. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all employees completed education on infection control. The facility identified specific training needs in the facility assessment. The facility did not have documentation or evidence the required training was completed for four of four employees (Certified Medication Technician (CMT) D, CMT J, Certified Nurse Assistant (CNA) R and CNA I) reviewed, or a current plan to ensure the training would be completed. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; -Include staff certification requirements as applicable, testing policies, and your competency evaluations; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff completed compliance and ethics training. The facility identified specific training needs in the facility assessment. The facility did not have documentation or evidence the required training was completed for two of four employees (Certified Medication Technician (CMT) D and CMT J - employees who had been working at the facility for at least one year), and one Certified Nurse Assistant (CNA) R, of two employees newly hired in the last year, or a current plan to ensure the training would be completed. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each Certified Nurse Aide (CNA) 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 two Certified Medication Technicians (CMTs) employed by the facility for more than a year (no CNAs or NAs had been employed for a year). Two CMTs (CMT J and CMT D), were sampled and two out of two did not have the required 12 hours of in-service education, or training for abuse. One CMT of two did attend an in-service that included the topic of abuse, but there was no agenda provided, depth or scope of the training. None of the two sampled staff attended an in-service that included the topic of dementia. One of the two sampled CMT's attended an in-service for behaviors, but there was no agenda, depth, or scope of the training. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an effective training program was in place for all new and existing staff. The facility identified specific training needs in the facility assessment, the facility did not have documentation or evidence the required training was completed for two employees (Certified Medication Technician (CMT) D and CMT J) of two employee education files (of employees who had been working at the facility for at least one year), and for two additional employees (CNA I and CNA R), (who had not been employed by the facility for one year) reviewed, or a current plan to ensure the training would be completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity and ensured full recognition of individuality for two residents (Resident #20 and #36), in a review of 20 sampled residents. The facility census was 87. Review of the facility policy Respect/Dignity/Right to have Personal Property, dated 11/1/22, showed the following: -It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. -Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, if those rules do not violate a regulatory requirement. -The resident has a right to be treated with respect and dignity. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, in the time frame required by Centers for Medicare and Medicaid (CMS) for two residents (Residents #4, and #241), in a sample of 20 residents, and for one additional resident (Resident #243). The facility census was 87. Review of the Resident Assessment Instrument (RAI) manual, revised October 2024, showed the following: -The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an significant change in status assessment (SCSA) has been completed since the most recent comprehensive assessment was completed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Residents #36 and #80), in a review of 20 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 87. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to decrease a psychotropic medication for one resident (Resident #73), in a review of 20 sampled residents. The census was 87. Review of Resident #73's care plan, last revised 10/4/24, showed the following: -Diagnoses included anxiety, bipolar disorder (high to low mood swings), depression and schizophrenia (disability to think, feel and behave clearly); -The resident had history of verbal aggression, rejection of medication, rejection of care, disruptive behaviors, delusional behaviors and aggressive behaviors and altercations with peers; -Administer medications as ordered. Review of the resident's Physician Order Sheet (POS), dated 11/2024 showed an order for diazepam 10 mg one tablet by mouth three times daily (original order dated 7/24/24). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist two residents (Residents #44 and 33), in a review of 20 sampled residents, to obtain vision services when the residents asked for an appointment. The census was 87. The facility provided no policy for vision services/appointments upon request. 1. Review of Resident #44's face sheet showed he/she was his/her own responsible party. Review of the resident's admission (readmission) Minimum Data Set (MDS), a federally required assessment completed by staff, dated 1/25/24, showed the resident was cognitively intact. During an interview on 11/19/24, at 11:45 A.M., the resident said he/she requested an appointment for the eye doctor and was waiting to go to the eye doctor for over a year. He/She could not see far away, and things up close were also fuzzy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #50), in a review of 20 sampled residents, received dental services when the resident was diagnosed with an abscessed tooth and was to be seen by a dentist. The facility census was 87. The facility provided no policy for dental services/appointments upon request. Review of Resident #50's face sheet showed he/she had a guardian. Review of the resident's progress note, dated 07/09/24 showed the following: -The resident was seen on the primary care physician's rounds; -The resident had complaints of left lower jaw pain secondary to dental abscess; -The resident had swelling in his/her left lower mandible (jaw bone) due to dental abscess; -The diagnosis was dental abscess; -The plan was to order an antibiotic and narcotic pain medication along with a dental appointment; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Quality Assurance Performance Improvement (QAPI) process training was completed for all staff. The facility identified specific training needs in the facility assessment. The facility did not have documentation or evidence the required training was completed for two employees of four employees (Certified Medication Technician (CMT) D and CMT J) (of employees who have been working at the facility for at least one year) reviewed, or a current plan to ensure the training would be completed. The facility census was 87. Review of the Facility Assessment, dated 09/26/24, showed the the following: -Staff training, education, and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents. The facility also failed to keep the survey binder up to date with all survey and complaint investigation results. The facility census was 87. Review of the facility undated policy, admission Contract and Authorization for Treatment, showed the following: -Examination or survey results, resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; -The results must be made available by the facility in a place readily accessible to the residents and the facility must post a notice of their availability. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative and failed to notify the State Ombudsman when three residents (Residents #242, #33 and #31), in a review of 20 sampled residents, and one additional resident (Resident #68) were transferred to the hospital. The facility census was 87. The facility did not provide a policy addressing written notification to the resident, the resident representative and the State Ombudsman when a resident was transferred to the hospital. 1. Review of Resident #68's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 11/16/24, showed the following: -The resident complained of chest, neck and heel pain and wanted transferred to the hospital; -Physician notified of resident's pain; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the bed hold policy with required information to the resident and/or resident representative at the time of transfer to the hospital for three residents (Residents #242, #33, and #31), in a review of 20 sampled residents, and one additional resident (Resident #68). The facility census was 87. A request for a facility Bed Hold Policy was made but the facility was unable to provide a policy. 1. Review of Resident #242's face sheet showed the resident had a guardian who was his/her responsible party. Review of the resident's progress note, dated 05/25/24 at 10:39 P.M., showed the following: -The resident stated he/she had tried to strangulate him/herself but the string broke from his/her sweat pants; -He/She stated he/she did not want to live anymore; [...]

