Birch Creek Post Acute & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to provide the choice of routine personal hair hygiene services, free simple haircuts and trims by a facility employee or a professional haircut by a licensed barber or beautician at a cost for 7 of 8 residents (Resident 2, 3, 4, 5, 6, 7 & 8) reviewed for services covered under Medicaid. Failure of the facility to ensure charges were not imposed against personal funds without documenting the residents' choice, including if the residents knew they had the right to simple haircuts and trims included in their room and board costs, and that they chose to have and pay for a professional service, violated residents' rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to attain or maintain the highest practicable physical, self-care and independence in accordance with their comprehensive assessment and plan of care for 1 of 3 residents (Resident 1) reviewed for quality of care Failure of the facility placed the resident at risk of decreased ability to return to prior level of assistance, decrease level of mobility, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers, limited out-of-bed activity and muscle atrophy.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for transportation was provided supervision for a medical appointment. Failure to provide an escort placed the resident at risk of missing their appointment, getting lost, falling or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed of a long-term medication being discontinued for 1 of 3 sampled residents (Resident 1). This failure disallowed the resident and/or the resident representative to exercise their rights and provide the facility with provider contacts and/or documentation to support continuing the medication.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision, identify fall trends and implement progressive resident centered interventions for 1 of 3 residents (Resident 6) reviewed for falls. Resident 6, who had 5 falls since [DATE] and a decline in their strength/condition, experienced harm when they fell and broke their ankle that required transfer to the emergency department for evaluation and treatment. This failure placed residents at risk of repeated falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for urinary catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for complications associated with indwelling urinary catheters. Failure of the facility to coordinate with urology and monitor for urinary retention following catheter removal, resulted in harm to Resident 1 when they experienced prolonged pain and discomfort as evidenced by crying out and a change in level of consciousness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care. The facility failed to ensure the nursing staff (Staff H, Licensed Practical Nurse (LPN), Staff I, Registered Nurse (RN) & Staff G, LPN) administered medications according to professional standards of practice for 10 of 10 residents (Residents 7, 9, 8, 3, 16, 15, 11, 13, 14, & 1) reviewed for medication administration. This failure placed facility residents at risk of medication errors and poor outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menus according to Resident Council Minutes for 4 of 6 months (October, November, January, and February 2026) and 1 of 1 kitchen observation (03/22/2026) when reviewed for kitchen. This failure placed residents at risk of inadequate nutritional intake, avoidable weight loss, a decline in clinical condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food storage and/or preparation for 2 of 2 kitchen observations (Initial and Second) and failed to ensure resident foods were sanitarily stored for 2 of 2 resident refrigerators (North and South) when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse side effects and behaviors for 3 of 5 sampled residents (Residents 26, 89, and 88) when reviewed for unnecessary medications. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a thorough investigation to rule out abuse/neglect was conducted after resident accidents for 2 of 4 sampled residents (Residents 5 and 32) when reviewed for abuse/neglect. This failure placed residents at risk of continued abuse, continued neglect, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to screen residents for additional mental health supports on admission and/or after a change in mental health diagnoses for 7 of 8 sampled residents (Residents 32, 13, 2, 11, 88, 89, and 9) when reviewed for Pre-admission Screening and Resident Review (PASSAR, a mental health screening tool). This failure placed residents at risk of not having needed mental health supports, increased adverse behaviors, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 4 of 21 sampled residents (Residents 1, 9, 10, and 26) when reviewed for comprehensive care plans. Failure to develop care plans that accurately reflected resident care needs related to oxygen therapy, wound/skin impairment, use of an indwelling catheter (a thin flexible tube that is inserted through the urethra/tube like structure into the bladder to continuously drain urine), and antidepressant medication use placed residents at risk of unmet care needs and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 1, 9, and 67) reviewed for respiratory care. Failure to obtain and/or follow provider orders for oxygen (O2) therapy, ensure O2 tubing was appropriately maintained, regularly changed and dated, and O2 concentrator (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for avoidable respiratory disease, unmet needs, and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to periodically review and provide assistance with advanced directives (legal documents that appoints a trusted person to make healthcare decisions on your behalf if you become unable to communicate or incapacitated) for 2 of 3 sampled residents (Residents 5 and 4) when reviewed for advanced directives. This failure placed residents at risk of not having a healthcare decisionmaker, inability to control care received when incapacitated, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) were provided timely and/or completed as required for 2 of 3 sampled residents (Residents 18 and 54) when reviewed for Beneficiary Notification. Failure to provide SNF ABN notification at least two calendar days before the Medicare coverage ended placed the residents and/or the residents' representative at risk of not having adequate information to make financial decisions related to a continued stay in the facility.

