Bentwood Nursing & Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided to treat pressure ulcers (skin and tissue damage caused by prolonged, unrelieved pressure on the skin) and/or wounds for one resident (Resident #2). On 06/05/26, a nurse identified a Stage II (a partial-thickness skin loss that damages the outer epidermis and dermis) pressure ulcer on the resident's right buttock but failed to obtain treatment orders until 06/18/26, after the resident had a fall and a full skin assessment was completed. The sample was 5. The census was 105. Review of the facility's Wound Management Policy, revised 11/15/22, showed:-Policy: To promote wound healing of various types of wounds. The facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: -Wound Management: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist for the facility's infection prevention control program. The census was 100. Review of the facility's Surveillance for Healthcare Associated Infection, dated 10/2021, showed:-Surveillance for Healthcare Associated Infections (HAI) will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infections.- Complete the Monthly Infection Control Surveillance Log utilizing a new form each month or complete electronic version on medical record software. Complete the data as indicated;--Identifying the information i.e. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for one of one sampled resident who expired (Resident #110). The sample was 22. The census was 100. Review of the facility's admission agreement, showed:-You have the right to manage your personal financial affairs or have someone you trust do so, including the facility. With your written approval, the facility will open a personal account for you through Resident Fund Management Services (RFMS). The personal resident trust account is controlled by you or your Resident Representative only. We will provide you with an accounting of these funds upon your request, and at least once every three months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs. The facility failed to ensure one resident received showers, was dressed in clothing, and was assisted out of bed (Resident #40) and failed to ensure one resident received nail care and facial hair was removed (Resident #98). The sample was 22. The census was 100. Review of the facility's nail care policy, dated 7/21/22, showed:-Policy: the purpose of nail care is to clean the nail bed, trim nails, and prevent infection;-Key Points: nails may be cleaned during bathing. Nail care includes daily cleaning and regular trimming. Stop and report to the Charge Nurse ingrown nails, infection, pain, or nails that are thick and difficult to trim. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's order(s) were followed for treatments related to a post-surgical site for a resident's left hand. For one of three residents sampled (Resident #81). The sample was 22. The census was 100. Review of the facility's Physician Order Policy, dated 10/2022, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, State & Federal guidelines;-Responsibility: Licensed Nurses- Registered Nurse (RN) and License Practical Nurse (LPN), Nursing Administration, & Director of Nursing (DON);-Orders must be Recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders must be documented clearly in the medical record. The required components of a complete Order: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed for treatments, pressure reducing boots in place, and the air mattress set no higher than the resident's weight, for one of three sampled residents for wounds (Resident #25). The sample was 22. The census was 100. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident (Resident #40), who had limited mobility, the appropriate services, equipment and assistance to maintain or improve their mobility. The sample was 22. The census was 100. During an interview on 2/24/26 at approximately 9:00 A.M., the Director of Nursing (DON) said the facility did not have a restorative therapy (RT) policy that focuses on regaining or maintaining physical function. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/30/25, showed:-No rejection of care;-Functional limitation of range of motion: No impairment to the upper extremities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe transfer technique for two residents who required assistance with transfers. Staff failed to ensure a gait belt was use for one resident (Resident #19). In addition, staff failed to ensure two staff transported a resident by mechanical lift (Resident #14) after a family member was observed assisting staff. The sample was 22. The census was 100. Review of the facility's Gait Belt Transfer policy last reviewed,10/25/22, showed:-Policy: the facility will utilize a gait belt for residents who require one assist with transfer to promote safety during resident transfers;-Procedure: -Ensure the resident is wearing non-skid footwear; -Place the gait belt around the resident's waist over their clothing with the buckle facing the front; -Buckle and fasten the gait belt; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure supra pubic catheter (medical device used to collect bodily waste) care was provided by staff and physician orders were obtained for a gauze to cover the site for one resident (Resident #25). The facility also failed to ensure one resident with a Foley catheter (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a bag, held in place by a small, water-filled balloon) had appropriate physician's orders for the catheter, catheter tube change, and urine output (Resident #14). The facility identified three residents with a catheter, two were sampled and issues were identified with both residents. The sample was 22. The census was 100. Review of the facility's Catheter Care Policy, dated July 2022, showed:Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nutritional needs were met for two of two sampled residents receiving tube feedings. The facility failed to ensure the tube feeding pump was working properly, resulting in weight loss for one resident (Resident #13), and failed to ensure one resident received his/her scheduled bolus (method of delivering formula into the stomach through a feeding tube using a syringe) feeding (Resident #8). The sample was 22. The census was 100. Review of the facility's tube