Inspectors wroteBased on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from April 1, 2024 through June 30, 2024. The facility census was 87. The facility provided no policy regarding PBJ upon request. 1. Review of the CMS PBJ Staffing Data Report, dated 11/12/24, showed no staffing data reported for the period of April 1, 2024 through June 30, 2024. During an interview on 11/20/24 at 11:00 A.M., the Business Office Manager (BOM) said she was new to the facility. She was not employed during the reporting time on the report (when data submission was due for April 1, 2024 through June 30, 2024). Since starting at the facility she has had difficulty signing into the system and missed a deadline to submit PBJ data. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and provide an admission agreement to one resident's (Residents #241's), guardian upon the resident's admission to the facility, in a review of 20 sampled residents. The facility census was 87. Review of the undated facility admission packet showed the following: -admission contract and authorization for treatment: The admission contract and authorization for treatment (contract) is made and entered into on this (date of admission) between (Resident) and the facility, a secured long term care facility with secured/locked unit for special needs residents; -Payment agreement sections to include: Private pay resident, Medicare resident, Medicaid resident, and third party payor; -Resident responsibilities; -Facility responsibilities; -Arbitration of disputes; -Agreements and acknowledgements included: Attachment A. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation to show staff clearly explained the binding arbitration agreement process (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) to two residents (Residents #44 and #241), in a review of 20 sampled residents, and two additional residents (Residents #4 and #46). The facility census was 87. During an interview on 11/25/24 at 2:46 P.M., the Administrator 1 said the facility did not have a policy for binding arbitration agreements. Review of the undated facility admission packet showed the following: -Arbitration of Dispute: [...]

Inspectors wroteBased on interview, and record review, the facility failed to safely transfer one resident (Resident #14), who had a diagnosis of right dominant hemiparesis (weakness or paralysis of one side of the body), in a review of 17 sampled residents. Facility staff failed to utilize a gait belt appropriately and grabbed the resident under the arms which resulted in a displaced right proximal humeral fracture (a break in the upper arm bone where the bone fragments have shifted out of position). The facility census was 98. On 9/10/24 at 12:02 P.M., the administrator was notified of the past noncompliance which occurred on 8/9/24. Upon discovery of the injury, the facility completed an investigation, notified appropriate parties, and interviewed staff. The facility staff were educated on the facility policy on transfers and mechanical lifts. [...]

Inspectors wroteRefer to Event ID C0JV13 Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). [...]

Inspectors wroteRefer to Event ID C0JV13 Based on observation, interview, and record review, the facility failed to ensure eight residents, in a review of 29 sampled residents, were treated in a manner to maintain dignity and respect when they failed to communicate with four residents (Residents #2, #7, #9, #10, and #6) in a respectful manner, and provide one resident (Resident #5), who was incontinent, with incontinence briefs when in bed. The resident reported staff told him/her to urinate in his/her bed and they would clean the resident up later. The facility also failed to provide adequate hygiene for one resident (Resident #3) to ensure removal of unwanted facial and underarm hair prior to the resident going out to a physician's appointment. The resident was observed crying and said she was sad and embarrassed by her appearance and that other residents made fun of her. The facility census was 102. [...]

Inspectors wroteRefer to Event ID C0JV13 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 05/29/24. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in resident rooms. The facility census was 102. Review of the facility policy Synergy Cleaning dated 8/1/24 showed the following: -The purpose is to provide a safe and clean environment for residents; -Clean horizontal services, including window sills; -Spot check floors, clean any spills or trouble areas and pick up any trash. Identify any odors and attend to them immediately; -Sweep floors, move furniture and beds away from walls; -Wet mop floors, move furniture and beds away from walls. During an interview on 7/24/24 at 11:25 A.M. [...]

Inspectors wroteRefer to Event ID C0JV13 Based on observation, interview and record review, the facility failed to ensure two female residents (Residents #4 and #3) received the necessary services to maintain grooming and hygiene including bathing, removal of facial and underarm hair, and nail care. The failure caused one resident to be tearful and expressed being sad and embarrassed, stating other residents made fun her. This deficient practice impacted two residents (Residents #4 and #3) in a review 29 sampled residents. The facility census was 102. Review of the facility policy Personal Care, Hygiene and Grooming, dated 11/1/22, showed the most important aspect of maintaining good health was good hygiene. Personal hygiene, also referred to as a personal care, included bathing and showering, hair care, nail care, oral hygiene and dental care and shaving; [...]

Inspectors wroteRefer to Event ID C0JV13 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 05/29/24. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in resident rooms. The facility census was 102. Review of the facility policy Synergy Cleaning dated 8/1/24 showed the following: -The purpose is to provide a safe and clean environment for residents; -Clean horizontal services, including window sills; -Spot check floors, clean any spills or trouble areas and pick up any trash. Identify any odors and attend to them immediately; -Sweep floors, move furniture and beds away from walls; -Wet mop floors, move furniture and beds away from walls. During an interview on 7/24/24 at 11:25 A.M. [...]

Inspectors wroteRefer to Event ID C0JV13 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 05/29/24. Based on observation, interview, and record review, the facility failed to accommodate resident preferences by not consistently providing alternate food items per the resident's preference for four residents (Residents #7, #10, #15, and #1), a review of 29 sampled residents. The facility census was 102. Review of the facility policy, Alternative Meal Choices, Substitutions and Snacks, dated 11/01/22, showed the following: -The facility will ensure all residents are provided with a nourishing, palatable, well-balance diet or appropriate substitute; -All residents will be offered alternative meal/snacks if they choose not to accept what is being served; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for two residents (Resident #5 and #7) in a review of 12 sampled residents. Staff failed to monitor Resident #5 who was left outside from approximately 10:00 A.M. to 12:00 P.M. The resident sat in a wheelchair in the facility courtyard in direct sunlight with temperatures of 87 degrees Fahrenheit (F) and a 91 degree F heat index. The resident was assessed to have altered mental status, was difficult to arouse, and had low oxygen saturation. The resident was sent to the hospital where he/she was admitted with diagnoses of encephalopathy (chemical imbalance in the blood caused by illness) and possible heat stroke (severe heat-related illness that occurs when the body can not regulate its temperature). [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure four Residents (Resident #4, #9, #10, and #11) were free from verbal abuse when one resident (Resident #8) yelled and cursed at these residents on multiple occasions and staff told the residents to go to their rooms and ignore Resident #8 which caused the residents increased anxiety and fear they would have increased behaviors if Resident #8 continued to yell and curse at them. Resident #4 said he/she was concerned he/she was going to act out towards the resident. Resident #8 caused an increase in his/her anxiety, he/she was having difficulties calming down, and wanting to harm the other resident; Resident #10 said Resident #8 made him/her upset and angry and if something wasn't done to address the resident's behaviors he/she was going to end up in a fight with Resident #8. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure four residents (Resident #2, #7, #12 and #14), were treated in a dignified manner when the residents were not allowed to wear incontinence briefs when in bed as they wished. Resident #2 said he/she had refused visitors, because he/she was afraid of exposing himself/herself due to not being allowed to wear incontinent briefs. The facility census was 103. Review of the facility's Resident Rights policy, dated 11/1/22, showed the following: -All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. Each resident has the right to be treated with dignity and respect. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for one resident (Resident #4), who was readmitted to the facility on [DATE] following an inpatient psychiatric evaluation for a suicide attempt. The facility failed to administer Klonopin (a sedative used to treat panic disorder and anxiety) as ordered to the resident following his/her return from the hospital, for over four days. The census was 103. Review of the facility Medication Administration Policy, dated 11/30/22, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing. and administering of all medications, to meet the needs of each resident; -When getting the medication out of the resident's drawer, check to make sure it is the: -a. Right resident; -b. Right medication; -c. Right dose; -d. [...]

