Beth Haven Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment by not maintaining the indoor air temperatures of resident rooms in the facility between 71.0 F. (degrees Fahrenheit) and 81.0 F. for 19 sampled residents on the east wing of the facility (Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #18, #19, #20, #21, #22 and #23) with room temperatures ranging from 82.0 degrees Fahrenheit ( F.) to 90 F. The facility failed to have a comprehensive monitoring system including documentation of resident room temperatures and each resident's condition. The facility census was 69. The Administrator was notified on 6/23/25 at 5:15 P.M., of the Immediate Jeopardy (IJ) which began on 6/23/25. The IJ was removed on 6/24/25, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, was free from verbal abuse when Licensed Practical Nurse (LPN) A, after denying to get the resident a cup of coffee when he/she requested one, proceeded to pursue the resident to another wing of the facility, yelled loudly he/she already told the resident the resident could not have a cup of coffee, and LPN A meant it in a demeaning manner at the resident while pointing his/her finger at the resident's face. Witnesses reported the resident had a surprised look on his/her face and asked what he/she had done wrong. The facility investigation showed when interviewed, Resident #1 confirmed LPN A had treated him/her very nasty, pointed his/her finger in the resident's face, and felt like LPN A dismissed him/her like a dog over a cup of coffee. [...]

Inspectors wroteRefer to Y0CV12. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 02/06/25. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7) in a review of 15 sampled residents, had a proper fitting wheelchair that did not cause him/her pain. The census was 65. Review of the facility policy, Accommodation of Needs, last revised March 2021, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; [...]

Inspectors wroteRefer to Y0CV12. Based on interview and record review, the facility failed to ensure residents received physical, occupational, and speech therapy services under an arrangement agreed upon by both the facility and the provider of outpatient therapy services. This failure resulted in lack of communication between the facility and the provider, lack of coordination of care with agreed upon goals, lack of communication to ensure residents had their at home programs implemented at the facility, and failed to ensure residents could toilet and have basic assistance while at therapy for two residents (Resident's #400 and #402) in a review of two residents receiving outpatient therapy services. The facility census was 65.

Inspectors wroteBased on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, date, store per manufacturer's instructions, or properly thaw food items in order to prevent potential contamination. Staff did not practice proper hand and glove hygiene, hair restraint usage, and consumption of personal food and beverage items. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris or demonstrate proper surface sanitization procedures and knowledge of chemical sanitizer levels. Staff did not ensure dishes and utensils were stored and handled in a sanitary manner. Staff failed to ensure an air gap was present at the facility's ice machine drains to prevent possible backflow from the drain back into the ice machines. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from 07/01/24 through 09/30/24. The facility census was 71. 1. Review of the CMS PBJ Staffing Data Report, dated 1/28/25, showed the facility did not report staffing data for the period of 07/01/24 through 09/30/24. During an interview on 2/5/25 at 2:50 P.M., the Administrator said the following: -The facility had not been submitting their PBJ information; -The last person responsible for submission was the payroll clerk who had since left employment; -Their payroll service was responsible for submitting the PBJ for them once the contract began.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Residents #43, #66, and #5 and #175), and during medication pass for one resident (Resident #25), in a review of 18 sampled residents. The facility failed to ensure three different staff properly performed infection control procedures when they did not clean the tips of insulin pens prior to applying a needle cap and administering insulin to three residents (Residents #22, #20 and #4). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had reasonable access to their personal funds. Residents were unable to gain access to their funds on the weekends including one resident (Resident #2) in a review of 18 sampled residents. The facility managed funds for 43 residents. The facility census was 71. Request was made of the facility for a facility policy regarding the Resident Trust Fund and no policy was provided. 1. During an interview on 02/02/25 at 2:44 P.M., Resident #2 said he/she was unable to access his/her resident funds on the weekends. Review of the facility log, listing residents the facility held resident funds for, showed Resident #2 was one of 43 residents that held funds in the resident trust fund account. During an interview on 02/03/25 at 2:49 P.M., the Admissions/Social Services staff said the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) sufficient to ensure protection of all personal funds the facility held for 43 residents in the resident fund account. The facility census was 71. Request for a facility policy regarding Resident Trust Fund and/or Surety Bond was made with no policy provided. 1. Review of the facility log, listing residents the facility held resident funds for, showed 43 residents held funds in the resident trust fund account. Review of the facility surety bond, dated 02/06/13, showed the facility had an approved surety bond in the amount of $25,000.00. Review of the resident trust fund account for February 2024 to January 2025 showed an average monthly balance of $26,341.93. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks for four residents (Residents #47, #68, #14 and #10), in a review of 18 sampled residents. The facility census was 71. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 3/2022 showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for three residents (Residents #55, #46, and #19), in a review of 18 sampled residents, and one additional resident (Resident #65). The facility failed to obtain lab work as ordered for one resident (Resident #55), failed to document treatments and medication administration as completed for three residents (Residents #55, #46 and #19), and failed to ensure staff observed one additional resident (Resident #65) take his/her medications during a medication pass. The census was 71. Review of the facility's policy, Administering Medications, dated 2001 and last revised April 2019, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for incontinence care for three residents (Residents #43, #46, and #5), in a review of 18 sampled residents, and for one additional resident (Resident #175), who required assistance with their activities of daily living. Staff failed to provide oral care for three residents (#43, #46 and #5). The facility census was 71. Review of the facility's policy, Perineal Care, dated 2001 and revised February 2018, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition; -For a female resident wet washcloth and apply soap or skin cleansing agent; wash perineal area, wiping from front to back; Separate labia and wash area downward from front to back. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record accurately and consistently indicated the resident's code status for three residents (Residents #7, #31, and #46), in a review of 18 sampled residents. The facility census was 71. Review of the facility policy, Advance Directives, last revised [DATE], showed the following: -Advance directives are honored in accordance with state law and facility policy; -Do Not Resuscitate (DNR) - indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure harmful chemicals were kept in locked cabinets and not accessible to residents. The census was 71. 1. Observation on 2/3/25 from 1:35 P.M. to 2:37 P.M., during the dietary and sanitation tour of the facility, showed the following: -One unlabeled cup containing a pink paste substance, one unlabeled cup containing a blue liquid with a spoon in the liquid, and three cans of heavy duty cleaning spray located in an unlocked lower cabinet in the Gardens Special Care Unit (SCU - an area of the facility dedicated to care for residents with dementia who are generally ambulatory) dining room kitchenette. The label on the cans of cleaning spray read 'Keep out of reach of children'; -One gallon jug of concentrated descaler and delimer located on the open bottom shelf of the Gardens SCU dining room steam table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the facility's diet spreadsheet menu. The facility census was 71. 1. Review of the Diet Orders, printed 2/3/25, showed the following: -43 residents with a physician-ordered regular diet; -Ten residents with a physician-ordered consistent carbohydrate (CCHO) (low concentrated sweets (LCS)) diet; -Seven residents with a physician-ordered heart healthy diet; -Four residents with a physician-ordered large portion diet; -Six residents with a physician-ordered pureed diet. Review of the Diet Spreadsheet, for 2/4/25 (Day 24, Tuesday) Lunch, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature and taste. The facility census was 71. 1. Review of the Diet Orders, printed 2/3/25, showed the following: -13 residents with a physician-ordered mechanical soft diet; -Two residents who preferred to receive a mechanical soft diet; -Six residents with a physician-ordered pureed diet. Review of the facility's recipe binders, located on the food preparation counter and in a rack by the dietary manager's office, showed no recipes (or associated temperature guidelines) for the following food items: -Mechanical soft or pureed potato salad; -Pureed or chopped (mechanical soft) spinach; -Mechanical soft or pureed pork loin. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure lids on outdoor garbage and grease collection containers remained closed or covered when not in use. The census was 71. Observations on 2/3/25 at 3:38 P.M., during the outside sanitation tour near the basement service hall area, showed the following: -A dumpster, approximately 25% full of trash, did not have a lid on the top and front of the dumpster; -A grease container, approximately 90% full of grease, had a lid that hung off to the side of the container. The lid read Grease only. Close lid. A water bottle floated on the surface of the grease in the container. Black and light gray residue was visible on the grass in an approximate 4-foot by 20-foot area around and downhill of the grease container; -No staff were present or actively working in the area where the dumpster and grease container were located. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of regular maintenance program to identify areas of possible entrapment for three residents (Residents #68, #14, and #10), in a review of 18 sampled residents. The census was 71. Review of the Food and Drug Administration (FDA) document, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment to deter pests from entering the facility's kitchen, satellite dining rooms, kitchenettes, and food storage areas. The facility census was 71. 1. Observation on 2/3/25 at 10:49 A.M., in the kitchen above the three compartment sink, showed an approximate 1-foot by 3-foot window was open and did not contain a screen. Observation on 2/3/25 at 3:38 P.M., during the exterior and interior sanitation tour of the facility, showed the following: -Two approximately 1-foot by 3-foot windows were open to the kitchen and contained no screens on the windows; -An exterior door to the service hall, located near the outside dumpster and grease collection container, was propped fully open with a metal ramp. Both the dumpster and grease container were open. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one wheelchair bound resident (Resident #7), had a proper fitting wheelchair for his/her height and weight which did not cause him/her pain. The facility also failed to ensure call lights were within reach for one resident (Resident #34). The census was 71. Review of the facility policy, Accommodation of Needs, last revised March 2021, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure reasonable care for the protection of resident property from loss, when two residents (Resident #59 and #67), and one additional resident (Resident #4), sent items to be laundered and not all items were returned, and failed to ensure one resident's (Resident #4), clothing was free from bleach stains upon return from the laundry department. The facility census was 71. Review of the facility's policy, Personal Property, revised August 2022, showed the following: -Facility staff will treat the residents' belongings with respect, regardless of perceived value; -The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. 1. Review of Resident #4's inventory list, dated 02/11/23, showed the resident had one gray undergarment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate one resident (Resident #375's) in the use of a power recliner chair as a restraint, in a review of 18 sampled residents. The motorized recliner which staff sat the resident was positioned so the resident's legs were in front of him/her (horizontal with the floor). The resident was mentally and physically incapable of using power chair remote to put his/her own feet to the floor. The facility census was 71. Review of the facility's policy, Use of Restraints, revised April 2017, showed the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; [...]

