Bentleys Extended Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) was free from physical abuse when Certified Nurse Aide (CNA) C covered and twisted the resident's mouth when he/she cried during a shower, which resulted in bruising to the resident's face. The sample was 3. The census was 49. Review of the facility's Abuse Prevention Program policy, undated, showed:-Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Aides (NAs) employed by the facility were not charged for a competency evaluation program. The census was 52. Review of the facility's Certified Nurse Aide (CNA) Training Program Assistance Agreement, dated 2025, showed:- Student collectively referred to as Parties or individually as a Party;-Whereas, the Student desires to participate in a CNA Training Program Assistance, and whereas, the facility is willing to provide the necessary training and educational materials to the student for the purpose of obtaining a CNA certification;-Now, therefore, in consideration of the mutual covenants and promises contained herein, the parties agree as follows;-CNA Training Program Assistance Scope and Duration; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to re-order anti-seizure medication for one resident (Resident #1) within 72 hours of its last available dose, per facility policy, resulting in the resident missing doses of the medication on two days. Facility staff failed to administer two of the resident's other anti-seizure medications for one day and the resident had a seizure the next day. The sample was 4. The census was 52. Review of the facility's Medication Administration policy, dated 2/2020, showed: -Policy Statement: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) B assessed a resident and notified one resident's physician after Certified Nursing Assistant (CNA) G informed the RN the resident complained of pain and could not stand or walk, which was a change in condition for the resident (Resident #11). Facility staff did not assess the resident or call the physician for at least six hours after the change of condition was noticed. When the resident was evaluated at the hospital, he/she was diagnosed with a wrist fracture. The resident sample was 18. The census was 52. Review of the facility Change in a Resident's Condition or Status policy, revised 12/2016, showed:-Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident fall was thoroughly investigated/evaluated to determine the cause of the fall and failed to implement new interventions and/or modify existing interventions to prevent future falls or reduce the potential of injury or serious injury from future falls. In addition, the facility failed to ensure residents' care plans were updated to reflect current fall interventions and failed to have an updated system in place to communicate fall interventions to staff. Three residents with a history of falls were sampled and problems were identified with all three. (Residents #3, #9 and #7). The census was 57. Review of the facility Assessing Falls and Their Causes policy, undated, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's (Resident #11's) pain was addressed when he/she experienced a change of condition. On 1/31/26 at approximately 9:00 A.M., the resident complained of pain and could not stand or walk as he/she usually could. Certified Nursing Assistant (CNA) G informed Registered Nurse (RN) B. RN B did not assess the resident's pain, contact the physician or administer any pain medication. Facility staff did not address the resident's pain or call the physician, until approximately 1/31/26 at 3:00 P.M. when the evening shift started work, which was at least six hours after the resident's pain was first noticed. When the resident was evaluated at the hospital, he/she was diagnosed with a wrist fracture. The resident sample was 18. The census was 52. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one resident (Resident #10) who chipped their tooth while at the facility. The sample was 10. The census was 54. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/25, showed the following: -Cognitively intact; -Dependent with transfers, dressing and wheelchair locomotion; -Diagnoses included diabetes, hemiplegia flaccid of left side (paralysis on left side of body), cerebral infarction (stroke) and nontraumatic intracranial hemorrhage (bleed in the brain), seizures, and malnutrition; -Oral/Dental status: blank. Review of the resident's care plan, dated 4/30/25, showed no documentation regarding the resident's oral care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse when an allegation of physical abuse was made for one resident (Resident #1). On 2/1/25 at approximately 10:00 A.M., Registered Nurse (RN) A heard banging on the wall inside the resident's room, and someone yelling, Stop that, stop that, do it again, then a loud slap inside the resident's room and when he/she opened the resident's door he/she saw Certified Nurse Aide (CNA) B holding the resident against the wall. RN A notified the Director of Nurses (DON) of an allegation of abuse and the DON directed RN A not to send CNA B home. CNA B remained in the facility providing care to other residents for over five hours after the allegation was reported. The facility did not immediately begin an investigation into the allegation of abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from accident hazards. Certified Nurse Aide (CNA) B performed a Hoyer (mechanical lift) transfer for one resident (Resident #6) without the assistance of a second person, and the resident was struck in the face with the lift, causing injuries to his/her face. The employee failed to report the incident at the time it occurred, and staff failed to perform neurological assessments for 72 hours following the incident, in accordance with facility policy. In a separate incident, Certified Medication Technician (CMT) C performed a Hoyer transfer for the resident without the assistance of a second person, and failed to ensure the resident's physician-ordered fall mats were positioned at bedside before leaving the room. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving one resident (Resident #1) to the State Survey Agency immediately and not later than two hours after the allegation was made. The sample was 8. The census was 49. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -Policy Interpretation and Implementation: --Reporting: [...]