Inspectors wroteRefer to C0JV12 Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in showers and bathrooms. The facility census was 98. 1. During an interview on 5/29/24 at 4:20 P.M., the administrator said they did not have a policy for housekeeping services. Observation of the shower room located on C Hall on 5/28/24 at 12:15 P.M. showed the following: -There was fecal material on the toilet seat and around the toilet bowl; -The floor in front of the toilet was dirty with fecal material; -A washcloth was present on the back of the stool with fecal material on the washcloth; -Hangers and clothes were scattered around the shower room floor; -The bathroom had a strong odor of urine and feces. Observation of the shower room located on C Hall on 5/28/24 at 3:40 P.M. showed the following: [...]

Inspectors wroteRefer to C0JV12 Based on observation and interview, the facility failed to ensure staff prepared and served food items that were attractive and palatable. The facility census was 98. Review of the policy provided by the facility labeled dining room-meals dated 8/2024 showed no documented procedures for food preparation service. 1. During an interview on 5/28/24 at 11:20 A.M., Resident #16 said the following: -He/She described the food served at the facility as slop; -The food tasted nasty and was cold; -He/She sent the food back 99% of the time because it was not edible. During an interview on 5/28/24 at 11:25 A.M., Resident #17 said the food was cold and tasted nasty. During an interview on 5/28/24 at 11:30 A.M. Resident #6 said the following: -The food the facility served did not have any flavor; -The vegetables were usually mushy. [...]