Inspectors wroteBased on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (which would disqualify an individual from working in the facility) for two of ten newly hired employees reviewed. The facility census was 71. 1. Review of the Receptionist's employee file showed the following: -Date of hire 04/10/24; -No documentation the facility completed a Nurse Aide Registry check. 2. Review of Certified Medication Technician (CMT) BB's employee file showed the following: -Date of hire 01/26/24; -No documentation the facility completed a Nurse Aide Registry check. During an interview on 02/04/24 at 1:58 P.M., Human Resources staff she was responsible for completing the Criminal Background and Employee Disqualification List checks but was not aware she was to be completing the Nurse Aide Registry checks on newly hired staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence. Schedule III and IV medications have a lower potential for abuse) and schedule III through IV controlled substance medication, were reconciled by at least two qualified staff to ensure accountability. The facility census was 71. Request for a facility policy regarding Controlled Substances or Narcotic Reconciliation was requested with no policy provided. 1. Review of the [NAME] Unit, Team 1 facility Narcotic Count Sheet, on 02/03/25 at 1:02 P.M. showed the following shift-to-shift documentation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer insulin according to manufacturers' recommendations to ensure staff administered the prescribed insulin dose for two residents (Resident #20 and #22) in a review of 18 sampled residents. The facility census was 71. Review of the facility policy, Insulin Administration, revised September 2014, showed no direction to staff regarding the use of insulin pens. Review of the Lispro Insulin (fast-acting insulin to treat diabetes) Pen manufacturer's instructions for use showed the following: -Priming your pen: -Prime before each injection; -Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; -If you do not prime before each injection, you may get too much or too little insulin; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure discontinued medications for one resident (Resident #52), and medications for two discharged residents (Resident #301 and #300), were destroyed or returned to the pharmacy timely. The facility census was 71. 1. Review of Resident #52's physician orders, dated September 2024, showed the resident had an order for Lantus (long-acting injectable medication used to treat diabetes) 24 units subcutaneously in the morning. The order was discontinued 09/04/24. Observation on 02/03/25 at 1:30 P.M. of the [NAME] Unit Team 2 medication cart showed a Lantus insulin pen, labeled for the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received physical and occupational services as ordered by a physician for one resident (Resident's #400), in a sample of 15 residents. The facility failed to document why the order was not acted upon or why the order was discontinued for physical therapy (PT) and occupational therapy (OT) evaluation and treatment. The facility census was 65. Policies and agreements were requested for, but the facility did not provide a policy on outpatient therapy services. During an interview on 04/10/25 at 3:00 P.M., the Administrator said she did not have a specific policy for therapy orders. Review of Resident #400's Nurses Progress Notes, dated 02/13/25, showed the resident admitted to the facility after a fall at home where he/she sustained bilateral fractures of the lower legs; the resident had casts on both lower legs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received physical, occupational, and speech therapy services under an arrangement agreed upon by both the facility and the provider of outpatient therapy services. This failure resulted in lack of communication between the facility and the provider, lack of coordination of care with agreed upon goals, lack of communication to ensure residents had their at home programs implemented at the facility, and failed to ensure residents could toilet and have basic assistance while at therapy for two residents (Resident's #400 and #402) in a review of two residents receiving outpatient therapy services. The facility census was 65. Policies and agreements were requested for, but the facility did not provide a policy on outpatient therapy services or on facility outside resource agreements. [...]

Inspectors wroteBased on observation and interview, the facility failed to post daily staffing for four out of the four days of the survey. The facility census was 71. Review of the facility policy, Posting Direct Care Daily Staffing Numbers, last revised August 2022, showed the following: -Within two hours of the beginning of each shift, the number of licensed nurses (registered nurses (RNs), licensed practical nurses (LPNs), and licensed vocational nurses (LVNs)) and the number of unlicensed nursing personnel (certified nursing assistants (CNAs) and nurse assistants (NAs)) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. -Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: -The name of the facility; [...]

