Bickford Health Care Center

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #6) reviewed for ADLs, the facility failed to ensure the record directed staff how to transfer the resident, and failed to ensure an assessment was completed timely for a change in transfer ability.

Inspectors wroteBased on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #4) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care, and for one of five residents (Resident #7) reviewed for accidents, the facility failed to ensure an alarm was in use in accordance with physician orders and the plan of care.

Inspectors wroteBased on clinical record review, facility policy review, and interviews for two of two residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include the name of the individual documenting in the electronic medical record, in accordance with facility policy.

Inspectors wroteBased on facility documentation, facility policies and interviews, the facility failed to ensure the provision and oversight of a Medical Director in accordance with federal requirements.

Inspectors wroteBased on facility documentation review, and interviews for facility review of QAPI, the facility failed to ensure quarterly Medical Staff meetings were held.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #4) reviewed for wandering, the facility failed to ensure the assessment accurately reflected the resident's status for behaviors and wander/elopement alarm at the time of the assessment.

Inspectors wroteBased on clinical record review, facility documentation, facility policies, and staff interviews, for two of five residents (Resident #1 and #2), reviewed for wandering behaviors, the facility failed to ensure elopement risk assessments were completed timely and a physician order for wander guard use was obtained timely for Resident #1, failed to replace Resident #2's wander guard device timely, and failed to ensure implementation of every 15-minute safety checks for Resident #2 after the resident's wander guard device malfunctioned and was not replaced on 2/27/2026.

Inspectors wroteBased on observations and interviews for facility egress review, the facility failed to ensure staff knew how to silence door alarms, failed to responded to door alarms timely, and failed to ensure exit doors were secured to prevent unauthorized exit.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for five of five residents (Resident #1, #2, #3, #4, and #5), the facility failed to ensure a complete and accurate record to include wander guard devices for function and placement.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure the resident was free from neglect when the facility failed to notify the local police department within 15-minutes when a resident was identified missing from the facility in accordance with facility policy, and failed to notify emergency services timely when a resident was found unresponsive outside the building in below freezing temperatures. The failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1), the facility failed to adequately supervise a resident with a diagnosis of dementia and was identified wander risk who ambulated independently. Resident #1 was able to exit the facility without staff knowledge in subfreezing temperatures. The failure resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #1 and #5) reviewed for wandering behaviors, the facility failed to ensure the physician was notified timely following Resident #1's significant change in condition and failed to ensure the physician was notified timely when laboratory results were received (Resident #5).

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy review, and interviews for one of four residents (Resident #1 and #3) reviewed for wandering behaviors, the facility failed to ensure physician orders were obtained that directed to check the wander guards function, and failed to ensure an elopement risk assessment was completed timely.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for laboratory services to ensure required laboratory services are available timely to meet resident needs.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for radiology and other diagnostic services to ensure required diagnostic services were available timely to meet resident needs.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of physician coverage available 24-hours per day for emergency care.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of a written agreement designating a Medical Director responsible for implementation of resident care policies and coordination of medical care in the facility.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy review and interviews for three of four residents (Resident #1, #2, and #3) reviewed for wandering behaviors, the facility failed to ensure the clinical record was complete and accurate to include rounds performed for resident location (Resident #1's care checks) and to accurately document the resident's (#1, #2, and #3) wander guard devices.

Inspectors wroteBased on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital.

Inspectors wroteBased on observation, clinical record review, facility policy review and interviews, the facility failed to ensure residents at high risk for pressure ulcer development were promptly assessed and provided timely preventative interventions. Specifically, for one sampled resident (Resident #7), the facility failed to implement turning and repositioning, and other preventive measures despite known risk factors and an existing pressure injury and failed to develop and implement a care plan to prevent pressure ulcers. These failures resulted in the development of a new pressure injury to the coccyx that progressed to an unstageable wound and ultimately to a Stage 4 pressure ulcer, causing actual harm. Resident #7 was admitted on [DATE] with diagnoses that included dementia, nutritional deficiency, stage 4 pressure ulcer wound, and osteoarthritis. [...]

