Bluestone Health and Rehabilitation

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure precautions were taken for resident's when the smoking assessment and the resident's care plan indicated a need for the resident to wear a smoking apron for safety when smoking. This was true for one (1) of three (3) residents reviewed during the complaint survey process. Resident Identifier: #7. Facility Census: 54. Findings Included: a) Resident #7 A record review, completed on 06/17/26 at 8:50 PM, revealed Resident #7 had a smoking safety evaluation that was dated 05/08/26. The evaluation noted the resident was safe to smoke with a smoking apron and supervision. During an observation on 06/18/26 at 8:50 AM, Resident #7 was brought to the smoking area. Resident #7 was permitted to begin smoking with no smoking apron. [...]

Inspectors wroteBased upon record review, staff interviews, resident interview, and observation, the facility failed to maintain a resident environment as free from accident hazards as possible. This was true for three (3) of the three residents reviewed during the long term care survey process. The facility's failure to thoroughly review circumstances and change the processes for deliveries to residents created a risk of serious harm related to residents ordering over-the-counter medications known to be abused as well as THC gummies and offering them to other residents. Resident identifiers: #27, #54, #57 #5 and #42. Facility census: 57.

Inspectors wroteBased on resident interview and record review the facility failed to protect two (2) residents from neglect by failing to provide care timely incontinence care Resident #1 and failing to provide the correct texture of food for Resident #3. Resident identiifers: #1, and #3. Resident #1 sustained actual physical harm from this action. Facility Census 57. Findings Included:

Inspectors wroteBased on record reviews and staff interviews the facility failed to develop and implement a person centered comprehensive care plan regarding activities for residents #37,#29,#25,#8,#1,#2, and accidents hazards for resident #54,#57 and Positioning and mobility for residents #7 and #18. These failed practices had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #37,#29,#25,#8,#1,#2,#57 #7 and #18 Facility census: 57 Findings Included: a) Resident #37 Record review completed on 04/23/26 revealed the following Activities-Resident Preferences Evaluation Section A Daily Preferences Question nine (9) Daily preferences note Resident stated he likes to play cards and checkers. Resident enjoys taking showers in the evening. Section B Activity Preferences question two (2)a Preferred music genre(s): [...]

Inspectors wroteBased upon record review, observation, and staff interview, the facility failed to post accurate nurse staffing data in a prominent location viewable by staff and visitors. This was found to be true for 22 days of 23 days of staffing reviewed during the long term care survey process. Facility census: 57.

Inspectors wroteBased on record review, resident interviews, staff interviews, observations, the facility administration failed to effectively operate the facility in a manner that ensured residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. The facility failed to provide administrative oversight to ensure adequate staffing, resident protection systems, abuse/neglect reporting and investigation, and a person-centered activity program were implemented and monitored. These systemic failures resulted in repeat deficient practices and had the potential to affect all residents residing in the facility. Facility census: 57.

Inspectors wroteBased on record review and staff interviews the facility failed to maintain a complete accurate medical record for resident #54 regarding Nothing by Mouth (NPO) Resident #63's skin assessments, Resident#18's NPO orders, and Resident #63's POST form. These were random opportunities of discovery during the Long-Term care survey process and has the potential to affect more than a minimal number of residents residing in the facility. Resident identifier: #54, #63, #18 Facility census: 57 a) Resident #54 Record review of orders completed on 04/13/26 revealed the following intervention in the care plan may give all medications and liquids via gastrostomy tube r/t resident is NPO Further record review revealed the following orders; [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to notify the ombudsman and resident/resident representative of the resident's transfer and provide information on the bed hold notification. This was found to be true for two (2) of two (2) residents reviewed during the long term care survey process. Resident identifiers: #62, #27. Facility census: 57.

Inspectors wroteBased on record review and staff interview, the facility failed to update the Pre-admission Screening and Resident Review (PASARR) when a diagnoses of Post Traumatic Stress Disorder (PTSD), was added for Resident #5. This was true for one (1) of four (4) residents reviewed for PASARR. Resident identifier: #5. Facility census: 57.