Inspectors wroteBased on interview and record review the facility failed to electronically submit to the Center of Medicaid and Medicare Services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for three quarters proceeding the annual survey. The census was 47. Review of the fiscal years Payroll Based Journal (PBJ) staffing report, showed the facility triggered for failing to submit data for: -Fiscal year quarter 1, 2024 (October 1 to December 31); -Fiscal year quarter 2, 2024 (January 1 to March 31); -Fiscal year quarter 3, 2024 (April 1 through June 30). During an interview on 10/24/24 at 12:31 P.M. the Assistant Administrator said it was his responsibility to submit the PBJ report to CMS. He was aware that the report needed to be sent and had not done so.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dignity of residents by failing to ensure staff members stayed off their cell phones during care (Residents #1, #22, #40 and #44), failing to ensure staff were seated next to the residents while feedings residents (Residents #9 and #20), and failing to ensure staff replaced silverware for a resident who dropped theirs (Resident #21). The sample was 12. The census was 47. Review of the facility's Quality of Life, Dignity policy, dated august 2009, showed: -Policy Statement: each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Policy Implementation: residents shall be treated with dignity and respect at all times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans with resident-specific interventions to meet the resident's preferences and goals, and to address the resident's medical, physical, and psychosocial needs for five residents (Residents #31, #19, #20, #41, and #44). The sample was 12. The census was 47. Review of the facility's Care Plans - Comprehensive Person-Centered policy, revised December 2016, showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable outcomes and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents when staff failed to prevent residents' feet from dragging on the floor during staff-assisted propelling for two residents (Residents #41 and #32). Facility staff failed to use gait belts during assisted transfers for three residents (Residents #40, #20, and #41) and failed to ensure one resident with a history of falling from his/her wheelchair was appropriately repositioned in his/her chair (Resident #21). The sample was 12. The census was 47. The facility did not have a written policy regarding transfer protocols. 1. Review of Resident #41's medical record, showed diagnoses of dementia, depression, high blood pressure, high cholesterol, and overweight. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 47. Review of the facility's Staffing policy, revised, April, 2007, showed: -The facility provides adequate staffing to meet needed care and services of the resident population; -The facility maintains adequate staffing on each shift to ensure that the residents' needs and services are met; -Licensed RN and licensed nursing staff are available to provide and monitor the delivery of resident care services. Review of the facility's staffing sheets dated 10/1 through 10/21/24 showed no RN coverage for: 10/1, 10/2, 10/3, 10/4, 10/6, 10/8, 10/10, 10/11, 10/13, 10/14, and 10/19/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 47. Review of the facility's Controlled Substances policy, revised December, 2012, showed: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (a drug classification) narcotics and other controlled substances; -Nursing staff must count controlled medications at the end of each shift; The nurse coming on duty and the nurse going off duty must make the count together. Review of the Narcotic Count Sheets dated 10/1 through 10/19/24 on the 400 and 500 medication cart showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals stored in the medication room refrigerator were being stored at a proper temperature for one out of one medication rooms observed. The medication room refrigerator also had food and nutritional supplements stored with the medications. The census was 47. Review of the facility's Storage of Medications policy, revised, April, 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation area in a clean, safe, and sanitary manner; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff performed appropriate hand hygiene during meal service which effected 15 residents (Residents #21, #36, #11, #39, #20, #1, #13, #14, #35, #37, #9, #43, #19, #41, and #17). The sample was 12. The census was 79. Review of the facility's handwashing/hand hygiene policy, dated August 2015, Showed: -Policy statement: this facility considers hand hygiene the primary means to prevent the spread of infections; -Policy implementation: all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water for the following situations: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used good infection control practices for one resident when providing wound care (Residents #38). The facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs can spread that requires gown and glove use during high contact resident care activities for certain residents) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with urinary catheters (a tube that drains the bladder) and wounds requiring treatments (Residents #38 and #31). [...]