Inspectors wroteBased on review of facility documentation, review of facility policy, and interviews, reviewed for infection surveillance and water management, the facility failed to ensure that the infection control surveillance data collected monthly was analyzed for trends and was included into the quarterly infection control report, and the facility failed to provide documentation that the water management plan was implemented to identify an established flushing program logs of low flow areas, eyewash station protocol, and annual water management committee meetings were held.

Inspectors wroteBased on observations, review of the clinical record, review of facility documentation, review of facility policy and procedures and interviews for the facility and one resident (Resident #24) investigated for environment, the facility failed to ensure resident rooms were kept at comfortable and safe temperature levels between the regulatory recommended temperatures of 71 degrees to 81 degrees.

Inspectors wroteBased on review of clinical records, review of facility documentation, review of facility policy/procedures, and interviews for 3 of 5 sampled residents (Resident #11, Resident #39, and Resident #42) reviewed for (PASRR), the facility failed to ensure the recommendations from a level II PASRR determination were included in the resident's care plan.

Inspectors wroteBased on review of the clinical records, review of facility documentation review of facility policy and interviews for one sampled resident (Resident #48) reviewed for death, the facility failed to ensure resident's care plan was revised to reflect hospice services and recommendations, and for one of five residents (Resident #3) reviewed for (PASRR), the facility failed to ensure the recommendations from a level II PASRR determination were included in the resident's care plan and for one sampled resident (Resident #38) reviewed for Hospice services, the facility failed to ensure the care plan was reviewed and revised to include the Hospice recommendations.

Inspectors wroteNumber of residents sampled:Number of residents cited:Resident #2's diagnoses included dementia, muscle weakness, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, required maximal assistance with toileting hygiene, lower body dressing, personal hygiene, transfers, and bed mobility. The assessment further identified the resident was non-ambulatory, did not exhibit behaviors, utilized a wheelchair, and had skin tears. The care plan dated 10/21/25 identified Resident #2 was at risk for skin tears and bruising related to fragile skin, history of skin tears and history of bumping arms with interventions that included, check skin weekly and provide daily moisturizing lotion to extremities. [...]

Inspectors wroteBased on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure it had an established system of audit and reconciliation for controlled substances.

Inspectors wroteBased on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure expired medications were removed from active circulation and failed to ensure medications were stored according to manufacturer guidelines and failed to ensure controlled substances were monitored correctly and had corresponding administration sign off sheets.

Inspectors wroteBased clinical record reviews, review of facility documentation, review of facility policy and interview for 3 of 5 residents (Resident #20, Resident #39, and Resident #41) reviewed for immunizations, the facility to ensure that the COVID-19 booster vaccine was offered and administered when requested by residents.

Inspectors wroteBased on review of facility documentation, review of facility policy and procedure and interviews for the social worker (designee), the facility failed to ensure the employee was appropriately screened prior to employment.

Inspectors wroteBased on clinical record review, review of facility policy documentation, review of facility policy and procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to report the allegation of neglect to the State Survey Agency.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy and procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to initiate an investigation of the alleged neglect.

Inspectors wroteBased on clinical record review and interviews for one of two sampled residents (Resident #7) reviewed for facility acquired pressure ulcers, the facility failed to develop a baseline care plan to prevent pressure ulcer/injury on admission.

Inspectors wroteBased on clinical record review, facility documentation, facility policy review, and interviews for one of two sampled residents (Resident #7) reviewed for facility acquired pressure ulcers, the facility failed to ensure the registered nurse assessed a newly admitted resident in accordance with facility practice.

Inspectors wroteBased on observation, review of clinical records, review of facility documentation, review of facility policy and procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to ensure the resident received incontinent care as outlined in the care plan in a timely manner.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one sample resident (Resident #39) reviewed for podiatry services, the facility failed to ensure podiatry consultation visit was reviewed and the recommendation of treatment by the podiatrist was followed through.

Inspectors wroteBased on clinical record review, review of facility policy, and interviews for one of two sampled residents (Resident #5) reviewed for accidents, the facility failed to provide adequate supervision to prevent the resident from smoking in the courtyard, failed to develop a comprehensive smoking policy and procedures, failed to develop a systems to ensure resident/family aware of the facility's non-smoking status.