feeding policy, dated 7/31/25, showed:-Policy: Residents with an order for tube feeding will be assessed and monitored by a registered dietitian to ensure nutritional needs are being met;-Procedure: Nursing will receive tube feeding order written by physician. Resident may be weighed weekly or more often as ordered by physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory services consistent with professional standards of practice by failing to ensure oxygen tubing was stored properly, oxygen tubing was changed, and the oxygen rate was set properly for one of one sampled resident investigated for respiratory services and who was on oxygen (Resident #100). The census was 100. Review of the facility's undated oxygen administration policy showed implementation: Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Review of the facility's oral inhalation administration policy, dated 9/2014, showed:-Policy: to allow for safe, accurate, and effective administration of medication using an oral inhaler or nebulizer (delivers medication directly to the lungs);-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. Out of 27 opportunities observed, five errors occurred, resulting in a 18.52% error rate (Residents #17 and #70). The census was 100. Review of the facility's Medication Administration policy, dated December 2017, showed:-Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so;-Procedures:-Medications are prepared only by licensed nursing, medical, pharmacy, or other personnel, authorized by state laws and regulations to prepare and administer medications;--Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow enhanced barrier precautions during care and failed to follow acceptable infection control practices during wound care for two of two residents observed for wound care (Residents #25 and #67). In addition, staff failed to ensure one out of five residents sampled for vaccinations and health screenings had a two-step Tuberculosis (TB, infectious lung disease) Screening within the 48-72 hours post admission per facility policy (Resident #67). The sample was 22. The census was 100. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident, identified as high risk for falls, received adequate supervision to prevent accidents (Resident #1). Staff placed the resident near the nurses' station for close observation in a locked wheelchair. Staff left the area, during which time Resident #1 attempted to get up and fell from the wheelchair, resulting in a fractured wrist. In addition, the facility failed to ensure fall prevention interventions for three residents who were identified as high risk for falls, were consistently and accurately documented across the care plan, physician orders, and progress notes, as required by the facility's Fall Management Policy and Incident Documentation and Investigation Policy (Residents #1, #3 and #4). The sample size was three. The census was 91. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the facility's policy regarding gastronomy tube (g-tube, a small rubber tube surgically inserted through the abdomen in to the stomach to administer nutrition, fluids and medications) feedings by not recording on the bag the name of the formula, the date and time hung and the resident's name, failed to accurately determine the amount of food and fluid consumed per meal and also failed to follow physician orders for two residents (Residents #3 and #40) out of three sampled residents. The facility also failed to ensure staff correctly positioned a resident who received tube feedings (Resident #3). The census was 96. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy by failing to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and perform wound treatments for two of three residents sampled (Residents #9 and #12). The census was 106. Review of the facility's Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Procedure: Wound treatment will be provided in accordance with physician's orders; -Cleansing method; -Type of dressing; -Frequency of dressing change; -Charge Nurse will notify physician in the absence of treatment orders; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident #1) received proper treatment and care to maintain mobility and good foot health. The sample was four. The census was 106. Review of the facility's Activities of Daily Living (ADL) policy, reviewed 7/21/22, showed: -Policy: Nursing staff will assist in bathing resident to promote cleanliness and dignity; The charge nurse will be made aware of residents who refuse bathing. -Bed Bath: Wash feet and in between toes. Review of the facility's Podiatry (foot) Services policy, reviewed 10/7/21, showed; -To provide podiatry services to the residents as needed; -Responsibility: Licensed Nurse; -Procedure: -Determine when the podiatrist will be in the facility; -The charge nurse will prepare a list of residents who require podiatry services; [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of two residents (Resident (R)73 and R84) reviewed for abuse. The census was 106. Review of the facility's policy titled, Abuse Prevention revised 10/21/22, revealed the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogated, sponsors, friends, visitors, or any other individual. Review of R73's admission Record, located in the Profile' tab of the EMR, showed R73 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, anxiety disorder, attention deficit hyperactivity disorder and major depressive disorder. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to utilize Enhanced Barrier Precautions for three of 33 residents sampled (Resident (R)19, R60, and R77). The failure had the potential to increase the risk of adverse events of spreading infections to other residents in the facility.

Inspectors wroteBased on interview, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics for one of 33 residents sampled (Resident (R)77). This had the potential to affect residents being prescribed antibiotics that were potentially unnecessary.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to offer and/or provide pneumococcal vaccines in two of five residents (Resident (R)77, and R98) reviewed for immunizations out of a total sample of 33 residents. This failure of not offering and/or providing immunization against pneumonia increases the risk of residents having this infection.