Inspectors wroteRefer to C0JV12 Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #1 and #4) of 17 sampled residents were provided with a nourishing, palatable, well-balanced diet when staff failed to serve appropriate food substitutes to honor resident preferences. The facility census was 98. Review of the facility's policy, Dining Room-Meals dated 8/2024, showed the following: -Offer substitutes to any resident who refused food; -Assist the resident with meals as indicated on the resident's care plan. 1. Review of Resident #1's dietary assessment, dated 1/9/24, showed the following: -He/She was prescribed a regular diet; -He/She was edentulous (without teeth); -There was no documentation of the resident's preferences. Review of the resident's care plan, last revised on 4/16/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five confidential residents (Resident #6, #7, #8, #9 and #10) felt like they could voice concerns to staff or the state agency (SA) without fear of retaliation. The facility also failed to ensure residents were treated with dignity and respect when Registered Nurse (RN) A talked to residents in a rude and disrespectful manner and used profanity around the residents. Certified Nurse Assistant (CNA) B told Resident #9 to clean up his/her mess in the bathroom after the resident was incontinent of stool on the bathroom floor. CNA B pulled Resident #8's blankets off of him/her early in the morning and said the resident could not have his/her blanket back until the resident got out of bed. The facility census was 97. Review of the facility's policy, Resident Rights, dated 11/1/22, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 06/18/24. Based on observation, interview, and record review, the facility failed to ensure eight residents, in a review of 29 sampled residents, were treated in a manner to maintain dignity and respect when they failed to communicate with four residents (Residents #2, #7, #9, #10, and #6) in a respectful manner, and provide one resident (Resident #5), who was incontinent, with incontinence briefs when in bed. The resident reported staff told him/her to urinate in his/her bed and they would clean the resident up later. The facility also failed to provide adequate hygiene for one resident (Resident #3) to ensure removal of unwanted facial and underarm hair prior to the resident going out to a physician's appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #6, #7 and #8) in a review of seven sampled residents and two additional residents (Resident #9 and #10), received care and services in accordance with professional standards of practice. The facility failed to ensure Residents #6, #7, and #8 received their ordered morning medications on time, failed to report abnormal blood pressures for Resident #9 and #10 to a nurse and failed to secure medication cards (with medication in them) before leaving a medication cart unattended in the hallway. The facility census was 91. Review of the facility Medication Administration Policy, dated 11/30/22, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two female residents (Residents #4 and #3) received the necessary services to maintain grooming and hygiene including bathing, removal of facial and underarm hair, and nail care. The failure caused one resident to be tearful and expressed being sad and embarrassed, stating other residents made fun her. This deficient practice impacted two residents (Residents #4 and #3) in a review 29 sampled residents. The facility census was 102. Review of the facility policy Personal Care, Hygiene and Grooming, dated 11/1/22, showed the most important aspect of maintaining good health was good hygiene. Personal hygiene, also referred to as a personal care, included bathing and showering, hair care, nail care, oral hygiene and dental care and shaving; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #7, and #8), of 15 sampled residents with mental disorders received individualized treatment and services to meet their needs. Resident #7 had verbal and physical behaviors towards others. The resident also displayed suicidal ideation and attempted suicide when he/she tied a cord around his/her neck with intent to hang himself/herself and end his/her life. Resident #8 who had a history of suicide attempts, told his/her guardian he/she wanted to hang himself/herself while at the facility, and was sent out for a mental health evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in showers and bathrooms. The facility census was 98. 1. During an interview on 5/29/24 at 4:20 P.M., the administrator said they did not have a policy for housekeeping services. Observation of the shower room located on C Hall on 5/28/24 at 12:15 P.M. showed the following: -There was fecal material on the toilet seat and around the toilet bowl; -The floor in front of the toilet was dirty with fecal material; -A washcloth was present on the back of the stool with fecal material on the washcloth; -Hangers and clothes were scattered around the shower room floor; -The bathroom had a strong odor of urine and feces. Observation of the shower room located on C Hall on 5/28/24 at 3:40 P.M. showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately administer insulin (injectable medication used to treat diabetes) to four residents (Resident #1, #2, #3 and #4) of four sampled residents who received insulin injections, when Licensed Practical Nurse (LPN) A did not prime (remove air) from the insulin pen needle prior to administration, and did not hold the needle in the skin after administration as directed by the manufacturer of the medication. The census was 91. Review of the facility policy, Blood Glucose Monitoring, dated 01/10/22, showed it did not address the specific procedure to follow when administering insulin via an insulin pen. Review of the facility policy, Medication Administration, dated 11/30/22, showed it did not address the specific procedure to follow when administering insulin via an insulin pen. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff prepared and served food items that were attractive and palatable. The facility census was 98. Review of the policy provided by the facility labeled dining room-meals dated 8/2024 showed no documented procedures for food preparation service. 1. During an interview on 5/28/24 at 11:20 A.M., Resident #16 said the following: -He/She described the food served at the facility as slop; -The food tasted nasty and was cold; -He/She sent the food back 99% of the time because it was not edible. During an interview on 5/28/24 at 11:25 A.M., Resident #17 said the food was cold and tasted nasty. During an interview on 5/28/24 at 11:30 A.M. Resident #6 said the following: -The food the facility served did not have any flavor; -The vegetables were usually mushy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #1 and #4) of 17 sampled residents were provided with a nourishing, palatable, well-balanced diet when staff failed to serve appropriate food substitutes to honor resident preferences. The facility census was 98. Review of the facility's policy, Dining Room-Meals dated 8/2024, showed the following: -Offer substitutes to any resident who refused food; -Assist the resident with meals as indicated on the resident's care plan. 1. Review of Resident #1's dietary assessment, dated 1/9/24, showed the following: -He/She was prescribed a regular diet; -He/She was edentulous (without teeth); -There was no documentation of the resident's preferences. Review of the resident's care plan, last revised on 4/16/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for residents who wished to have a snack for five residents (Resident #1, #4, #8 #11, and #13) of 29 sampled residents. The facility also failed to ensure all residents were provided equal opportunity to have a snack. The facility census was 102. Review of a facility policy provided for provision of resident snacks showed the policy did not address snacks. 1. During an interview on 7/25/24 at 4:00 P.M., Resident #11 said the following: -He/She was a diabetic; -He/She had no money to buy his/her own snacks; -Staff placed snacks at the nurse's station in the evening, around 8:30 P.M., but if you did not get up there soon enough, you would not get a snack; -Residents have to ask for them or go get them themselves; -Snacks consisted of honey buns and [NAME] Butter cookies; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures were appropriately followed when Licensed Practical Nurse (LPN) A failed to properly sanitize the glucometer (a device used to evaluate the amount of sugar in the blood by obtaining a droplet of blood for sampling) in between use and after becoming soiled for four residents (Residents #1, #2, #3 and #4), of four sampled residents who had blood sugars tested. The facility census was 91. Review of the facility Blood Glucose Monitoring Policy, dated 01/10/22, showed the following: -Clean and disinfect blood glucose meter after use according to manufacturer specifications if it is used on more than one resident; -Cleaning, and disinfection of blood glucose meters: a. Each resident who has orders for blood sugar checks should have blood sugars checked with the glucometer; b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a call light at each resident's bedside for the residents to call staff for assistance, affecting Resident #26 and Resident #27, and the entire 100-hall. Twenty-four residents resided on the 100-hall including Resident #1, #28, #29 and #24). The facility census was 102. During an interview on 7/25/24, at 3:30 P.M., the Administrator said the facility did not have a policy for call lights. Observation on 7/24/24 at 1:26 P.M., showed Resident #26 and Resident #27 lived in the same bedroom. There were no call lights in the room. Review of Resident #26's Care Plan, dated 6/4/24, showed the following: -Resident admitted [DATE]; -Diagnosis of schizophrenia (mental disorder with rapid thoughts and perceptions that may not be true) and bipolar (mental disorder with manic or severe depression episodes); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for one resident under guardianship (Resident #23) in a review of 29 sampled residents. The facility enforced restrictions from the guardian without rationale for the safety or well-being of the resident. The facility census was 102. Review of the facility's policy Resident Restriction per Facility/Guardian and Compassionate Care Visits, dated 11/1/22, showed the following: -The primary goal of compassionate care is to give residents a sense of dignity while respecting the resident's privacy and wishes. It emphasizes improving the quality of life through empathy and quality of care. -A health care facility may adopt reasonable safety or security restrictions or other requirements for visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided alternative meal options of similar nutritive value to residents who chose not to eat the planned menu for the meal. The facility census was 82. During interview on 2/7/24 at 1:30 P.M. the Assistant Administrator said the facility had no policy regarding alternative meal options and nutritional requirements. Review of the facility menu, week at a glance, for week one, dated 11/26/23, showed the menu did not include an alternative meal option for each meal that was served on the menu. During an interview on 2/5/24 at 10:42 A.M., Resident #8 said he/she didn't always like what was served at meals. The only alternate option served was a grilled cheese sandwich and cheese puffs (a puffed corn snack coated with cheese or cheese flavored powder). [...]