Inspectors wroteBased on interview and record review the facility failed to offer and vaccinate as desired, eligible residents for the pneumococcal (pneumonia) vaccine for 4 out of 5 residents sampled for immunizations (Resident #12, #11, #38, #22). The census was 47. Review of the facility's Pneumococcal Vaccine policy, revised August, 2016, showed; -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccination status will be conducted within 5 working days of the resident's admission if not conducted prior to admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer the COVID-19 vaccines for four out of five residents sampled for immunizations (Resident #11, #38, #22, and #14). The census was 47. Review of the facility's COVID -19 Vaccination of Residents policy, revised, May, 2023, showed: -Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated; -Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so; -The resident or the resident's representative has the opportunity to accept or refuse COVID-19 vaccine, and to change his/her decision; -COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his/her designee; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistants (CNA) received a minimum of 12 hours on ongoing education annually for five out of five sampled CNAs. The census was 47. A policy related to CNA 12-hour training was requested and not provided by the facility. 1. Review of CNA M's employee file showed hire date: 1/15/20. No in-service training records provided upon request. 2. Review of CNA N's, employee filed showed hire date: 9/28/22. No in-service training records provided upon request. 3. Review of CNA O's employee file showed hire date: 9/10/21. No in-service training records provided upon request. 4. Review of Certified Medication Technician (CMT) F's employee file showed hire Date: 12/12/22. No in-service training records provided upon request. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the physician of abnormal lab results for one resident (Resident #11) and to notify the resident and the resident's representative of abnormal lab results and new orders for medications to treat a urinary tract infection (UTI). The sample was 12. The census was 47. Review of the facility's Change in a Resident's Condition or Status policy, revised December 2016, showed: -Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -Policy Interpretation and Implementation: -The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative with emergency written notices of transfer/discharge for two residents transferred to the hospital for acute medical reasons (Residents #31 and #19). The sample was 12. The census was 47. Review of the facility's Transfer or Discharge Notice policy, revised December 2016, showed: -Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a 30-day written notice of an impending transfer or discharge; -Policy Interpretation and Implementation: -A resident and/or his or her representative (sponsor) will be given a 30-day advance notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative with written information on the facility's bed hold policy at the time of transfer for two residents transferred to the hospital for acute medical reasons (Residents #31 and #19). The sample was 12. The census was 47. Review of the facility's Bed Holds and Returns policy, revised March 2017, showed: -Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Policy Interpretation and Implementation: -Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: --The rights and limitations of the resident regarding bed-holds; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident received an accurate assessment, reflective of the resident's status at the time of assessment, by failing to identify the resident's unplanned significant weight loss, unhealed pressure ulcers (injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), and other skin problems (Resident #31). The sample was 12. The census was 47. Review of Resident #31's medical record, showed diagnoses included bullous pemphigoid (an autoimmune skin disorder that causes blisters on the skin). Review of the resident's weights, showed: -On 2/19/24, weighed 147.2 pounds (lbs); -On 8/19/24, weighed 120.0 lbs; -Significant weight loss of -18.48% in six months. Review of the resident's nutrition quarterly review, dated 8/20/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's care needs for four residents (Residents #38, #46, #22, and #32) of 12 sampled residents. The facility census was 47. Review of facility's, undated, Care Plans, Comprehensive Person-Centered policy, showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implanted for each resident; -Policy Interpretation and Implementation: Areas of concern that identified during the resident assessment will be evaluated before intervention are added to the care plan. The comprehensive, person-centered care plan is developed with seven (7) days of the completion of the required comprehensive assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff certified in cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) received their CPR certification through a provider whose training includes hands-on practice and in-person skills assessment. The facility identified 10 CPR-certified staff and problems were found with three. The sample was 12. The census was 47. Review of the facility's Advance Directives policy, revised [DATE], showed no guidance for ensuring staff received CPR certification through a provide whose training includes hands-on practice and in-person skills assessment. Review of the facility's resident code status report, reviewed [DATE], showed 22 residents with full code status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services consistent with acceptable standards of practice for one resident when staff failed to accurately assess the appropriate wheelchair size, resulting in skin irritation and indentations to the resident's legs, and failed to reposition the resident for six hours (Resident #41). In addition, the facility failed to date when a dressing was completed for one resident (Resident #16). The sample size was 12. The census was 47. Review of the facility's undated admission Assessment and Follow Up: Role of the Nurse, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foot care was maintained for two of 12 sampled residents (Resident #44 and Resident #21) resulting in long nails and dry feet. The census was 47. Review of the facility's activities of daily living (ADL) Policy, dated march 2018, showed: -Policy statement: residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Policy Implementation: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were followed for a resident with an order for continuous oxygen usage (Resident #44). In addition, the facility failed to ensure oxygen masks were properly stored while not in use and the facility had a process to ensure routine changing of the oxygen tubing for infection control purposes, for two sampled residents (Resident #44 and Resident #14). The sample was 12. The Census was 47. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nursing Assistants (NAs) that were employed by the facility were certified within 4 months of hire for five out of five NA's, who worked in the facility for more than 4 months. The census was 47. Review of the Facility Assessment, reviewed 7/21/23, showed: -Staff training and education that are necessary to provide level and types of support and care needed for the resident population included certification and licensure requirements, yearly in-services, and additional education provided when needs are trends are identified. Record review the hire dates for of all NAs, reviewed on 10/23/24, showed: -The facility hired NA R on 5/5/21; -The facility hired NA J on 8/2/23; -The facility hired NA S on 4/3/24; -The facility hired NA C on 4/26/24; -The facility hired NA T on 5/20/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications when one resident (Resident #19) was prescribed Haldol (haloperidol, antipsychotic medication) without appropriate documentation in the resident's medical record to support the clinical need for the medication. The facility failed to appropriately monitor for adverse consequences and medication effectiveness when the resident had an increase in falls after the adjustment to his/her psychotropic medications, and no improvement with his/her psychiatric symptoms. The sample was 12. The census was 47. Review of the facility's Antipsychotic Medication Use policy, revised [DATE], showed: -Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week; and failed to hire, maintain or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. This deficiency had the potential to affect all residents. The census was 50. Review of the facility's undated list of Department Heads, provided on 7/1/24, showed no DON employed within the facility. Review of the facility's daily assignment sheets, dated 6/17/24 through 7/2/24, showed no DON for all 16 days and no RN in the facility on 6/17, 6/18, 6/19, 6/20, 6/26, 6/28, 6/29 and 7/1/24, for a total of 8 out of 16 days. During an interview on 7/1/24 at 12:54 P.M., Certified Nursing Assistant (CNA) A said they had not had a DON in a couple of months. [...]