Inspectors wroteBased on resident interviews, Resident Council review, record review, observations, and staff interviews, the facility failed to provide an ongoing, person-centered activity program that met the interests and needs of the resident population, including providing age-appropriate activities, evening programming, and individualized/sensory activities for low-functioning residents. This deficient practice had the potential to affect all residents residing in the facility by failing to promote psychosocial well-being, meaningful engagement, and quality of life. Resident identifier; #48,#19,#25,#8,#1,#2,#3,#37,#45,#23 Facility Census

Inspectors wroteBased on observation, staff interview, staff postings review and resident interview the facility failed to ensurse sufficient nursing staff across all shifts and units to meet the needs of depdendent residents. Resident identifiers: #1. Facility census: 57. a)

Inspectors wroteBased on observation and resident and staff interviews, the facility failed to provide meals that were palatable and attractive. This had the potential to affect all residents receiving nutrition from the kitchen. Resident identifiers: #2, #35 and #27. Census: 57Findings include: a) Resident #2 During initial interviews on 04/20/26 at 12:55PM, Resident #2 stated that the food is terrible. b) Resident #35 On 04/21/26 1:47 PM Resident #35 stated the food is sometimes cold and it does not taste good A sample tray with hamburger and french fries was brought to state surveyors on 04/28/26. The hamburger was not apealing to they eye, the French Fries were mushy and pale, the hamburger lacked seasoning and left a tasted not desired after eating, On 04/28/26 at 1:00 PM Registered Nurse Consultant #87 confirmed the meal looked unappetizing. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Resident #3 received food in the form to meet her needs. This was a random opportunity for discovery during the Long-Term Care Survey Process. Census: 57 Resident identifier: #3Findings include: a) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads, Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the [Certified Nurse Aid] CNA noticed and she coughed a few times and then was fine. CNA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. [...]

Inspectors wroteBased on observations and staff interview the facility failed to ensure pans were dry before stacking rusulting in Wet nesting a dangerous practice of stacking or storing washed, wet items (like bowls, plates, or pots) together before they are fully dry. This trapped moisture creates a dark, low-air environment that allows bacteria to grow rapidly this failed practice had the potential to affect more than a minimal number of residents residing in the long termcare facility. Facility censuse:57During the initial tour of the kitchen on 04/20/26 with the Dietary Manager, two (2) metal pans and one clear plastic serving container was observed on the shelf stacked and wet. The Dietary Manager pulled them and stated, I'll take care of these now. On 04/21/26 at 10:00 AM during a follow-up kitchen tour, another metal pan was observed wet on the shelf. [...]

Inspectors wroteBased on observations and staff interview the facility failed to ensure call light was within reach of Resident #54. This was a random opportunity for discovery. Resident identifier: #54 Facility census: 57Findings Include: a) Resident #54On 04/22/26 at 2:10 PM the surveyor observed Resident #54 in a geri chair beside his bed. The call light was hanging off the back of the headboard, out of reach. During an interview on 04/22/26 2:30 PM with Nurse Aide (NA) #30 this surveyor asked where his call light was, NA#30 stated, We normally hook it to his shirt but he can point and tell us what he needs,it should be within reach to get our attention. An interview with the Director of Nursing (DON) on 4/23/26 at approximately 11:00 AM confirmed that the call light should be within resident's reach.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to ensure a resident's right to receive written notice, including reason for change, before resident's room or roommate is changed. Resident identifiers: #45, and #25. Facility census: 57.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to allow a resident and/or their responsible party to exercise his or her right to file an anonymous grievance for facility and follow grievance policy on a grievance completed for another resident. Resident identifier: #22. Facility census: 57. a) Resident Council Resident Council meeting was held on 04/21/2026 at 11:00 AM with a group of 11 (eleven) residents who reported they had no method to anonymously file a grievance. Residents reported they did not want to report complaints for fear of retaliation. They felt concerns brought up in the resident council were not taken seriously. An interview with the Social Worker on 04/21/26 at 6:39 PM revealed there was no method for an anonymous grievance. She reported residents and family members had to ask a nurse or department head for a grievance form. [...]

Inspectors wroteBased on resident interview and record review the facility failed to report a resident allegation of neglect involving not having a brief changed and an instance where a resident was given the wrong consistency of food. The facility also failed to report the reasonable suspicion of a crime where a resident brought in THC gummies and distributed them to other residents. Resident identifiers: #3 and #1. Facility census: 57. Findings Included: a) Resident #1 A policy titled, Abuse includes a definition for neglect that reads, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. [...]