Inspectors wroteBased on observation and interview, the facility failed to make needed repairs to maintain a homelike environment for 1 of 4 halls (200 hall) when reviewed for environment. This failure placed residents at risk of decreased mood and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 3 of 21 sampled residents (Residents 9, 6, and 40) when reviewed for accuracy of assessments. Failure to accurately reflect Resident 9's skin/wound status, Resident 6's mental health screening status, and Resident 40's medication use status placed the residents at risk for unmet care, inaccurate medical record data, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care conferences occurred timely for 1 of 3 sampled residents (Resident 32) when reviewed to care conferences and accurately reflected a resident's eating status for 1 of 3 sampled residents (Resident 87) when reviewed for tube feeding. This failure placed the residents at risk of not providing input into the plan of care, impaired nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services that met professional standards of practice for 2 of 22 sampled residents (Residents 2 and 26) when reviewed quality of care. Failure to provide wound care for Resident 2 and failure to follow provider orders for parameters when administering blood pressure medications for Resident 26 placed the residents at risk for complications, poor clinical outcomes, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment conductive to healing of a pressure ulcer and failed to have documentation describing the progress of the pressure ulcer for 1 of 3 sampled residents (Resident 111) when reviewed for pressure ulcer. This failure placed residents at risk for worsening pressure ulcers and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from continued accident risk when it failed to thoroughly investigate an accident for 1 of 4 sampled residents (Resident 5) when reviewed for accident hazards. This failure placed the resident at risk of continued risk of accident, avoidable injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fluid restrictions (limits the amount of fluids a person can consume through food/drink) for 1 of 1 sampled resident (Resident 26) when reviewed for nutrition. This failure placed the resident at risk for fluid overload, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with providers orders and professional standards of practice for 1 of 3 sampled residents (Resident 87) when reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food product) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management that was consistent with professional standards for 2 of 3 sampled residents (Residents 2 and 26) when reviewed for pain management. Failure to assess and monitor Resident 2's pain and provide nonpharmacological interventions for Resident 26 placed the residents at risk for uncontrolled pain and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promptly provide denture care when requested for 1 of 3 sampled residents (Resident 13) when reviewed for dental. This failure placed residents at risk for unmet dental needs, inability to eat, avoidable weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 (Resident 1 & 2) residents who experienced dementia-related behaviors received care and services to mitigate adverse behaviors. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered care plan prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their abuse prohibition policy for 1 of 3 residents (Resident 5) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 5's injury of unknown origin. The failure to initiate incident reports, conduct a thorough investigation to identify root cause(s) and all contributing factors placed the residents at risk for unidentified abuse or neglect, unidentified corrective actions, risk for injury, and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate monitoring and supervision and implement preventative measures to prevent unsafe feeding for one (Resident 1) of three residents reviewed for accidents. Failure to identify known risks, implement individualized, resident-centered interventions, including adequate supervision, communicating interventions to all relevant staff, provide training as needed to reduce those risks and ensure interventions were put into action, placed the resident at risk of being force fed, choked, developing aspiration pneumonia, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place that ensured fluid intake/output was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated for 5 of 5 residents (Resident 2, 3, 4, 5 & 6) reviewed for dehydration and fluid restriction (a diet which limits the amount of daily fluid intake). These failures placed residents at risk for fluid and electrolyte imbalances, dehydration, fluid overload, and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to identify, and timely report an allegation of potential abuse for 1 of 3 Residents (Resident 1) reviewed for abuse. Failure of the facility to ensure 4 of 4 staff (Staff D, E, F, and G) timely reported alleged abuse, placed residents at risk of abuse, psychological distress, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of potential abuse and implement interventions to prevent further suspected abuse for 1 of 3 Residents (Resident 1) reviewed for abuse. These failures placed the residents at risk of abuse, psychological distress, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in manner which prevents food illness when reviewed for kitchen. This failure placed residents at risk for foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain advanced directives (AD) and/or perform periodic reviews to determine if residents had an AD, and if not, determine whether the residents wished to formulate an AD for 3 of 4 sampled residents (Residents 22, 43, and 77) when reviewed for AD. This failure denied the residents the opportunity to direct their health care in the event they were to become unable to make decisions or communicate their health care preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with mental health disorders were screened for the need of additional mental health support for 5 of 9 sampled residents (Residents 77, 95, 103, 22, and 26) when reviewed for Preadmission Screening and Resident Review (PASARR, a mental health screening tool). This failure placed residents at risk of lacking needed mental health support, avoidable adverse behaviors, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 3 of 21 sampled residents (Residents 30, 103 and 215) when reviewed for care plans. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life.