Inspectors wroteBased on observation and interview, the facility failed to place the facility's most recent survey results in an area accessible to the residents and visitors, and failed to post signage of the location of the survey results in large enough print to be read and accessible to residents in wheelchairs. The census was 71. During an interview on 2/2/25 at 12:40 P.M., an unidentified resident's family member asked how they could find out the results of a survey. Observation on 2/2/25 at 3:10 P.M. showed a printed white paper (with black lettering) on the front hall bulletin board (located to the right of the front entrance) which read, Last three years survey certificates and complaint investigations available East and [NAME] nurses station, in binder, in filing cabinet, top drawer. The document was higher than eye level when standing. Observation on 2/2/25 at 3:12 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a transfer in a safe manner for one resident (Resident #2) in a review of five sampled residents when two staff members Certified Nurse Aide (CNA) C and CNA D transferred the resident inappropriately with a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair and assist with sitting and standing). The resident's Care Plan directed staff to transfer the resident with a mechanical lift (a device that helps move and transfer people who need more support than caregivers can provide manually). Staff transferred the resident from a recliner to his/her wheelchair with a gait belt and did not utilize a mechanical lift. The resident did not bear weight during the transfer. The facility census was 71. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence an investigation was completed after a one resident (Resident #2), reported staff repeatedly slapped him/her on the hand, and failed to provide evidence a thorough investigation was completed following an allegation of staff misappropriation of narcotics for two residents (Resident #1 and #3) of seven sampled residents. The facility failed to report the results of the investigation regarding Resident #1 and #3 to the state agency within five working days of the incident. The facility census was 68. Review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, undated, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain effective pest control measures to prevent mice and roaches in the facility including the east dining room and facility kitchen. The facility census was 68. Review of the facility's policy, Pest Control, undated showed the following: -Our facility shall maintain an effective pest control program; -This facility maintains an ongoing pest control program to ensure that the building was kept free of insects and rodents; -Garbage and trash are not permitted to accumulate and are removed from the facility daily; -Maintain services, assist when appropriate and necessary, in providing pest control services. 1. Observation on 7/16/24 at 10:25 A.M., showed a resident sat at the table in the east dining room eating his/her breakfast. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Resident #1 and #3), in a review of seven residents, were free from misappropriation of property, when a Licensed Practical Nurse (LPN) D misappropriated narcotics from the residents. The facility census was 68. Review of the facility policy, Identifying Exploitation, Theft and Misappropriation of Resident Property, dated April 2021, showed the following: -Exploitation, theft and misappropriation of resident property are strictly prohibited; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; -Examples of misappropriation of resident property includes drug diversion (taking the resident's medication). 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to document the administration of a controlled medication removed from the Nexus (locked emergency medication dispense machine) and individual resident controlled medication count sheets, removed future doses of controlled medication from the Nexus machine, and individual resident controlled medication count sheets prior to the ordered administration times. Nursing staff who removed the controlled medication was not the same nursing staff member who administered and documented the medication was administered for two sampled residents (Resident #11 and #13), of 13 sampled residents and one closed record (Resident #15). Facility staff removed a controlled medication from the Nexus machine without a physician's order for one closed record (Resident #16) of three closed record residents. The facility census was 73. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe transfers and prevent bruising and skin tears for one resident (Resident #9), in a review of 12 residents who staff identified at risk for bruising and skin tears. Staff transferred the resident by lifting the resident under the arms with a gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair) and pulled on the resident's arms while dressing and undressing the resident. The facility census was 73. Review of the facility policy, Safe Lifting and Movement of Residents, dated July 2017, showed the following: -In order to protect the safety and well-being of staff and residents and to promote quality care the facility used appropriate techniques and devices to lift and move residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for one resident (Resident #9), in a review of 12 sampled residents, who the facility identified needed specialized equipment to assist with eating and drinking. The facility census was 73. Review of the facility Assessment and Care Planning policy, Assisting the Nurse in Examining and Assessing the Resident, dated September 2010, showed the following: -The purpose was to assist the nurse in gathering information about the overall condition of the resident and his/her performance of Activities of Daily Living (ADLs); -The assessment process was continuous. It began upon admission and continued until the resident was discharged ; -ADLs included the resident's physical, psychological, social and spiritual activities; [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the state agency timely for one resident (Resident #1), in a review of ten sampled residents when staff reported allegations of sexual abuse by a family member toward the resident to the charge nurse. The facility census was 79. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating (Revised September 2022), showed the following: -All reports of resident abuse are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of sexual abuse reported by a staff member regarding one resident (Resident #1) in a review of ten sampled residents. The facility census was 79. Review of the facility policy, Identifying Types of Abuse (revised September 2022), showed the following: -As part of the abuse prevention strategy, volunteers, employees and contactors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents; -Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating (Revised September 2022), showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents on the facility special care unit, including four residents (Resident #54, #59, #500 and #501), in a review of thirteen sampled residents, from verbal and sexual abuse by one resident (Resident #68). Resident #68 had a history of verbal and physical sexually inappropriate behavior. The resident exhibited inappropriate sexual behavior towards other residents on the unit which included touching or attempts to touch their bodies with his/her hands or mouth in a sexual manner and made sexual comments toward them. Resident #501, a cognitively intact resident, experienced psychosocial distress due to interactions with Resident #68 when the resident made him/her feel sexually harassed and mentally abused. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to identify signs and symptoms of hyperglycemia (an excess of glucose in the bloodstream) on 4/25/23 for one resident, (Resident #32), who had a diagnosis of diabetes, when the resident presented with shaking and excessive thirst. The resident's care plan instructed staff to be alert to signs of high blood sugar and contact the physician as indicated. Facility staff did not check the resident's blood sugar or call the resident's physician to report the noted signs and symptoms. On the morning of 4/26/23, the facility failed to obtain a fasting blood sugar as ordered. On the afternoon of 4/26/23, the facility notified the resident's physician the resident had become lethargic, unresponsive and pale. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The facility failed to ensure all areas of the kitchen were clean and in good repair; failed to ensure staff washed their hands and changed their gloves to prevent the potential for contamination; and failed to ensure staff wore hair nets and beard restraints when in the kitchen and preparing food. The facility census was 76. Review of the facility policy, Sanitation, dated November 2022, showed all kitchen areas are to be kept clean, free from garbage and debris, and protected from rodents and insects. Review of the facility policy, Preventing Food borne Illness - Employee Hygiene and Sanitary Practices, dated November 2022, showed the following: -Employees must wash their hands: -After personal body functions; -After using tobacco, eating or drinking; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility census was 76. Review of the facility policy Nurse Aide In-Service Training, revised August 2022, showed the following: -All personnel are required to participate in regular in-service education; -Annual in-services to ensure the competency of nurse aides are due no less than 12 hours per employment year and should address the special needs of the residents, as determined by the facility assessment. 1. Review of the facility assessment, last reviewed 12/1/22, showed the following: -The assessment must include or address an evaluation of the facility's training program to ensure any training needs are met for all new or existing staff; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment by failing to ensure walls and floors were in good repair. The facility census was 76. Review of the facility policy Homelike Environment revised February 2021 showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Review of the facility policy Maintenance Service revised December 2009 showed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the state agency for four residents (Resident #54, #59, #500 and #501), in a review of 13 sampled residents, when one resident (Resident #68), who had a history of sexually inappropriate behaviors, abused residents sexually by touching or attempting to touch their bodies with his/her hands or mouth in a sexual manner and making sexual comments toward them. The facility census was 73. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating (Revised September 2022), showed the following: -All reports of resident abuse are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate allegations of sexual abuse reported by one resident (Resident #501) and documented by facility staff for three residents (Resident #54, #59 and #500) in a review of 13 sampled residents. The facility census was 73. Review of the facility policy identifying Types of Abuse (revised September 2022), showed the following: -As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents; -Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse; ; -Abuse toward a resident can occur as resident-to-resident abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Residents #68, #54 and #8), in a review of 27 sampled residents. The facility census was 73. Review of the facility's Care Plans, Comprehensive Person-Centered, Revised March 2022, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin as ordered for one resident (Resident #53), check blood glucose levels for two residents (Resident #53 and Resident #67), collect a urine sample per physician order for two residents (Resident #25 and Resident #67), and obtain labs per physician order for three residents (Resident #53, Resident #25, and Resident #67). The facility census was 76. Review of the facility policy, Regarding Physician Orders, dated 8/19/21, showed the following: -It is the responsibility of each charge nurse to assess, document, provide and initiate interventions and to consult with that resident's Primary Care Physician with any/all abnormal findings regarding the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good personal hygiene for four residents (Residents #8, #22, #51, and #33) who required assistance to perform their activities of daily living, in a review of 22 sampled residents. The facility census was 76. Review of the facility policy, Mouth Care, revised February 2018, showed the purpose of this procedure is to keep the resident's lips and oral tissues moist, to clean and freshen the resident's mouth and to prevent oral infection. The policy did not provide direction to staff regarding frequency of mouth care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed facility policy to protect the nebulizer mouthpiece while not in use for one resident (Resident #4), and did not clean equipment by rinsing and air drying the medication cup, mouthpiece and mask of the nebulizer equipment for two residents (Resident #4 and Resident #48), according to the facility policy. The facility also failed to label oxygen and/or nebulizer tubing and the humidification bubbler for oxygen concentrators