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse when one resident (Resident #1) in a review of 17 residents, tested positive for cocaine on 1/20/23 in a urine drug test following transfer to the hospital on 1/19/23 for medical care. The facility became aware of the positive urine drug screen on 1/23/24. The facility census was 82. Review of the facility Abuse and Neglect Policy dated 12/28/23 showed the following: -The purpose was to outline procedures for reporting and investigation complaints of abuse and neglect and to ensure investigation and assessment of all residents involved was completed; -Upon learning of the report of abuse or neglect, the administrator shall initiate an incident investigation. The nursing staff was additionally responsible for reporting and investigating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #16), in a review of 17 sampled residents, received dental services, including care of decayed and lost teeth, who experienced tooth pain and difficulty eating. The facility also failed to follow up with recommendations for further dental intervention. The facility census was 82. During interview on 2/7/24 at 1:20 P.M. the Assistant Administrator said the facility had no dental care policy regarding dental appointments and follow up to recommendations for dental care. 1. Review of Resident #16's care plan, revised 10/22/23, showed the following: -Diagnoses of tremors, macular degeneration, abnormal gait and mobility, anxiety, major depressive disorder, and COPD; -Difficulty with completing activities of daily living (ADLs). Staff should provide assistance with ADLs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Resident #3, #4, and #8) who required staff assistance with showers, received the necessary care and services to maintain good personal hygiene, in a review of eight sampled residents. Staff failed to provide assistance with nail care, grooming, and shaving. The facility census was 76. Review of the facility policy Personal Care, Hygiene, and Grooming, revised 1/21/23, showed the following: -The most important aspect of maintaining good health is good hygiene. Personal hygiene, which is referred to as personal care, includes bathing, showering, hair care, nail care, oral hygiene and dental care, and shaving; -Personal care is keeping the body clean. This helps prevent the spread of germs. Grooming is essential for the well being of the resident; [...]

Inspectors wroteBased on interview and record review the facility failed to maintain professional standards of practice when staff failed to complete weekly skin assessments for two residents (Resident #2 and #3) per facility policy, in a review of eight sampled residents. The facility also failed to follow physician orders for dressing changes as ordered for one resident (Resident #3). The facility census was 76. Review of the facility policy Skin Assessment, dated 11/30/22, showed the following: -The facility will ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; -Assess the resident's skin on day one of admission, and immediately implement care planning for a resident at risk for pressure ulcers; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders in a timely manner for rehabilitation services for three residents (Resident #2, #4, #7) in a review of eight sampled residents. The facility census was 76. Review of the facility policy Specialized Rehabilitative and Restorative Services, dated 1/17/23, showed the following: -It is the policy of the facility to provide specialized rehabilitative and restorative services in accordance with state and federal regulations; -The facility will provide specialized rehabilitative services such as, but not limited to physical therapy, speech language pathology, occupational therapy, respiratory therapy and rehabilitative services for mental illness and intellectual disability or services of lesser intensity as set forth at 483.120 (c), as required in the resident's comprehensive care plan; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for seven residents (Resident #3, #4, #6, #7, #8, #9 and #10). The facility census was 72. 1. Record review of the facility maintained Accounts Receivable Report for the period 10/01/22 through 10/16/23, showed the following residents with personal funds held in the facility operating account; Resident Amount Held in Operating Account #4 $514.32 #6 $88.00 #7 $1,419.00 #8 $7,641.09 #9 $6,324.10 #10 $9.78 Total $15,996.29 During an interview on 10/16/23 at 3:58 P.M., the Administrator said a new biller started in 07/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed complete background checks as required for eight employees (Housekeeping Supervisor, Maintenance Supervisor, administrator, Minimum Data Set Coordinator, Social Services, Transportation E, Nurse Aide D, and Certified Nurse Aide/Certified Medication Technician F) in a review of ten new employees hired prior to employment. Further review showed the facility failed to check the Certified Nurse Assistant (CNA) Registry for any Federal indicators of abuse, neglect or misappropriation of property for eight new employees (Housekeeping Supervisor, RN C, Maintenance Supervisor, Administrator, NA D, Director of Nurses, Minimum Data Set Coordinator or Transportation E) prior to employment. Additionally the facility failed to develop/implement a policy for investigation of a misappropriation of personal property in a sample of 20 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure sanitary practices in the kitchen. The facility census was 78. Observations in the kitchen on 11/28/22 at 9:44 A.M. and on 11/29/22 at 8:51 A.M., showed the following: -The baffle filters in the range hood were covered with a thick layer of clear grease and dust; -A 24 inch by 24 inch ceiling vent, located above the steam table area, was covered in a thick layer of dust; -A 24 inch by 24 inch ceiling vent, located above the desert/drink preparation area, was covered in a thick layer of dust -A 24 inch by 24 inch ceiling vent, located above the food preparation area, was covered in a thick layer of dust. Observation in the kitchen on 11/28/22 at 10:04 A.M., showed the dishwashing staff stacked wet food storage containers and steam table pans and put them away while they were wet. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use. The facility failed to fully complete the antibiotic tracking done from 9/30/22-11/24/22. The facility also failed to include one sampled resident's (Resident #37) out of 20 sampled residents, and two additionally sampled resident's (Resident #18, and #176) in the antibiotic tracking done from 9/30/22-11/24/22. The facility census was 78. Review of the facility's Policy Infection Control Nurse-Job Description, dated 11/1/22, showed the following: -Directs and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in the facility; -Acts a facility's Antibiotic Steward: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff, as well as contracted staff, were routinely tested for Coronavirus disease (COVID-19/an infectious disease cause by the SARS-CoV-2 virus) according to facility policy. This affected nine staff members and two contract staff and had the potential to affect all residents. The facility census was 78. Review of the facility's undated policy Action Plan - COVID-19, showed the following: -The following action plan captures the most up-to-date information enabling us to be proactive in adopting practices to keep our residents, staff, and visitors safe; -Facility-onset case definition: Following the definition from Centers for Medicare and Medicaid Services (CMS), a COVID-19 case that originated in the facility; -Round of testing definition: [...]