Inspectors wroteResident 77 Review of the EHR showed Resident 77 was admitted to the facility on [DATE] with diagnoses to include dementia (impairment of brain function that causes loss of memory and thinking) with psychosis (mental disorder characterized by a disconnection from reality), anxiety, and insomnia (inability to sleep). Resident 77 was not able to communicate needs. Review of the significant change MDS dated [DATE] showed Resident 77 was dependent on staff to provide activities of daily leaving (ADL) care. Observations from 03/10/2025 to 03/14/2025 showed Resident 77 in bed with closed eyes. During an interview on 03/12/2025 at 9:15 AM, Resident 59, who was a roommate of Resident 77, stated Resident 77 has been in the bed for three months. [...]

Inspectors wroteResident 77 Review of the EHR showed Resident 77 was admitted to the facility on [DATE] with diagnoses to include dementia with psychosis (mental disorder characterized by a disconnection from reality), anxiety and insomnia (inability to sleep). Resident 77 was not able to communicate needs. Review of the EHR showed Resident 77 was placed on isolation on 12/20/2024 for testing positive for COVID-19. Review of the care plan dated 12/20/2024 showed Resident 77 to continue to need isolation for COVID-19. Observations on 03/12/2025 at 9:15 AM showed Resident 77's room to have no signs for isolation. During an interview on 03/13/2025 at 10:45 AM, Staff L, LPN/UM, stated Resident 77's care plan was developed by the infection preventionist nurse and was not updated when the isolation stopped. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was maintained related to medications at bedside and falls for 3 of 6 sampled residents (Residents 45, 5 and 22) when reviewed for accidents. Failure to ensure fall interventions were in place for Residents 22 and 5 and to assess and care plan self-medication administration for Resident 45 and placed residents at risk for avoidable injuries and a diminished quality of life. <FALLS> Review of facility document titled, Fall Protocols, undated, showed in the event of an actual fall the facility would implement a resident-centered fall prevention plan to reduce the specific risk factor of falls for each resident at risk or with a history of falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 residents (Residents 418, 419 and 420) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure and document that each resident was informed about the benefits and risks of and had the opportunity to receive the influenza and pneumococcal vaccines unless medically contraindicated, refused or was already immunized for 4 of 5 sampled residents (Resident 87, 27, 92 and 78) when reviewed for immunizations. These failures placed the residents at an increased risk of viral infections, lack of knowledge to make an informed decision, and poor clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure and document that each resident was informed about the benefits and risks of and had the opportunity to receive Covid-19 vaccine unless medically contraindicated, refused or was already immunized for 3 of 5 sampled residents (Residents 87, 27, and 92) when reviewed for immunizations. This failure placed the residents at an increased risk of Covid-19 infections, lack of knowledge to make an informed decisions and poor clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) consents completed prior to receiving medications for 1 of 5 sampled residents (Resident 26) reviewed for unnecessary medication use. This failure placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to honor resident shower preferences for 1 of 3 sampled residents (Resident 216) reviewed for choices. This failure placed the resident at risk for infection, medical complications, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment in resident rooms for 2 of 4 hallways (200 and 100 halls) when review for environment. This failure placed residents at risk of decreased mood and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete criminal background check prior to hire for 1 of 5 staff (Staff F) when reviewed for abuse and neglect prevention. This failure placed the residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 2 sampled residents (Resident 216) when reviewed for abuse. This failure placed the resident at risk of further abuse, psychological distress, and diminished quality of life. Finings included . Review of the electronic health record (EHR) showed Resident 216 was re-admitted to the facility on [DATE] with diagnoses to include bipolar disorder (disorder associated with mood swings ranging from depressive low to manic highs), heart failure, spinal stenosis (spaces inside the bones of the spine get too small and causes pressure on the nerves) and morbid obesity (disorder that involves having too much body fat). Resident 216 was able to communicate needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow provider's order for 1 of 5 sampled residents (Resident 215) reviewed for professional standard of care and services. This failure placed the resident at risk for avoidable pain, medical complications, and diminished quality of life.

Inspectors wroteResident 30 Review of the EHR showed Resident 30 admitted to the facility on [DATE] with diagnoses including cancer of the colon (lower intestines), dementia, and diabetes. The resident was unable to make needs known. During an interview on 03/12/2025 at 9:01 AM, Collateral Contact Z (CCZ), stated Resident 30 did not eat on their own and staff took the tray out without assisting them. CCZ stated staff did not get Resident 30 up out of bed during the day. During an interview and observation on 03/12/2025 at 9:01 AM, CCZ stated Resident 30 needed assistance with meals and to get up out of bed. Resident 30 was observed lying in bed while CCZ assisted them with the morning meal. Observations on 03/12/2025 at 11:08 AM, 1:18 PM, and 3:31 PM showed Resident 30 laid in bed with an absorbent pad under them. Their position was unchanged. [...]