Inspectors wroteBased on observation, record review staff interview and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at bedside and that the correct dose was given for one (Resident (R)169) out of four residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to provide and maintain complete accounting records, regarding the reconciliation of petty cash kept on hand, for the resident trust account. The census was 111. Review of the facility's Business Office Resident Trust Fund Policy and Procedure, undated, showed the following: -Policy Statement: Residents of a skilled nursing center are to have their funds managed and personal spending money available to them. Regardless of payment source, residents have the right to choose whether or not to open a Resident Trust Fund account with the Center. If the choice to open a trust fund account is made, the resident has the right to have their money safeguarded and accounted for by the Center. The residents have the right to have any funds deposited with the center, in an interest-bearing account, according to state guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #201, #202 and #203). The census was 111. 1. Review of Resident #201's medical record, showed the following: -Expired on [DATE]; -Ending balance of $5781.19; -TPL completed on [DATE]. 2. Review of Resident #202's medical record, showed the following: -Expired on [DATE]; -Ending balance of $3029.82; -TPL completed on [DATE]. 3. Review of Resident #203's medical record, showed the following: -Expired on [DATE]; -Ending balance of $200.34; -TPL completed on [DATE] 4. During an interview on [DATE] at 12:16 P.M., the Business Office Manager (BOM) said she is responsible to ensure the ending balances are sent back within 30 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for five of 10 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 111. Review of the facility's Abuse Prevention Policy, dated 10/21/22, showed the following: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Screening: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to send written notice of transfer/discharge to resident or resident representative for two of two resident (Residents (R) 63 and 108) reviewed for hospitalizations.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure a bed hold notice was provided to resident or resident representative for one of one resident ( Residents (R) 63) reviewed for hospitalizations.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an accurate Level 1 pre-screening of the resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed or correct for one (Residents (R) 20) of four reviewed for Level 1 Pre-admission Screening and Resident Review (PASARR).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a activities care plan for two (Resident (R) 20 and R40) of two resident reviewed for activities. Failure to have activities care plan in place for R20 and R40 at risk for psychosocial decline.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to ensure one-to-one activity for two residents (R20 and R40) of three observed in the facility for activities. This had the potential to result in a decline of the resident's psycho-social well-being. The facility census was 106 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to appropriately address a resident's aggressive behaviors and put interventions to assist the resident with proper coping skills to prevent violent outbursts and acts of aggression towards others for one out of one resident (Resident (R)84) reviewed for behaviors.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one of five residents (Resident (R) 16) reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when one resident (Resident #2) was involved in a physical altercation with a visitor of two residents who resided in a different room (Residents #3 and #5) resulting in the visitor hitting the resident. The sample was 5. The facility census was 104. The facility was notified of past non-compliance on 3/15/24. Facility staff immediately intervened, notified administration, removed the visitor from the facility and provided assessment and services to Resident #2. Staff were in-serviced on abuse and neglect prevention and de-escalation techniques. The deficiency was corrected on 3/6/24. Review of the facility's Abuse Prevention Policy, revised 10/21/22, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, by failing to facilitate a resident's right to make choices about aspects of his/her life that are significant to the resident, when the facility staff failed to honor a resident's choice to get out of bed, resulting in the resident remaining in bed all day (Resident #5). The sample size was 12. The census was 105. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/23, showed: -Moderate cognitive impairment; -Sit to stand: dependent, helper does all the effort. Chair/bed to chair: dependent, helper does all the effort. Lower extremities (hip, knee, ankle, foot) functional limitation on both sides; Wheelchair: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered rehabilitative services to assist one resident to attain, maintain or restore his/her highest practicable level of physical functioning (Resident #5). The sample size was 12. The census was 105. Review of the facility's Physician Order policy, last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Responsibility: Licensed Nursed, Nursing, Administration, and Director of Nursing (DON); -Procedure: Physician orders must be documented clearly in the medical record. The required components of a complete order: -Date and time of order; -Name of practitioner providing the order; -Name and strength of medication/treatment; -Quantity/Duration; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) in a timely manner for one of seven sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). Additionally, not all direct care staff were aware of the location of the code status documentation in residents' records (Residents #2 and #3). Also, the facility policy did not address the location of the code status documentation and how the information would be communicated throughout the facility so that staff would know immediately what action to take or not take when an emergency arises. The census was 114. [...]