Inspectors wrote8. Review of Resident #8's admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfers and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The MDS indicated the resident had no limitations in range of motion and used a wheelchair for mobility. According to the MDS, the resident did not have falls prior to or since admission. [...]

Inspectors wrote3. Review of Resident #8's admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff with bed mobility and transfer and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The resident had no limitations in range of motion and used a wheelchair for mobility. The MDS indicated the resident had no falls since admission or prior to admission. A review of Resident #8's medical record revealed there was no comprehensive care plan for Resident #8. [...]

Inspectors wroteBased on observations, interviews, record review, the facility failed to assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on resident beds for 2 (Resident #96 and Resident #10) of 7 residents reviewed for side rail use. Resident #96 stated the side rails were barriers, made her feel confined and stranded, and she had a fear of not being able to get out of bed because of them- causing her to not want to get into her bed to sleep at night. As a result she fell asleep in her chair, fell forward and obtained a large hematoma on the right side of her forehead. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to identify significant weight loss and implement nutritional interventions for one (Resident #17) of two residents reviewed for weight loss. Specifically, Resident #17 lost 11.4 pounds (8.06%) in seven days and 21.0 pounds (14.85%) in 28 days and had no nutritional interventions implemented. The facility census was 42.

Inspectors wroteBased on facility document review, interviews, and facility policy review, the facility failed to ensure nursing assistants (NAs), who were full-time employees, completed the required competency exam for certification within four months of hire for 6 (NAs #3, #4, #8, #11, #16, and #20) of 13 nursing assistants reviewed for competencies. This had the potential to affect all residents. The facility census was 42.

Inspectors wroteBased on observation, interviews, and facility document and policy review, the facility failed to maintain proper kitchen sanitation in 1 of 1 kitchen when Dietary Aide (DA) #1 and the [NAME] did not know how to ensure proper sanitizer concentration for a low temperature dish machine. The facility census was 42.