Inspectors wroteBased on review of the clinical records, review of facility documentation and interviews for one sampled resident (Resident #16), reviewed for an allegation of neglect, the facility failed to ensure adequate staffing to meet the needs of the residents.

Inspectors wroteBased on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #38) reviewed for Hospice services, the facility failed to ensure Resident #38's medical record was complete and readily accessible and for one sample resident (Resident #39) reviewed for podiatry visits, the facility failed to ensure the podiatry consultations were included in the resident's medical record.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for the one sampled resident (Resident #38) reviewed for Hospice services the facility failed to identify and ensure the communication process between the facility and the hospice provider was established, failed to identify the designated facility staff responsible for the coordination of care, failed to ensure the hospice care plan was in place, and failed to ensure other pertinent documentation related to hospice care was in place, and failed to ensure hospice staff was oriented to the facility 's policies and procedures.

Inspectors wroteBased on review of clinical records, review of facility documentation, and interviews for one sampled resident (Resident #6) reviewed for discharge, the facility failed to ensure that the Ombudsman's office was provided with the required notification of the transfer.

Inspectors wroteBased on review of clinical record, review of facility documentation, and interviews for one sampled resident (Resident #48) review for death, the facility failed to ensure the Significant Change in Status Assessment (SCSA) was completed for a resident who was admitted to hospice care.

Inspectors wroteBased on review of the clinical records, facility policy/procedures and interviews for 3 of 5 sampled residents (Resident #3, Resident #11 and Resident #39) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the comprehensive assessments were accurately coded for residents with a positive Level II PASRR screening.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of five sampled residents (Resident #4) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the level 1 PASRR screening was accurately completed to determine whether level II PASRR screening needed to be completed.

Inspectors wroteBased on review of facility documentation, facility policy/procedure, and interviews for 1 of 4 nurse aides (NA #7), the facility failed to ensure performance evaluations were completed 90 days after hire and every year thereafter according to the facility's policy.

Inspectors wroteBased on review of facility documentation and interviews for 1 of 4 nurse aides (NA #7), reviewed for required yearly in servicing, the facility failed to provide evidence of the required 12 hours of nurse aide training provided per year that included abuse.

Inspectors wroteBased on observations, interviews, facility documentation, and policy review, the facility failed to ensure safe water temperatures to areas occupied and accessible by residents on resident care units creating a hazard which could have resulted in a burn injury.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to report a deterioration in wound status to the physician, ensure wound care was completed in accordance with physicians orders, and ensure an air mattress was provided timely which resulted in a deterioration of a pressure ulcer.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to notify the practioner timely of deterioration to a pressure ulcer.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure that a pressure ulcer was treated in accordance with physician's orders.

Inspectors wroteBased on clinical record review, facility documentation and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to complete monthly maintenance checks to ensure resident's bedframes were free from sharp/jagged edges in accordance with manufacturer's recommendations resulting in a laceration to the leg requiring (8) eight sutures.

Inspectors wroteBased on clinical record review, observations, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents (Resident #7) reviewed for activities of daily living, the facility failed to follow care plan as directed.

Inspectors wroteBased on clinical record review, facility documentation review, and interviews for three (3) of five (5) residents (Resident #1, #2, #5), reviewed for medication administration, the facility failed to ensure the clinical record was complete and accurate to include documentation of medication administration and blood sugar monitoring.

Inspectors wroteBased on observations, review of facility documentation and interviews the facility failed to ensure a staff member applied hair/beard net while in the kitchen, consistently logged dishwasher temps daily, document what was done when dishwasher temperatures were not within range, and consistently document food temperatures for all meals daily per facility practice.

Inspectors wroteBased on a review of the facility grievance file, observations, facility documentation, facility policy and interviews, the facility failed to inform residents of how to file a grievance and failed to ensure the required information related to contact information for filing a grievance with government officials were posted in the facility. The facility also failed to maintain the results of all grievances for at least 3 years.