Inspectors wroteResident 64 Review of the EHR showed Resident 64 admitted to the facility on [DATE] with diagnoses that included disorder of muscle, lymphedema (tissue swelling caused by accumulation of fluid), and difficulty walking. Review of the admission MDS dated [DATE] showed Resident 64 was assessed to have lower extremity impairment of both sides. During an interview on 03/12/2025 at 1:52 PM, Resident 64 stated Staff never do what they're supposed to do here. I'm supposed to get my legs wrapped daily and it doesn't get done. Observations on 03/12/2025 at 9:51 AM and 03/13/2025 at 11:03 AM showed Resident 64's legs were not wrapped. Review of Resident 64's provider's order dated 02/28/2025 showed staff were to apply ACE wraps (elastic bandages) to bilateral extremities one time a day for edema and remove at night per schedule. [...]

Inspectors wroteResident 88 Review of the EHR showed Resident 88 admitted to the facility on [DATE] with diagnoses of cognitive communication deficit (when someone has trouble with one or more cognitive processes involved in communication) and diabetes (when the body cannot process sugar effectively). The resident was able to make needs known. Observation and interview on 03/11/2025 at 9:36 AM showed Resident 88 laid in bed. The resident had their left hand resting on their chest with the fingers curled and the skin appeared dry and flakey. Resident 88 attempted to move their fingers on the left hand but was unable and stated I can't open my hand. [...]

Inspectors wroteResident 82 Review of the EHR showed Resident 82 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease) and congestive heart failure (CHF, when the heart does not pump enough causing fluid buildup). The resident was able to make needs known. Observation on 03/10/2025 at 9:38 AM showed Resident 82 laid in bed. There was a full water pitcher on the overbed table. Observation and interview on 03/11/2025 at 10:22 AM showed Resident 82 laid in bed. There was a full water pitcher, a half empty bottle of soda on the overbed table, and a half drank bottle of water on the bedside table. Resident 82 stated they were aware they were on a fluid restriction and they do not drink the fluids on the meal trays. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 36) when reviewed for enteral nutrition. The facility failed to ensure the amount of enteral formula (liquid food products) Resident 36 received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, hydration, and other adverse outcomes.

Inspectors wroteResident 82 Review of the EHR showed Resident 82 admitted to the facility on [DATE] with diagnoses of COPD and CHF. The resident was able to make needs known. Review of the EHR showed a provider order with a start date of 01/31/2025 for oxygen to be provided at three L per minute through a nasal canula every shift for COPD. Observations on 03/10/2025 at 9:51 AM, 03/11/2025 at 1:16 PM, and 03/12/2025 at 10:50 AM showed oxygen being delivered at two L per minute through a nasal canula. During an interview on 03/13/2025 at 9:39 AM, Staff P, LPN, stated they should check each shift if O2 was set correctly, and Resident 82 should be receiving three L per minute. During an interview on 03/13/2025 at 11:18 AM, Staff B, DNS, stated Resident 82 should have been checked once a shift for oxygen needs and they should be receiving the ordered amount. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide non-pharmacological interventions (health interventions/approaches used instead of medication) for 2 of 11 sampled residents (Residents 26 and 88) when reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk for receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor behaviors related to psychotropic medication (a medication that affects behavior, mood, thoughts and/or perception) use, and/or conduct a psychotropic medication gradual dose reduction for 2 of 5 sampled residents (Residents 22 and 77) reviewed for unnecessary medications. These failures placed residents at risk for adverse side effects, unknown behaviors, medical complications, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a skin condition was accurately assessed, treated and monitored for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for unmet care needs, discomfort, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information was accurate and submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 annual quarters (Quarter 4- October 1, 2023, through December 31, 2023) reviewed for Payroll-Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of staffing level data collected by CMS and had the potential to impact resident care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to prevent the occurrance of an avoidable pressure ulcer/pressure injury (PU/PI) for 1 of 3 sampled Residents (Resident 1) reviewed for PU/PI. The failure to implement physician ordered (PO) weekly skin observations and adequately evaluate, document, and monitor a newly identified PU/PI placed residents at risk for worsening skin conditions, unmet care needs, and dimished quality of care/quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure physician orders were clarified and treatment was provided according to physician orders for 3 of 5 sampled residents (Residents 1, 4 & 7) reviewed for wound care. This failure placed residents at risk for delayed healing or deterioration of wounds and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, report to administrator and investigate an allegation of neglect for 1 of 3 sampled residents (Resident 1) reviewed for abuse and neglect. Failure to report alleged abuse and neglect placed the residents at risk for unidentified abuse, mistreatment, and a diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, facility failed to provide care and treatment according to professional standards to prevent development or deterioration of pressure injuries for 2 of 5 residents (Residents 1 & 2) reviewed for pressure injury prevention when it did not develop, revise and implement individualized care planned interventions for incontinence care, positioning and behaviors. This failure placed residents at risk for new or worsening pressure injuries and a diminished quality of life.