Inspectors wroteBased on record review and interview, the facility failed to verify and implement hospital discharge orders for a Bilevel Positive Airway Pressure (BiPAP, a machine that helps push air into the lungs through a mask or nasal plugs) and oxygen therapy for one resident (Resident #1) who had a diagnosis of acute or chronic hypoxemic respiratory failure (absence of enough oxygen in the tissues to sustain bodily functions). In addition, the facility failed to address the resident's respiratory needs on the care plan and failed to have a policy regarding BiPAP use to direct staff on providing care. The sample was three and issues were found with one. The census was 107. Review of the facility's Physician Orders Policy, last reviewed 9/28/22, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardio-pulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to restore spontaneous blood circulation and breathing in a person in cardiac arrest), to any resident requiring such care in accordance with physician's orders and the resident's advanced directives. The facility failed to have a system to ensure residents' code statuses are obtained timely upon admission, updated when changed and documented congruently through the medical record. Staff identified the hard chart (the paper medical record/chart) as the first place they would look for a resident's code status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management was provided to Resident #40 when the facility failed to medicate the resident prior to treatment of a Stage IV pressure ulcer (Full-thickness tissue loss with exposed muscle and bone. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) resulting in pain to the resident. The facility failed to ensure routine orders of pain medication were filled for Resident #37 who had pain in the lower extremities, which resulted in several days of missed doses, causing the resident to experience high levels of pain. The sample size was 18. The census was 90. Review of the facility's Pain Management Guidelines policy, revised 9/2017 and located at the nurses station, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure the walls and ceilings of the kitchen were free from dust and stains, the shelf under the steam table was free from rust and lime buildup, and the deep fat fryer was free of caked on food particles. Staff failed to rinse dishes and immerse in sanitizer for at least 30 seconds in the pot sink and failed to perform good hand hygiene when going from dirty dishes to clean dishes. Additionally, staff also failed to allow dishes to completely air-dry before stacking, failed to wear hairnets to cover all hair, and failed to ensure there was an air gap for the ice machine to prevent back flow. These deficient practices had the potential to effect all residents who ate meals at the facility. The census was 90. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area. The call light system monitor and speaker, located at the long-term care nurse station failed to alert staff to a resident's call light. Several resident room light indicators, located above the room door, were not visible from the nurse's station. In addition, one resident's call light did not function for several days of survey (Resident #534). The census was 90. 1. Review of the maintenance log, located and the long-term care nurses station, showed: -On 2/4/22, room [ROOM NUMBER] A & B call light out, signed as corrected; -On 3/14/22, room [ROOM NUMBER] call light broken, signed as corrected; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a clean, comfortable and homelike environment by not ensuring resident rooms, bathrooms and shower rooms were clean and in good repair. The census was 90. 1. Observations of the shower room located between the 200 and 400 halls for three of three days of observation, on 5/1/22 at 6:43 A.M., 5/2/22 at 6:52 A.M., and 5/3/22 at 9:48 A.M., showed: -A shower chair sat next to the sink with a bath basin and several towels on the seat that appeared to be thrown/tossed on the chair and not stacked. Three batteries for mechanical lifts sat on the sink, charging next to a can of hairspray; -Folded linen and a brief on the sink. Some of the towels hung over the edge of the sink; -A wheelchair and some railings stored in the corner near the tub. A bedside table with folded linen next to the wheelchair; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their admission/readmission checklist and physician admission orders by ensuring nurses processed admission medication orders for two residents who missed several days of their medications (Residents #135 and #136). The facility failed to promptly provide Resident #30, who had a wet cough, with a nebulizer treatment, failed to assess the resident's lungs prior to and after the nebulizer treatment and expected unlicensed nursing staff to assess lung sounds, which is not within their scope of practice. The facility failed to ensure the physician was notified of Resident #134's low blood pressures, failed to ensure physician orders were documented in a manner that was able to be understood by peers, and failed to document a respiratory assessment as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who are unable to carry out activities of daily living received showers and care as scheduled/desired (Residents #68, #17, #35, #234, #6 and #66). The sample was 18. The census was 90. 1. Review of Resident #68's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/6/22, showed: -Cognitively intact; -Rejection of care not exhibited; -Required extensive assistance of one person physical assist for transfers and locomotion; -Required limited assistance of one person physical assist for personal hygiene; -Required one person physical assist for bathing; -Upper and lower extremities impaired on one side; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy when staff failed to ensure fall interventions were in place for one resident (Resident #234). The facility also failed to ensure the resident environment remains as free of accident hazards as is possible when three out of four shower rooms observed contained unsecured razors, unsecured cleaning chemicals and a toilet that had chipped, broken and sharp edges. The sample was 18. The census was 90. Review of the facility's Fall Management Guidelines, located at the long-term care nurse's station and revised on 7/14/17, showed: -The facility will establish and utilize a systemic approach to resident choices in the fall management guidelines; -Newly admitted residents: -Upon admission, the admission nurse will complete the fall risk assessments in the electronic medical record system. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs, biologicals, and other supplies stored in the medication carts and rooms, were not kept past their expiration dates in two medication carts and one medication room. The facility identified having two medication rooms and six medication carts. In addition, the facility failed to ensure prescription medications are properly stored, and unattended medication carts are locked or inaccessible to unauthorized staff and residents. Furthermore, the facility failed to implement an effective method of measuring temperature in the medication refrigerator. The census was 90. Review of the facility's Storage of Medication policy, revised 11/2018, showed: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they did not implement appropriate interventions to correct ongoing, systemic issues. The sample size was 18. The census was 90. Review of the facility's QAPI policy, last reviewed 8/20/20, showed: -Policy: -The QAPI plan will describe how the facility will ensure care and services delivered meet acceptable standards of quality, identify, problems and opportunities for improvement, and assure progress towards improvement is achieved and sustained. The quality assessment and assurance (QAA) committee will meet monthly to assess and monitor the quality of services provided to residents and identify potential problems or areas of opportunity for improvement. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on communicable disease by failing to ensure 10 of 10 sampled staff, hired within the past 12 months, received their two-step tuberculin skin test (tests for latent tuberculosis). The census was 90. Review of the facility's Tuberculosis (TB) Skin Test Consent policy, undated, showed: General information: The Centers for Disease Control and Prevention (CDC) recommends that every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of Mycobacterium tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting. TB screening is a requirement for obtaining employment in this center. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed or followed up on for the final accounting for residents who expired, within 30 days. This affected two of six residents who expired and had money in their account (Residents #136 and #236). The census was 90. 1. Review of Resident #136's resident fund account, showed the following: -He/she expired [DATE]; -He/she had a balance of $150.01; -No documentation of TPL completed. 2. Review of Resident #236's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $5,911.90; -TPL completed [DATE]; -As of [DATE], the resident's account remained open with a balance of $5,911.90. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #134's physician and emergency contacts were notified after low blood pressure assessments and a change in condition. Additionally, the facility failed to notify Resident #335's emergency contacts after the resident had a fall (Residents #134 and #335). The census was 90. Review of the facility Notification of a Change in a Resident's Condition, dated [DATE], showed: Policy: -The attending physician and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; Responsibility: -All licensed nursing personnel; Procedure: Guidelines for notifications of physician/resident representative include: -Significant change or unstable vital signs; -Any accident or incident (per Federal and State regulations); [...]

Inspectors wroteBased on interview and record review, the facility failed to complete admission comprehensive assessments within 14 calendar days after admission to the facility and annual comprehensive assessments not less than once every 12 months to assess functional capacity using the resident assessment instrument (RAI) for three residents (Residents #185, #234, and #235). The census was 90. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument manual, version 1.17.1m dated October 2019, showed: -admission comprehensive: Completion date no later than 14th calendar day of the resident's admission; -Annual comprehensive: No later than 366 calendar days of the assessment reference date (ARD) of the previous comprehensive assessment. 1. Review of Resident #185's medical record, showed: -admitted [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for four residents (Residents #135, #235, #78, and #86) within 48 hours of admission, to provide instructions for the provision of effective and person-centered care. The sample was 18. The census was 90. Review of the facility's Registered Nurse (RN) job description, dated 11/1/18, showed: Summary/Objective: -The RN position is to assess, plan, implement, and evaluate the nursing care of the resident within the company. Responsible for ensuring the care of the residents between shifts by providing direct care as well as supervising the care given by Certified Nursing Assistants (CNAs), Certified Medication Technicians (CMTs), and Licensed Practical Nurses (LPNs) and supportive staff members; Essential Functions include: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing restorative (RT) nursing program to ensure residents maintained their functional ability to the greatest extent possible. One resident did not receive restorative therapy services, and no restorative program was in place (Resident #35). The sample was 18. The census was 90. Review of the facility Policy and Procedure Establishment of an Individual Restorative Program, dated 1/1/14, showed: Purpose: -To provide treatment and services to maintain and improve