Inspectors wroteBased on interviews and facility document and policy review, the facility failed to ensure the facility was administered in a manner that effectively and efficiently attained or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility failed to: - Thoroughly investigate falls to determine causal factors, implement and evaluate interventions to prevent falls, and provide sufficient supervision. - Assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on residents' beds. [...]

Inspectors wroteBased on interviews and facility document and policy review, it was determined that the facility failed to conduct and accurately document a facility-wide assessment to determine what resources were necessary to competently care for its residents and failed to review this assessment at least annually. This had the potential to affect all residents. The facility census was 42.

Inspectors wroteBased on interviews and facility document and policy review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program that obtained feedback, used data, took action to conduct structured, systematic investigations and analyzed underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life and, resident safety. Specifically, the facility QAPI program failed to: - Identify that the facility did not investigate falls to determine causal factors, implement and evaluate interventions to prevent falls, and provide sufficient supervision to residents. [...]

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. Certified Nursing Assistant (CNA) #17 followed the steps for hand hygiene when providing incontinent care for 1 (Resident #145) of 2 residents reviewed for incontinence care; 2. Certified Medicine Technician (CMT) #19 did not touch medication with her bare hands when administering medication for 1 (Resident #96) of 6 residents reviewed for medication administration; and 3. [...]

Inspectors wroteBased on interviews and facility policy review, it was determined the facility failed to ensure an antibiotic stewardship program was in place. The facility's failure to develop, promote, and implement a facility-wide system to monitor the use of antibiotics had the potential to affect all 43 residents living in the facility.

Inspectors wroteBased on interviews and facility policy review, it was determined the facility failed to employ a qualified infection preventionist. The facility's failure to employ a qualified infection preventionist to be responsible for the infection prevention and control program had the potential to affect all 43 residents living in the facility.

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain a process to follow Generally Accepted Accounting Principles (GAAP) to reconcile the Resident Trust Fund (RTF) Account monthly. The facility census was 42. Record review of the facility maintained RTF Cash Reconciliation Statement for the period 6/2022 through 5/2023, showed the facility did not follow GAAP, and did not investigate (identify or detail) why there were several outstanding transactions (old checks) from 2017 - 2019. Record review of the facility maintained RTF attempted reconciliation for the period 6/2022 through 5/2023, showed the facility carried over a difference each month for transactions from 2017 - 2019, for the following months, without identifying or detailing the outstanding transactions. [...]

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to transmit a Minimum Data Set (MDS) within the required 7-day time frame for 5 (Residents #96, #10, #27, #23, and #36) of 29 residents reviewed for MDS transmission. The facility census was 42.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for 3 (Residents #6, #10, and #14) of 29 residents for whom MDS assessments were reviewed. Specifically, falls were not accurately coded on the assessments completed for Resident #10 and Resident #14 and administration of anticoagulant medication was inaccurately coded for Resident #6. The facility census was 42.

Inspectors wroteBased on observations, interviews, and facility policy reviews, the facility failed to ensure 2 (nurses' medication cart and 400/500 Hall medication cart) of 3 medication carts were maintained in a safe manner. Specifically, the facility failed to ensure narcotics were secured in a separately locked compartment, drugs were not expired, and that there were no loose medications in the med cart; and medications were not repackaged. The facility census was 42.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #96) was treated with respect and dignity and in an environment that promotes quality of life when a staff member used foul language in front of them while providing assistance. The facility census was 42.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the physician about a significant change in status for one (Resident #17) of two residents reviewed for weight loss. Specifically, the facility did not notify the physician when Resident #17 lost 11.4 pounds (8.06%) in seven days, and 21.0 pounds (14.85%) in 28 days. The facility census was 42.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete an admission comprehensive Minimum Data Set (MDS) assessment for 2 (Resident #145 and Resident #44) of 29 residents reviewed for resident assessments. The facility census was 42.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) level I screening for two (Resident #35 and Resident #23) of three residents reviewed for PASARRs. Specifically, the facility failed to submit an updated PASARR level I screen when Resident #35 was diagnosed with unspecified psychosis on 01/14/2022 after admission and when Resident #23 was diagnosed with bipolar disorder on 03/04/2019. The facility census was 42.