according to facility policy and physician orders for three residents (Resident #4, Resident #8 and Resident #48) in a review of 27 sampled residents. The facility census was 73. Review of the facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to maintain documentation to show sufficient information was provided to the resident or resident representative so they could provide informed consent for use of the bed rails for eleven residents (Resident #4, #10, #22, #67, #18, #32, #38, #44, #46, #48 and #66), in a review of 22 sampled residents, and for three additional residents (Residents #37, #63 and #226). The facility census was 76. Review of the Food and Drug Administration (FDA) document, Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, dated 12/11/17, showed the potential risk of bed rails may include: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 76. Review of the facility policy Nursing Department Supervision, revised August 2022, the following: -A licensed nurse is on duty twenty-four hours per day, seven days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift. 1. Review of the RN/Licensed Practical Nurse (LPN)/Certified Medication Technician (CMT) schedule dated 10/1/22 through 10/31/22 showed no RN coverage on 10/1/22, 10/2/22, 10/8/22, 10/9/22, 10/15/22, 10/16/22, 10/22/22, 10/23/22, 10/29/22, 10/30/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews. The facility census was 76. Review of the facility policy Nurse Aide In-Service Training, revised August 2022, showed the following: -The facility completes a performance review of nurse aides at least every 12 months; -In-service training is based on the outcome of the annual performance reviews. 1. Record review showed no documentation of nurse aide evaluations/competencies or annual performance reviews. During an interview on 5/2/23 at 7:05 P.M., the Assistant Director of Nursing (ADON) said she had not done any nurse aide evaluations/competencies or annual performance reviews. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure gradual dose reductions (GDRs; the stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discontinued) were attempted, or the physician documented the rationale for not attempting a GDR on antipsychotic medications (medications that affects brain activities associated with mental processes and behavior) for three residents (Residents #25, #33 and #61) in a review of 22 sampled residents. The facility census was 76. 1. Review of Resident #25's physician's orders showed an order forFluoxetinee (antidepressant) 40 milligrams (mg) by mouth daily, start date 5/28/19. Review of the resident's care plan, dated 10/17/22, showed the resident has alteration in his/her thought processes due to periods of confusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and destroy outdated medications, failed to remove and destroy expired stock medications (over-the-counter medications used for more than one resident), and medications belonging to discharged residents. The facility census was 76. 1. Observation in the medication room at the Memory Unit nurses station on 4/26/23 at 2:45 P.M., showed the following: -[NAME] RCI Nebulizer hoses, expiration date 1/24/23, total of seven, No resident name; -Myrbetiq 50 mg (milligrams), expiration date 10/20/23, seven count/one punched, no name and no date punched; -Erythromycin 5mg/gm (milligrams per gram) ointment eye-had been used, expiration date 5/22, labeled for Resident #58; -Assure Dose Solution, expiration date 12/31/19; -T-Drain Sponges, expiration date 2022; -New Sponge, expiration date 2019; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for residents on a pureed diet by not preparing pureed food by the recipe and by not serving the appropriate serving sizes as directed by the spreadsheet menu. The facility census was 73. Review of the facility policy Kitchen Weights and Measures, revised April 2007, showed the following: -Food services staff will be trained in proper use of cooking and serving measurements to maintain portion control; -Cooks and food services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes; -Staff will be trained in the comparison of volume and weight measures (e.g., 2 cups (volume) water 1 pound (weight), 1 ounce (oz) weight, 1 oz. volume, etc.); -Staff will be trained in size conversion of food cans to improve accurate measurements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was palatable and served at an appetizing temperature. The facility census was 76. Review of the facility policy, Food Preparation and Service, dated November 2022, showed the following: -Proper hot and cold temperatures are maintained during food distribution and service; -The temperature of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. 1. During interview on 4/24/23 at 3:25 P.M., Resident #2 said the food is terrible. During interview on 4/25/23 at 10:03 A.M., Resident #18 said the following: -His/her biscuits and gravy were cold; -The gravy was too greasy; -His/her fried eggs were cold and hard. 2. Review of the menu for the supper meal on 4/25/23 showed staff were to serve mushroom ravioli and roasted zucchini. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for one resident (Resident #33), in a review of 22 sampled residents, and also failed to ensure infection control measures were appropriately followed when staff failed to utilize protective barriers and properly sanitize the glucometer (a device used to evaluate blood glucose levels) in between use and after becoming soiled for four residents (Residents #7, #33, #401 and #59). Additionally, the facility failed to ensure proper infection control was utilized for respiratory care supplies for one resident (Resident #68). The facility census was 76. Review of the undated facility policy, Handwashing and Hand Antisepsis Guidelines, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when staff failed to report roaches when first identified in the kitchen which delayed treatment, and failed to ensure effective measures were implemented to ensure the potential source was eliminated. The facility census was 76. Review of the facility's policy, Pest Control, dated May 2008, showed the following: -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; -Garbage and trash are not permitted to accumulate and are removed from the facility daily; -Maintenance services assist, when appropriate and necessary, in providing pest control services. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's representative (Resident #67) in a review of 22 sampled residents, when the resident had falls. The facility census was 76. Review of the facility policy Change in a Resident's Condition or Status revised February 2021 showed the facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. Review of Resident #67's care plan dated 11/23/22 showed the resident is at risk for falls. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/5/23 showed the following: -Severely impaired cognition; -No falls since prior assessment. Review of the resident's progress notes dated 4/11/23 at 8:58 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently evaluate, implement and modify interventions, in accordance with current standards of practice and as necessary to reduce the risk of falls for two residents (Residents #44 and #67) in a review of 22 sampled residents. The facility census was 76. Review of the facility policy, Falls and Fall Risk, Managing revised March 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper care to a urinary catheter (a tube inserted into the bladder) for one resident (Resident #25), who had a history of urinary tract infections (UTIs) in a review of 22 sampled residents. The facility census was 76. Review of the facility policy Catheter Care, revised 9/30/2019, showed the following: -Make sure that the catheter bag and tubing is not touching the floor to help prevent the risk of infection; -The catheter bag or tubing should never be above the bladder (approximately waist height) to help prevent backflow of urine to decrease the risk of infection. 1. Review of Resident #25's care plan, dated 10/17/22, showed the resident needed extensive assistance with bathing and toileting. He/She is unable to clean him/herself after toileting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician response regarding pharmacist recommendations for two residents (Resident #33 and Resident #67), in a review of 22 sampled residents. The facility census was 76. Review of the facility policy Pharmacy Services-Role of the Consultant Pharmacist, revised 4/2019, showed the consultant pharmacist will provide specific activities related to medication regimen. These included appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medication and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer insulin pens according to manufacturers' recommendations to ensure staff administered the prescribed insulin dose for one resident (Resident #33) in a review of 22 sampled residents and one additional resident (Resident #7). The facility census was 76. Review of the facility policy Administering Medication, revised April 2019, showed the following: -Medications are administered in a safe and timely manner as prescribed; -The facility policy did not provide specific directions regarding the use of insulin pens. Review of the Levemir Injection Flexpen package instructions for use, dated 12/2022, showed the following: -Before every injection a small amount of air may collect in the cartridge during normal use. To avoid injection air and to ensure proper dosing: -Turn the dose selector to select 2 units; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 76. Review of the facility policy Posting Direct Care Daily Staffing Numbers, revised August 2022, showed the following: -The facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to notify the physician and re-evaluate interventions when a resident's wound deteriorated, stage a wound according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, or use air mattresses according to manufacturer's instructions to prevent development or worsening of pressure ulcers for one resident (Resident #6) in a review of two sampled residents with pressure ulcers, resulting in deterioration of the wound from a suspected deep tissue injury (pressure injury with of persistent non-blanchable deep red, maroon, purple discoloration, skin can be intact or non-intact) to a Stage IV wound (full-thickness loss of skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The facility census was 97. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for two residents (Resident #55 and #96), and failed to properly use a gait belt and safely transfer one resident (Resident #96), in a review of 20 sampled residents. The facility census was 99. 1. Record review of the facility's Falls Management Program Policy, dated as revised 7/20/09, showed the following: -A Fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment clean and free of debris, and failed to store and handle foods in a sanitary and safe manner. The facility census was 99. 1. Review of the facility's Fresh Ideas Culinary Hospitality Program, undated, showed the following: -The first step in preventing food borne disease is good personal hygiene; -Keep hair neat and clean. Always wear a hair net or hat; -Keep shelves and interiors of the coolers clean. 2. Observation on 9/9/19 at 10:10 A.M. during the initial kitchen inspection showed the following: -The reach-in refrigerator, labeled number six, had a large area of reddish, pink, substance dried on the floor and on the inside of the door; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice and physician orders for two residents (Residents #59 and #81), in a review of 20 sampled residents, and for one additional resident (Residents #67) when staff did not follow physician orders, did not check for residual or placement of the resident's gastrostomy tube (G-tube; a tube inserted into the stomach that brings nutrition/medications directly into the stomach) before administering medications, did not administer the g-tube medications or fluids correctly and failed to obtain an apical (a pulse taken at the area of the apex of the heart at the point of maximum impulse) pulse prior to administering Digoxin (a medication used to treat heart failure and heart rhythm problems). The facility census was 99. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were trained and available to provide Cardiopulmonary Resuscitation (CPR) (the manual application of chest compressions and ventilations to persons in cardiac arrest, done in an effort to maintain viability until advanced help arrives) when transporting residents who requested to be full code, in the facility van. Five residents (Resident #27, #30, #16, #148, and #65) in a review of 20 sampled residents and five additional residents (Resident #21, #37, #58, #68, and #10) , who were a full code, were transported multiple times by a facility transporter who was not certified to perform CPR. The facility census was 99. 1. Review of the list of resident code status provided by the Director of Nursing (DON) dated [DATE] showed Residents #27, #30, #16, #148, #65, #21, #37, #58, #68 and #10 were full code. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided four of 20 sampled residents (Resident #59 #71, #80 and #81) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 99. 