functional abilities per physician orders; Procedure: 1. A restorative program may be recommended for a resident by any of the following ways: -Recommendation by the therapist prior to the time of discharge from therapy; -Recommendation by the therapist for evaluation and establishment of a restorative program following a therapy screen; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate and sufficient services, treatment and care based on current standards of practice for one resident with a suprapubic catheter (a urinary catheter surgically inserted through the abdominal wall and into the bladder, to drain urine) (Resident #534). The facility identified seven residents as having urinary catheters. The census was 90. Review of the facility's Catheter Care policy, dated October 2016, showed: -Purpose: To maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevention of infection and other complications; -The policy did not address the process to cleanse a suprapubic catheter site. Review of Resident #534's electronic medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately maintain acceptable nutritional standards by failing to implement interventions as recommended by the registered dietician for 2 of 18 sampled residents who experienced weight loss (Residents #53 and #78). The census was 90. 1. Review of Resident #53's medical record, showed: -admission date of 3/4/22; -Diagnoses included cellulitis of left lower limb, localized edema, fluid overload, and amnesia; -Significant cognitive dysfunction. Review of the resident's monthly weights, showed: -3/5/22, 102 pounds (lbs). Review of the resident's active physician orders on 5/4/22 at 10:52 A.M. showed: -An active order dated 3/5/22 for regular diet, regular texture, and thin consistency liquids; -An active order dated 3/10/22 for Prostat liquid protein to be given twice per day; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident received gastrostomy tube (a tube inserted through the abdomen into the stomach to provide medication, nutrition, and hydration) feeding as ordered on a consistent basis, and to ensure the head of the resident's bed was elevated to prevent aspiration (choking). The facility identified five residents receiving tube feedings, two of which were sampled and problems were found with one (Resident #234). The sample was 18. The census was 90. Review of the facility's Continuous Tube Feeding policy, dated February 2016, showed: -Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally; -Procedure: -Verify physician order for tube feeding; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document attempts to use appropriate alternatives prior to installing a bed rail. If used, the facility failed to assess the resident for risk of entrapment prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. The sample size was 18 and three residents were identified during the survey with bed rails in use (Residents #30, #234 and #53). The census was 90. 1. During an interview on 5/05/22 11:43 A.M., the Director of Nursing (DON) said she was not sure if there should be an order for bed rail use. She was not sure of the process for determining if a resident needed a bed rail. She will have to review the policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from a significant medication error when the resident missed several doses of a chemotherapy medication (Resident #185). The census was 90. Review of the facility's Physician Orders policy, dated as revised on July 1, 2017, showed: -Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; -Clear and complete orders will be transcribed to the appropriate administration record; -Medications will be ordered from the pharmacy to ensure prompt delivery. Medications available from the emergency drug supply shall be utilized for the first dose until a supply arrives from pharmacy. Review of the facility's Medication Administration-Preparation and General Guidelines policy, dated 12/2017, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a hospice physician certification of terminal illness, and to develop a written plan of care including both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, for one of one resident sampled for hospice services (Resident #235). In addition, the facility failed to ensure the resident's hospice documentation was located in an area readily accessible to facility and hospice staff. The sample was 18. The census was 90. Review of Resident #235's hospice agreement, executed 4/11/22, showed: -Plan of care: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure when bed rails and mattresses are used and purchased separately from the bed frame, the bed rails, mattress, and bed frame were compatible for one resident (Resident #30). The resident's family purchased and installed the bed rail and the maintenance staff failed to assess the bedrail for proper instillation or compatibility. This resulted in the bed rail fitting loosely and the resident becoming stuck between the mattress and bed rail. The census was 90. Review of Resident #30's medical record, showed: -Diagnoses included altered mental status, stroke, seizure disorder, hemiplegia and hemiparesis (paralysis or severe weakness in one part of the body) due to stroke and lung disease; -A care plan for the admission date of 1/13/20, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care Ombudsman of emergency transfers/discharges for residents sent to a hospital for various medical reasons. The census was 90. Review of the facility's Notification of Transfer and Discharge policy, issued 3/2017, showed: -Policy: The facility will provide resident and resident representative notice of an impending transfer or discharge; -Policy interpretation: The facility will notify the resident and resident representative(s) of the impending transfer or discharge and the reasons for the move in writing and in a language and manner they will understand. The facility will also send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. Review of the facility's admission and discharge report from 1/1/22 through 5/1/22, showed: [...]