Inspectors wroteResident 22 Resident 22 admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD, a long-term lung disease). Observation on 05/20/2024 at 10:22 AM showed Resident 22 laid in bed with long facial hair and their hair appeared oily. During an interview on 05/20/2024 at 2:30 PM, Collateral Contact 1 stated Resident 22 had not been getting enough showers or being shaven. During an interview on 05/22/2024 at 8:54 AM, Staff F, CNA, stated they had assisted Resident 22 with bathing and that the resident wanted to be shaved but would rather a male caregiver do it. During an interview on 05/22/2024 at 8:50 AM, Staff G, CNA/Bath Aid, stated residents should receive at least two showers/bed baths a week and they should be shaved if needed at that time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy per provider orders and/or ensure oxygen tubing was dated and regularly changed for 2 of 2 sampled residents (Residents 41 and 22) reviewed for respiratory care. These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on and/or consistently follow the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for 3 of 5 sampled residents (Resident 20, 22, and 11) reviewed for unnecessary medication use. These failures placed the residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 3 of 7 sampled residents (Residents 20, 22, and 154) when reviewed for unnecessary medications and/or anticoagulant (blood thinner) medication use. The facility failed to monitor Resident 20's blood pressure (BP) and heart rate/pulse and follow parameters prior to giving medications; failed to ensure Residents 20 and 22 were provided non-pharmacological (NPI, non-medication) interventions prior to the use of as needed (PRN) pain medications; and monitor Resident 154's blood thinner medication side effects. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for 2 of 3 sampled residents (Resident 33 and 204) reviewed for dental services. This failure placed the resident at risk of difficulty eating, unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow therapeutic diets for 3 of 5 sampled residents (Residents 153, 79, and 92) when reviewed for kitchen. This failure placed residents at risk of choking, increased blood pressure, avoidable injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective infection prevention and control program was in place to prevent the transmission of communicable diseases and infections by completing the collection and analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 4 of 4 months (January, February, March, and April 2024) when reviewed for infection control. The facility failed to ensure the laundry/linen storage room had defined separation between dirty/contaminated waste and clean linen. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, cross-contamination, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to resolve grievances brought forward by the resident council (RC) for 2 of 3 months (March and April 2024) when reviewed for resident council. This failure placed the residents at risk of not having group grievances resolved, reduced capacity to provide input to the facility, and a diminished quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to report to the administrator and investigate an allegation of abuse for 1 of 2 sampled residents (Resident 19) reviewed for abuse and neglect. Failure to report alleged abuse and neglect placed the residents at risk for unidentified abuse, mistreatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 1 of 21 sampled residents (Resident 154) reviewed for monitoring. Failure to ensure clinical symptoms for congestive heart failure were monitored and addressed and failure to monitor for adverse side effects of an anticoagulant (AG, blood thinning medication) placed the resident at risk for decreased comfort, poor clinical outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hearing aids were implemented and/or provided the necessary auditory (hearing) services in a timely manner for 1 of 3 sampled residents (Resident 33) reviewed for communication/sensory. This failure placed the resident at risk for diminished independence with activities of daily living, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently reconcile controlled medications in 3 of 3 medication carts (Medication Carts 400, 100, and 300) reviewed for medication storage. This failure placed residents at risk for misappropriation of their medications and the facility at risk for diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the hospital to the resident or responsible party for 2 of 3 sampled residents (Residents 7 and 69) reviewed for Hospitalization. This failure placed the residents at risk for diminished protection from being inappropriately discharged .

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 sampled residents (Residents 7 and 69) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to take timely action for 1 of 3 who experienced a significant change in their baseline condition. Resident 1 experienced harm when the serious changes in cognition, blood pressure and temperature were not addressed timely, and they had to eventually be hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation on an unwitnessed fall for 1 of 3 residents (Resident 1) reviewed for accidents and/or incidents. This failure placed all residents at risk for inadequate interventions, recurrent falls, and a diminished quality of life.