Inspectors wroteBased on record review, interviews, and facility policy review, it was determined the facility failed to ensure physician orders were obtained for dialysis treatment and failed to ensure the facility's communication forms were completed for the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (Resident #36) of two sampled residents who received dialysis. The facility census was 42.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to maintain a medication error rate less than 5%. There were two errors in 25 opportunities, which resulted in an 8% medication error rate for 2 (Resident #96 and Resident #33) of 6 residents observed for medication pass. The facility census was 42.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a resident was free of significant medication error for 1 (Resident #33) of 6 residents observed during medication administration. Certified Medicine Technician (CMT) #19 failed to hold blood pressure medication when the resident's blood pressure was outside parameters established by the resident's physician orders. The facility census was 42.

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for three of three sampled residents (Resident #20, #31, and #105) who remained in the facility upon discharge from Medicare A services for rehabilitation. The facility census was 58. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four randomly selected certified nurse aides (CNA) received the required annual 12 hour resident care training. The census was 58. Review of the CNA individual in-service records, showed the following: -CNA A hired 9/12/13, with 0 hours of in-service education; -CNA B hired 3/9/01, with 0 hours of in-service education; -CNA C hired 8/1/05, with 0 hours of in-service education; -CNA D hired 3/3/17, with 0 hours of in-service education. Review of the facility assessment, showed the facility is required to develop, implement and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete perineal care (peri-care, cleansing from the front of the hips, in between the legs and buttocks to the back of the hips) was provided for two of two care observations (Residents #38 and #28). The census was 58. Review of the facility's undated peri-care procedure, showed: -Procedure: Expose the perineal area. Start at the top of the groin and wash down one side of the outer groin tissue, turn the wash cloth and wash the other side of the outer groin. Turn the wash cloth again and wash down the middle of the peri area in a downward motion and front to back manner. Obtain a clean wash cloth and continue cleaning down the legs as needed. Dry the peri area. Roll the resident onto one side and continue washing soiled and wet areas from front to back. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were followed up on, for one out of six residents sampled for medication regimen review (MRR) (Resident #39). In addition, the facility medication review policy failed to include the appropriate time frames for the different steps in the MRR process. The sample was 15. The census was 58. Review of the facility's undated Medication Regimen Review policy, showed: -The consultant pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for the review; -The review of the medication regimen will include all medications, including medications that are ordered on an as needed basis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurately documented medical records for one of 15 sampled residents (Resident #28) identified as receiving one to one activities. The facility did not provide documentation of individualized one to one activities, what kind of activity was provided and length of time the activity was provided. The census was 58. Review of the facility's activity assessment policy, revised 10/2009, showed: -Policy: In order to promote the physical, mental and psychosocial wellbeing of residents, an activity assessment is conducted and maintained for each resident; -Policy interpretation and Implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a coordinated plan of care for residents receiving hospice services and maintain required hospice records onsite at the facility. The facility identified five residents who elected hospice services and all five were included in the sample. Issues were found with two of the five residents (Residents #28 and #225). The census was 58. 1. Review of Resident #28's hospice binder, showed: -admitted to hospice services on 3/12/16; -Hospice admission diagnosis: Malignant melanoma (cancer) of the face. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/19, showed: -Severe cognitive impairment; -Diagnoses of melanoma and dementia; -Received hospice services. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow the hand hygiene policy and prevent the potential spread of contaminates during personal care by failing to change gloves and wash hands for two of two care observations (Residents #28 and #38). The census was 58. Review of the facility's handwashing/hand hygiene policy, revised 10/2009, showed: -Purpose: To provide guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infections; -Objective: To prevent and control the spread of infectious diseases; -General Guidelines: Approximate 10 to 15 second handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make available in a place readily accessible to residents, family members and legal representatives of residents, deficiencies resulting from any subsequent complaint investigation since the most recent survey and the associated plan of correction. The census was 58. Observation on all days of the survey, 11/4, 11/5, 11/6, and 11/7/19, showed the facility's previous survey results, maintained in a binder on a desk at the side entrance to the building with a sign to refer to administration for previous surveys. Review of the survey binder, showed the most recent annual survey, dated 1/30/19, with the plan of correction. The survey binder also showed one previous survey, dated 3/20/18, with the plan of correction. [...]