Inspectors wroteBased on interview and record review the facility failed to convey resident funds within 30 days of discharge to the resident and/or responsible party for five residents (Resident #400, #401, #402, #403 and #404). The facility census was 78. Review of the facility Resident Trust Policy dated [DATE] showed the facility shall refund the balance of the resident's personal funds when a resident is discharged . The amount shall be refunded by the end of the month following the month of discharge or by State/Federal specific guidelines if such policies are more stringent. 1. Review of Resident #401's medical record showed the resident was discharged to another facility on [DATE]. Review of the facility's Trust Transaction History report dated [DATE] showed the resident's trust fund balance was $25.47. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment by failing to maintain walls, ceilings, floors and doors in resident rooms in good repair. The facility census was 78. 1. Observations on 11/28/22 at 10:42 A.M., in room [ROOM NUMBER], showed the following: -Large brown rings on the ceiling above the window that extended the length of window and approximately two feet out from the wall; -Scratches and deep gouges on the wall by the bed by the door to the room and holes in drywall in three places with white crumbling drywall exposed; -Particles of brown substance on the floor. The floor was sticky; -Scuffs on the bathroom door facing into the resident room. During an interview on 11/28/22 at 10:42 A.M., Resident #3 said the ceiling has been like that since he/she got to the facility (April 2022). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate comprehensive assessments to reflect the resident's status for three residents (Residents #14, #18, and #59), in a review of 20 sampled residents. The inaccuracy had the potential to negatively affect the person-center care plan and services the facility provided to the resident. The facility census was 78. Review of the Resident Assessment Instrument (RAI) manual, a manual with guidance on how to complete MDS assessments, dated 10/1/19, showed the Assessment Reference Date (ARD) refers to the last day of the observation (or look back) period that the assessment covers for the resident. Since a day begins at 12:00 A.M. and ends at 11:59 P.M., the ARD must also cover this time period. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person-centered care for seven residents (Residents #6, #14, #21, #24, #27, #36, and #59), in a review of 20 sampled residents, and for one additional resident (Resident #176). The facility census was 78. Review of the Resident Assessment Instrument (RAI) manual, dated October 2019, showed the following: -The admission Minimum Data Set (MDS) must be completed by the 14th day after admission, admission day being day one; -The comprehensive care plan must be completed no later than seven days after the completing of the admission MDS; -The overall care plan should be oriented towards: 1. Assisting the resident in achieving his/her goals, goals should be measurable. 2. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow professional standard of care for three residents (Resident #30, #19 and #41) when staff failed to follow physician's orders for care. The facility census was 78. Review of the facility policy Transcription of Orders and Following Physician's Orders dated 11/1/22 showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed; -The Licensed/Registered Nurse (RN) will check the emergency kit to verify if the medication is present in the facility to being immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff provided the necessary care and services to maintain good personal hygiene and prevent body odor for eight residents (Resident #6, #21, #24, #25, #27, #40, #61, and #125), who required assistance to perform their activities of daily living, in a review of 20 sampled residents. The facility census was 78. Review of the facility's Personal Care, Hygiene, and Grooming policy, dated 11/1/22, showed the following: -Personal hygiene which is also referred to as a personal care includes all the following: bathing and showering, hair care, nail care, oral hygiene and dental care, and shaving; -The resident's bath schedule is in the plan of care, located at the nurses' station and are initiated by the Director of Nursing in collaboration with the shower aide. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to implement respiratory and oxygen interventions and monitoring, maintain CPAP/BIPAP (continuous or bilevel positive airway pressure therapy, a common treatment for obstructive sleep apnea) equipment according to the facility's policy for two residents (Residents #3 and #37), in a review of 20 sampled residents, and for one additional resident (Resident #18). The facility census was 78. Review of the facility's Oxygen policy, dated 11/1/22, showed the following: -There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration and how long the oxygen is to be administered; -Setting up oxygen administration: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, or obtain informed consent with risks prior to installing and using a bed rail for three residents with bed rails (Residents #8, #20, and #27), in a review of 20 sampled residents. The facility census was 78. The facility did not have a policy on bed rail use. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments, and signed and dated all orders for six additional residents (Residents #10, #23, #35, #38, #48, and #52). The facility census was 78. Review of the facility's Physician Services policy, undated showed the following: -All verbal treatment orders will be countersigned by the physician or other health care professional on the next visit to the facility; -The physician will sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits were made by the physician and/or a physician assistant, nurse practitioner or clinical nurse at least every 30 days for six additional residents (Residents #10, #23, #35, #38, #48, and #52). The facility census was 78. Review of the facility's undated policy, Physician Services, showed the following: -A physician will approve in writing a recommendation that an individual be admitted to the facility; -A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs; -Each resident will remain under the care of a physician; -The physician will review the resident's total program of care, including medications and treatments, at each visit; -The physician will write, sign, and date progress notes at each visit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff and/or utilize staff in a manner to complete bathing for seven residents (Resident #6, #21, #24, #25, #27, #125, and #61), answer call lights timely for two residents (Resident #16 and #51), and provide restorative nursing services as directed for one resident (Resident #76) in a review of 20 sampled residents. The facility census was 78. 1. Review of Resident #6's care plan, dated 9/20/22, showed the resident was totally dependent on staff to provide a bath twice a week and as needed. Review of the resident's bathing documentation, dated September 2022, showed the following: -The resident received a shower on 9/2/22, 9/6/22, 9/9/22, and 9/13/22; -No documentation the resident received a shower on 9/14/22 through 9/19/22 (six days); [...]

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 78. Review of the facility's payroll detail, dated 9/25/22, showed the Director of Nursing (DON)worked eight hours. The facility did not have documented evidence of hours worked by the DON because they are paid a salary and not hourly, the DON does not document start and stop times. No other RN's were on the payroll on 9/25/22. Review of the facility's payroll detail, dated 10/1/22-10/31/22, showed the following: -One day with no RN hours (10/1/22); -15 days with only salaried RN's, three of those days the DON was the RN; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) on psychotropic medication or document a clinical justification to continue current dosage for three residents (Resident #3, #6, and #27), in a review of twenty sampled residents. The facility also failed to obtain a 14 day stop date on as needed (PRN) psychotropic medication for three sampled residents (Resident #3, #19, and #40), and did not provide documentation clinical reason to extend the PRN medications. The facility census was 78. Review of the facility ' s Medications-Antipsychotics policy, dated 11/1/22, showed the following: -Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident ' s assessed condition; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact and failed to change gloves during direct resident personal care for two residents (Resident #6 and #19) of 20 sampled residents. The facility also failed to practice acceptable infection control practices and prevent cross-contamination during the provision of wound care for one resident (Resident #6) and use of personal protective equipment (PPE) for one resident (Resident #30). Additionally, the facility failed to ensure proper infection control was utilized for respiratory care supplies for two residents (Resident #3, and #21). The facility census was 78. Review of facility's Clean (Aseptic) Treatment Technique policy, dated 3/2021, showed the following: -Wash or sanitize hand per your policy; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines (a vaccine that can protect against pneumococcal disease, which is any type of infection caused by streptococcus pneumoniae bacteria) for five residents (Resident #3, #12, #14, #21 and #25), in a review of 20 sampled residents, and for two additional residents (Residents #1 and #18). The census was 78. Review of the Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccine timing, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for adults [AGE] years old or older, and for adults 19 through [AGE] years old with certain underlying medical conditions including cigarette smoking; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity and ensure full recognition of individuality for one resident (Resident #25), in a review of 20 sampled residents. The facility census was 78. Review of the facility policy Resident Rights dated 11/1/22 showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state last guarantee certain basic rights to all residents of this facility; -Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity; 1. Review of Resident #25's care plan revised 10/4/22 showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to advocate for and create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for one resident under guardianship (Resident #37) in a review of 20 sampled residents. The facility enforced and encouraged restrictions from the guardian without rationale for the safety or well-being of the residents. The facility census was 78. Review of the facility policy Resident Rights dated 11/1/22 showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; These rights include the resident's right to: -Privacy and confidentiality; -Privacy in sending and receiving mail; -Visit and be visited by other from outside the facility; -Use a telephone in privacy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #37), in a review of 20 sampled residents, was able to receive approved visitors. The resident was under guardianship. The facility failed to coordinate with the ombudsman and advocate for the resident, failed to update approved visitors on the resident's care plan, denied the resident visitation by approved visitors, and failed to communicate discrepancies about the resident's diagnosis affecting the guardian's decision/rationale to limit visitation. The census was 78. Review of the facility policy Resident Rights dated 11/1/22 showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; These rights include the resident's right to: -Visit and be visited by other from outside the facility; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #21), in a review of 20 sampled residents remained free from misappropriation of property, when the resident's cell phone came up missing and was presumed stolen. The facility census was 78. Review of the facility policy, Abuse, dated 11/1/22, showed the following: -Misappropriation definition: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belonging or money without the resident's consent; [...]