Inspectors wroteBased on clinical record reviews, facility documentation, review of policy and staff interviews for 2 of 6 residents reviewed for abuse (Resident #26 and Resident # 44), the facility failed to ensure the residents were protected after an allegation of suspected verbal abuse to prevent further potential abuse and were free from physical abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 2 of 6 sampled residents (Residents #18 and # 26) who were reviewed for abuse, the facility failed to implement facility policies following an alleged incident of resident-to-resident physical and verbal mistreatment.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 3 of 6 sampled residents (Residents #18, # 40 and # 44) reviewed for abuse, the facility failed to report an allegation of staff to resident physical mistreatment and or initiate an investigation timely.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 3 of 6 sampled residents (Resident #18 and Resident # 40) reviewed for abuse, the facility failed to ensure the protection of resident(s) following an allegation of resident-to-resident physical mistreatment.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 4 of 6 sampled residents (Residents # 5, # 26, # 27 and # 34) who were reviewed for pressure ulcers, the facility failed to ensure a comprehensive care plan was developed to address the residents at risk for skin break down, prevention of pressure ulcer development and incontinence.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 2 of 6 residents ( Resident # 15 and Resident # 40) at risk for pressure ulcer development, the facility failed to revise the residents plan of care timely.

Inspectors wroteBased on clinical record reviews, review of facility policy and staff interviews for 5 of 10 residents ( Residents #1,# 15, #18, # 23 #26 and #34) reviewed for unnecessary medications and 5 of 5 residents (Resident # #3, #10, #12, #18, #23 and #33) observed during medication pass, the facility failed to ensure a reason or the rationale for the use of the routine and when needed medications were noted in the physician's orders to meet professional standards.

Inspectors wroteBased on clinical record reviews, facility documentation, review of policy and staff interviews for 4 of 6 residents reviewed for pressure ulcers (Residents #5 # 26 # 34 and # 40), the facility failed to initiate interventions to prevent the development of a pressure ulcer for a resident at risk for developing pressure injuries and who later developed a pressure ulcer and the facility failed to ensure a healed pressure did not reopen.

Inspectors wroteBased on review on clinical record reviews, facility documentation, facility policy and interviews for 3 of 4 Residents (Residents # 22, # 27 and #34) reviewed for nutrition, the facility failed to follow their policy for weight loss.

Inspectors wroteBased on staff interviews and review of Payroll Based Journal (PBJ) submissions for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023, the facility failed to to ensure the required number of Registered Nurse hours .

Inspectors wroteBased on staff interviews and review of Payroll Based Journal (PBJ) submissions for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023, the facility failed to ensure that PBJ data was complete and accurate.

Inspectors wroteBased on observations, Review of Resident Council Meetings, facility documentation, and interviews, the facility failed to follow up on resident concerns in Resident Council Meetings timely.

Inspectors wroteBased on clinical record, review of facility policy and interviews for 1 of 1 resident (Resident # 39), the facility failed to ensure the resident's Advanced Directive was reviewed with the responsible party timely.

Inspectors wroteBased on review of the clinical record, review of facility documentation and interviews for 1 of 2 residents (Resident #44) reviewed for hospitalization, the facility failed provide notification of transfer/discharge to the Regional Ombudsman's Office timely.

Inspectors wroteBased on review of the clinical record, review of policy and interviews for 1 of 2 residents (Resident #44) reviewed for hospitalization, the facility failed to provide evidence that the resident and or responsibly party was made aware of the facility bed hold notice upon hospitalization.

Inspectors wroteBased on review of the clinical record, and interview for 2 of 3 residents (Resident #1 and Resident #35) reviewed for Resident Assessments, the facility failed to complete and transmit the annual Minimum Data Set (MDS) assessments timely.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #26) who were reviewed for unnecessary medications, the facility failed to review or discontinue the use of a PRN (as needed) psychotropic medication.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for the 1 of 1 sampled resident (Resident #45) reviewed for death, the facility failed to ensure the resident's death certificate was in the clinical record.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #4, 8, and 230), the facility failed to ensure the physician's orders were reviewed and signed according to established timeframes.

Inspectors wroteBased on observations, review of the clinical records, facility policies, facility documentation and interviews, the facility lacked effective administration to maintain the highest practicable physical, mental and psychosocial well-being of the residents.

Inspectors wroteBased on review of facility documentation and interviews, the facility failed to demonstrate an active (engaged and involved) governing body responsible for establishing and implementing policies regarding the management of the facility.