1. Review of the facility policy, titled Activities Of Daily Living Care, revised 9/2015 showed: -Purpose: To provide all residents of this facility with acceptable and dignified personal hygiene on a routine basis; -All residents will receive the necessary care and services to maintain good personal hygiene to prevent body odor; -All residents will receive a partial bath daily when not given a shower; -All residents will be given or assisted with adequate oral hygiene at least once daily and PRN; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident's medication regimens were free from unnecessary medications when the facility failed to show adequate indications for use of an antipsychotic medication (a class of medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia and bipolar disorder) use, failed to have a system to monitor the residents to ensure gradual dose reductions (GDR) were made in an effort to reduce or discontinue the medications and failed to ensure that orders for as needed (PRN) psychotropic medications were limited to 14 days as required except when an attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared food items according to the recipe to conserve nutritive value, flavor and appearance. The facility census was 99. 1. Review of the facility's Fresh Ideas Culinary Hospitality Program, undated, showed the following: -To properly prepare a recipe, certain steps must be followed; -Read the recipe from start to finish and make any notes you may have for your supervisor; -Taste the food you are cooking during different stages throughout the process. Even though a recipe lists salt and pepper in quantities, it is important that judgement be your guide. 2. During group interview on 9/11/19 at 10:05 A.M., showed the following: -Resident #51 said most of the food served was barely warm. -Resident #56 said the food looks bad; -Resident #93 said the food spreads all over the plate; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that nursing staff washed their hands after each direct resident contact and when indicated by professional practices during personal care, failed to ensure staff did not touch medications during medication administration and failed to ensure staff followed facility policy and procedure during tracheostomy care for three residents (Resident #71, #59, and #81) in a review of 20 sampled residents and one additional resident (Resident #67). The facility census was 99. 1. Review of the facility policy titled, Handwashing and Hand Antisepsis Guidelines, dated 12/2002, showed: -When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non- antimicrobial soap and water or an antimicrobial soap and water. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity for two residents (Residents #81, and Resident # 299), in a review of 20 sampled residents. The facility had four residents with urinary catheters. Facility staff failed to cover the residents' urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bags with a dignity/privacy bag. The facility census was 99. 1. Review of the facility provided Resident Rights, undated, showed the following: -As a resident of the facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights; -The facility will treat you with dignity and respect in full recognition of your individuality. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #96), in a review of twenty sampled residents, remained free from abuse when Licensed Practical Nurse (LPN) A said he/she would duct tape the resident to the bed, would drill the resident if he/she hit him/her, and would get a shot to knock the resident out. The facility's census was 99. 1. Review of the facility's Resident Rights, undated, showed residents have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment and involuntary seclusion. Review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of verbal abuse for one resident (Resident #96) in a review of 20 sampled residents. The facility census was 99. 1. Review of the facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy, undated, showed the following: -It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinence care with a urinary catheter (a sterile tube inserted into the bladder to drain urine) consistent with acceptable standards of practice, failed to maintain the catheter bag below the level of the bladder, and failed to keep catheter tubing and drainage bag off the floor for two residents (Resident #30 and #81) in a review of 20 sampled residents. The facility census was 99. 1. Review of the undated facility policy titled, Catheter Care, showed: -Purpose: to prevent infection and to keep the resident comfortable and clean; -Catheter bag should be placed on side of bed opposite the direction that resident is turned; -The policy did not address any infection prevention. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess pain, provide PRN (as needed) pain medication, and intervene when the resident exhibited crying out during cares for one resident (Resident #71) in a review of 20 sampled residents. The facility census was 99. 1. Review of the facility policy Pain Management revised 11/2009 showed the following: Procedure: 1. Pain will be assessed on a regular basis with the goal of assessment to determine the cause of pain and develop an appropriate individualized treatment plan; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a policy and procedure, based on current standards of practice, to address the care of residents receiving dialysis services. The facility failed to monitor the dialysis access sites for one resident (Resident #80), in a review of 20 sampled residents, and for one additional resident (Resident #76) according to standards of practice. The facility identified two residents received dialysis services. The facility census was 99. 1. Review of Nursing Management: The Journal of Excellence in Nursing Leadership, October 2010, Volume 41, Issue 10, Caring for a Patient's Vascular Access for Hemodialysis showed the following: -A patient in end-stage kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and served food items according to the dietary spreadsheet menu for residents on physician-ordered gluten free and renal diets. The facility census was 99. 1. Review of Resident #148's physician order sheet for September 2019 showed an order for a gluten free diet. Review of the menu for gluten free diets for the evening meal on 9/9/19 showed the following: -Open faced roast beef sandwich (gluten free); -Homemade mashed potatoes; -Corn; -Cookies (gluten free) Observation on 9/9/19 at 5:52 P.M. showed staff only served the resident mashed potatoes and corn. During an interview on 9/9/19 at 6:15 P.M., the resident said he/she only received corn and mashed potatoes for his/her meal. It would have been nice to have something else and he/she would have eaten it if it was served. [...]