Inspectors wroteBased on interview and record review, facility staff failed to report misappropriation of resident's personal property to the state survey agency as required for one resident (Resident #21), in a review of 20 sampled residents. The facility census was 78. Review of the undated facility policy, Abuse, Neglect, Grievance Procedures, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that due process for appeals to the accused is outlined; -Purpose: To ensure immediate reporting of all abuse allegations to the administrator or designee and the Director of Nursing or designee and outside persons or agencies; -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation to show a thorough investigation was completed after one resident's (Resident #21), in a review of 20 sampled residents, cell phone came up missing and was presumed stolen. The facility census was 78. Review of the undated facility policy, Abuse, Neglect, Grievance Procedures, showed the following: -Purpose: To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. (The facility did not provide a specific procedures to follow when investigating an allegation of misappropriation of resident property.) 1. Review of Resident #21's face sheet showed the resident was his/her own decision maker. Record review of the resident's social service progress notes, dated 10/14/22 at 8:05 A.M. showed the following: [...]

Inspectors wroteBased on record review and interview the facility failed to complete a comprehensive admission Minimum Data Set (MDS) by 14 days after admission for one additionally sampled resident (Resident #176) out of 20 sampled residents. The facility census was 78 Review of the Resident Assessment Instrument (RAI) manual, dated October 2019, showed the following: -The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: a. This is the resident's first time in this facility, OR b. The resident has been admitted to this facility and was discharged return not anticipated, OR c. The resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a baseline care plan that accurately reflected the resident's needs to include instruction needed to provide effective and person-centered care within 48 hours of admission and give a written summary of the baseline care plan to the resident/resident representative for one sampled resident (Resident #59) of 20 sampled and one additional resident (Resident #176) . The facility census was 78. Review of the facility's General Care Planning Area policy, undated, showed the following: -Within 48 hours of admission to the facility, the facility must develop and implement a baseline care plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to assist one resident (Resident #76) in a review of 20 sampled residents, with mobility and/or limited range of motion to attain or maintain their highest level of functioning. The facility census was 78. During an interview on 12/1/22, at 2:30 P.M., the Assistant Administrator said the facility did not have a policy for restorative nursing at this time. 1. Review of Resident #76's care plan dated 4/28/22 showed the following: -The resident is at risk for falls related to impaired safety awareness, intermittent muscle weakness; -Evaluate the need for restorative program as needed. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Required extensive assist of one for bed mobility and transfers; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate use of a mechanical lift for one resident (Resident #6) out of a sample of 20 residents. The facility also failed to provide adequate supervision and oversight to prevent falls for one discharged resident, (Resident #76). The facility census was 78. Review of the facility's Transfers and Lifts policy, dated 11/1/22, showed the following: -For residents who are totally dependent or partial or non-weight bearing; -Must be used with two staff members; -Know weight limitations of the device; -Lock wheels of bed and lift before using; -Widen base of lift to transfer; -Apply sling properly and position it above shoulders and below buttocks; -Insert metal bars into the appropriate slots on the sling; -Make sure chain links are the appropriate lengths for the top and bottom; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medication from the medication room refrigerator for one resident (Resident #405). The facility census was 78. Review of the facility policy, Medication Storage, revised 11/1/22, showed the following: -Medications will be monitored by the Unit Nurse, Charge Nurse, and consultant pharmacist to assure that they are not expired, contaminated, or unusable; -Medication Room and Medication Carts will be inspected weekly and as needed at the direction of the Director of Nursing. Review of the facility policy, titled Medication Destruction, revised 11/1/22, showed the following: -Non-controlled and scheduled V controlled drugs (drugs with lower potential for abuse)must be destroyed in the presence of two licensed nurses; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #62) with food allergies, including allergy to cinnamon, in a review of 20 sampled residents, was not served foods containing cinnamon. The facility census was 78. The facility did not have a policy on food allergies. Review of Resident #62's face sheet showed the following allergies: -Honey; -Seafood; -Spices. Review of the resident's Care Plan, revised on 8/12/22, showed the following: -Staff will honor his/her preferences while caring for resident; -Resident is at nutritional risk related to multiple food allergies; -Reported food allergies: Spices, egg yolk, honey, mustard, pork, seafood (tuna ok). -Offer substitutes for dislikes; -Offer resident alternative meal plan if noted to not be eating meal offered; -Provide and serve diet as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or the resident representative or notify the ombudsman when three residents (Residents #36, #37, and #63), in a review of 20 sampled residents, were transferred to the hospital. The facility census was 78. The facility was unable to provide a policy related to this requirement. 1. Review of Resident #37's face sheet showed the resident was under guardianship. Review of the resident's Nurses Notes, dated 5/22/22, showed the following: -The resident had a fever of 101.6 (normal 98.6 degreesFahrenheitt); -History of rapid decline; -On-call physician gave orders to send to the resident to the emergency room via ambulance service. Review of the resident's census sheet, dated 7/18/22, showed the resident was transferred to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents (Residents #36, #37, and #63), in a review of 20 sampled residents. The facility census was 78. During an interview on 12/1/22, at 1:30 P.M., the Administrative Assistant said there was bed hold information in the admission packet, the facility did not have a bed hold policy related to transfers and discharges. 1. Review of Resident #37's face sheet showed he/she was under guardianship. Review of the resident's Nurses Notes, dated 5/22/22, showed the following: -The resident had a fever of 101.6 (normal 98.6degrees Fahrenheitt); -History of rapid decline; -On call physician gave orders to send to emergency room via ambulance service. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to post the census, Registered Nurse (RN) hours, total hours worked by other nursing staff (Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), and Licensed Practical Nurse (LPN)), with the name of the facility. The facility census was 78. Review of the facility's staffing posting documents, dated 11/1/22-11/27/222, showed the following: -No evidence of RN hours noted; -No hour totals for CNA's, CMT's, or LPN's; -No facility name or census. Observation on 11/28/22, at 11:45 A.M., showed the following: -Staffing posted at the nurses desk bulletin board; -The RN area was blank; -The staff hours were not totaled (CNA's, CMT's, or LPN's); -Did not include the name of the facility or the census. Observation on 11/29/22, at 9:34 A.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances identified by the resident council, and failed to provide the members of the resident council with responses, actions and rationale taken regarding their concerns. The facility census was 51. 1. Review of the facility policy Resident Council revised 2/2016 showed the following: -The designated staff member of the facility is to assist and help coordinate the council meetings; -The resident council shall meet at least one time per month with the facility staff who shall provide assistance to the council in preparing and disseminating a report of each meeting (minutes) to all the residents, the administrator, and the facility staff; -The council may communicate to the administrator the opinions and concerns of the residents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for four residents (Resident #28, #33, #42 and #304) of 14 sampled residents and four additional residents (Resident #9, #20, #21 and #40). [...]