Inspectors wroteBased on review of the clinical records, facility documentation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Inspectors wroteBased on review of the clinical records, facility documentation, and interviews, the facility failed to ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. A review of the facility infection control program identified no tracking of antibiotic use or evidence of practice utilizing the principles of antibiotic stewardship that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and implement a facility-wide system to monitor the use of antibiotics. A review of Quarterly Nursing Department quality assurance performance standards (QAPI) Medical Staff Review dated 4/2021 through 9/2021 did not include any tracking of antibiotic and outcomes. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, and interview for 1 resident (Resident #230) reviewed for notification of change, the facility failed to ensure the physician and POA were notified timely with a change in condition from hospice services.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interview, the facility failed to ensure the resident rooms were homelike.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 9 residents (Residents #4, 230, 2, 3, 6, 7, 9, 19, and 27) reviewed resident assessment, the facility failed to complete quarterly MDS assessments according to established timeframes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 9 residents (Residents #4, 230, 2, 3, 6, 7, 9, 19, and 27) reviewed resident assessment, the facility failed to transmit MDS assessments according to established timeframes.

Inspectors wroteBased on review of facility documentation and staff interviews the facility failed to ensure sufficient staffing on 12/22/21 which resulted in the DNS having to work 3 consecutive shifts.

Inspectors wroteBased on review of facility documentation and staff interviews, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for the residents', and failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents'.

Inspectors wroteBased on review of facility documentation, facility policy and staff interviews, the facility failed to ensure nurse aide competencies were completed per established guidelines.

Inspectors wroteBased on review of facility documentation, facility policy and staff interviews, the facility failed to ensure nurse aide performance reviews at least once every 12 months per established guidelines.

Inspectors wroteBased on observation, review of facility policy and interviews the facility failed to ensure the safe storage of a prescribed medication.

Inspectors wroteBased on review of facility documentation and interview the facility failed to ensure a facility assessment was completed and updated per established requirements.

Inspectors wroteBased on review of the clinical records, facility documentation and interviews for 3 of 5 residents (Resident #8, 14 and 114) reviewed for immunizations, the facility failed to maintain documentation of education for pneumococcal vaccines regarding the benefits and potential side effects of the immunization to the resident/ resident representative, failed to maintain a measured means of monitoring the status of the pneumococcal immunization for residents who received the vaccination in the past, the type of vaccination received (23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent pneumococcal conjugate vaccine (PCV13) or those that may have refused. Additionally, for Resident #124, the facility failed to identify the residents pneumococcal vaccination status and offer education upon admission.

Inspectors wroteBased on review of the clinical record, facility documentation and interviews for 1 resident (Resident #15) reviewed for infection control, the facility failed to ensure written notification was provided to the responsible party following a newly identified resident case of Covid 19.

Inspectors wroteBased on review of the clinical records, facility documentation and interviews, the facility failed to ensure Covid testing was completed, according to established requirements, to include testing of 'exempt staff, ' conducted at least weekly or more based on community spread, on a consistent basis and following a newly identified resident case of Covid.

Inspectors wroteBased on review of the clinical records, facility documentation and interviews, the facility failed to ensure Covid vaccines were offered and administered to staff as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 Residents (Resident #13) reviewed for abuse, the facility failed to ensure the state agency was notified of a large bruise of unknown origin.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #13) reviewed for abuse, the facility failed to conduct a thorough investigation into an injury of unknown origin.

Inspectors wroteBased on review of the clinical record, facility policy, and staff interviews for 1 of 2 residents (Resident #30) reviewed for closed records, the facility failed to maintain discharge documentation including a discharge summary and plan of care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #4, 8, 13 and 230), the facility failed to develop a comprehensive care plan according to established timeframes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 residents (Resident #13) reviewed for Quality of Care, the facility failed to ensure a RN assessment when the resident had a change of condition.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #13), the facility failed to ensure the annual history and physical was completed timely.

Inspectors wroteBased on observation and interview the facility failed to discard foods or products on or before expiration date and label food items stored on shelves and in refrigerator.

Inspectors wroteBased on observation, review of clinical records, review of facility documentation, and interviews, the facility failed to ensure that the Quality Assurance (QA) Committee identified, discussed deficient practices and/or developed and implemented plans of action to correct the identified deficiencies.