Inspectors wrote9. Review of Resident #47's face sheet showed diagnoses included high blood pressure, heart failure and major depressive disorder. Review of the resident's admission MDS, dated [DATE], showed the following: -Makes self-understood and understands others; -BIMS 13 indicating intact cognition; -No behaviors of concern documented; -No neurological diagnoses; -Anxiety disorder and depression were the listed psychotic/mood disorders; -Anti-anxiety medications had been received three of the last seven days. Review of the resident's December 2018 POS showed an order dated 12/17/18 for lorazepam 0.5mg every eight hours PRN (anxiety) (open ended with no limitation on number of days). Review of the resident's December 2018 MAR showed the following: -Staff documented administering the resident's PRN lorazepam one time on 12/19/18, 12/21/18, 12/22/18 and 12/25/18; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to accurately label insulin to facilitate consideration of precautions and safe administration for three additional residents (Resident #18, #22 and #45) of 14 sampled residents and 14 additional residents. Facility census was 51. 1. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated [DATE], showed the following: -Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications; -Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.); -Facility staff may record the expiration date based on date opened on the label of medications with shortened expiration dates; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at an appetizing temperature. The facility census was 51. 1. Review of the facility dietary manual showed no policy regarding food temperatures at the time of meal service. 2. During an interview on 4/29/19 at 11:32 A.M. and 2:52 P.M., Resident #18 said the following: -He/She ate his/her meals in his/her room and they were always cold; -Meals were the only thing he/she had to look forward to, so it was disappointing when the food was cold; -Lunch was terrible and the corn was cold. During interview on 4/29/19at 122:49 P.M., Resident #47 said the following: -Staff delivered his/her meal trays to his/her room; -The food served at lunch that day was not hot, specifically the corn, and the mashed potatoes and gravy were just kind of warm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilizedd appropriate infection control procedures when providing medication for two residents (Resident #28 and #304) and care to one resident (Resident #10) of 14 sampled residents and two additional residents (Resident #20 and #21) when Licensed Practical Nurse (LPN) J touched medication with his/her bare hands, did not don or use gloves with eye drop and nasal spray administration and did not properly wash his/her hands with soap and water or sanitize before and after resident contact. Further review showed Registered Nurse (RN) E, LPN F and LPN G did not utilize appropriate infection control procedures when providing cares for Resident #28. The census was 51. 1. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated 12/01/17, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #28 and #53), of 14 sampled residents received the necessary care and services during personal care. The facility census was 51. 1. Review of the Perineal Care policy, dated 2001 Med-Pass, Revised October 2010, showed the following: -Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Wash and dry your hands thoroughly; -Put on gloves; -Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary; -For a female resident: Wet washcloth and apply soap or skin cleansing agent; -Wash perineal area, wiping from front to back; -Separate labia and wash area downward from front to back. (Note: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one additional resident (Resident #38) the necessary care and services to maintain his/her highest practicable well-being when staff failed to assess the resident with change of condition, obtain daily weights as ordered by the physician and notify the physician of the resident's change in condition including elevated blood pressure readings, new onset edema and weakness. The resident was transferred to the hospital on 4/28/19 with lethargy, fever and elevated blood pressure. The facility census was 51. 1. Review of the undated facility policy Significant Condition Change & Notification showed the following: Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of a new pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #8), who had a pressure ulcer, and the facility identified at risk for the development of pressure ulcers in a review of 14 sampled residents. The facility census was 51. 1. Review of the facility's Wound Care System Requirements policy, revised April 2018, showed the following: -The facility has a designated Wound Care Nurse, who completes weekly assessment and documentation; -Certified Nurse Aides (CNAs) will observe skin during care daily. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe transfer during a mechanical lift transfer for one resident (Resident #53), in a review of 14 sampled residents. The facility census was 51. 1. Review of the Nurse Assistant in Long-Term Care Facility Student Reference, 2001 revision, showed the following: -Mechanical lift is a device used to lift and move residents who are unable to do so on their own; -If a resident is non-weight bearing, the nurse assistant should transfer him/her using a mechanical lift; -Follow manufacturer's directions regarding safe use. 2. Review of a facility policy, titled Safe Lifting and Movement of Residents, showed the following: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent a urinary tract infection (UTI) for one residents (Resident #8), who currently had or had a UTI and required antibiotics for treatment, in a review of 14 sampled residents. The facility census was 51. 1. Review of the Perineal Care policy, dated 2001 Med-Pass, Revised October 2010, showed the following: -Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Wash and dry your hands thoroughly; -Put on gloves; -Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary; -For a female resident: [...]