Inspectors wroteBased on resident interview and record review the facility failed to identify and thoroughly investigate allegations of neglect which included two (2) residents not receiving timely incontinence care and a resident receiving the incorrect texture of food. Resident identifiers: #1, #3 and #22. Facility Census 57. Findings Included:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to recognize standards of practice that address the identified limitations in ability to perform activities of daily living (ADL) to ensure Resident #57 received assistance with meals. This was true for one (1) of four (4) sampled for nutrition during the Long-Term Care Survey Process. Census: 57 Resident identifier: #57Findings include: a) Resident #57 The surveyor watched the lunch service on 04/22/26. Resident #57 was served his tray at 12:02 PM. Resident was observed falling asleep periodically during this meal. He finished his meal at 1:27 PM, and staff picked up the tray after he ate 51-75% of the meal. Staff provided no cueing during this time nor offered to reheat his meal. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards. This failure occurred because orders and a care plan directed applying a splint to the wrong hand for Resident #18. The facility also failed to notify the medical provider when a resident's blood sugar was over 400. Resident identifiers: #18 and #27. Facility census: 57.

Inspectors wroteBased on resident interview, record review and staff interviews, the facility failed to provide appropriate equipment to maintain mobility with the maximum practicable independence regarding Resident #2's bed rails. This was true for one (1) of three (3) residents sampled for activities of daily living during the Long-Term Care Survey Process. Census: 57 Resident identifier: #2Findings include: A policy titled, Bed Rail Risk and Safety reads: any resident being considered for using a bed with bed rail(s) is evaluated by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of bed rail(s), to identify any bed rail that might constitute physical restraint, and to identify individual characteristics that may increase the risk of entrapment by bed rails or mattress. [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure Resident #48 and Resident #57 received adequate hydration. This was true for two (2) of four (4) residents sampled for hydration during the Long-Term Care Survey Process. Resident identifiers: #48, #57. Census: 57. a) Resident #48 A policy titled, Resident Hydration and Prevention of Dehydration states that nursing staff will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. During the initial tour of the facility on 04/20/26 at approximately 1:00 PM, it was noted that Resident #48 did not have water at his bedside while in bed. Resident #48 stated that if he needed water, he had to ask for it. He also stated he needed a lot of water because he had undergone a kidney transplant. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain proper infection prevention by leaving Resident #54's tube feeding syringe open to the elements, this was a random opportunity of discovery during the long term care survey process. Resident Identifier: #54. Facility Census:

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to ensure a safe, clean, comfortable, homelike environment by not maintaining appropriate temperatures in the residents shower room. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents during the complaint survey. Facility Census 59. Findings Include:a) Short hall shower roomA tour of the short hall shower room on 12/15/25 at 11:45 AM, found that when you walk in the door of the shower room, it felt to be a good temperature. In the shower stall where the residents sit under the water felt to be cool. The Director of Maintenance (DOM), took the temperature of the room and confirmed that where the residents shower, was currently at 61 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, resident interview, and record review the facility failed to provide Activities of Daily Living (ADL) care to dependent resident in a timely manner. This failed practice was found true for (5) five of (5) five residents reviewed for ADL care during the complaint survey. Resident identifiers #19, #17, #49, #2, #10, #37. Facility census 59. Findings Include: Findings Include:a) Resident #19On 12/11/25 Program Manager II was on the phone with Resident #19 for 52 minutes. The call started at 8:32 AM. Resident #19 said she currently had a Urinary Tract Infection (UTI) and was soiled. She said they (nurse aides) had taken people out to smoke, and no one was answering her call light. Resident #19 confirmed that her call light was on. [...]

Inspectors wroteBased on observation, resident interview, family interview, and staff interview the facility failed to assure that there is sufficient nursing staff available at all times to provide nursing and related services to meet the needs of the residents. This failed practice was a random opportunity for discovery and had the potential to effect all residents currently living in the facility during the complaint survey process. Resident identifiers #60, #37, #19, #10, #19, #49, #2. Facility Census 59. Findings Include:a) Resident #60During an interview on 12/15/25 at 1:08 PM, Resident #60's Medical Power of Attorney (MPOA) stated, It was a constant battle .there were always issues especially on night shift with getting him changed. He would watch the clock, and it has been from 2 hours to 11 hours waiting to be changed. They always seemed short-staffed and constantly new staff. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete documentation for three (3) of 11 residents. Resident #60, #17 and #2. Facility Census: 59. Findings Include:a) Resident #60On 12/15/25 at 1:00 PM, a record review was completed for Resident #60. The review included a complaint dated 12/04/25 as well as a facility-reported incident (FRI) dated 12/02/25. The allegation was neglect; not providing incontinence care on 12/01/25 as well as 12/02/25. The facility did complete the investigation and found the resident was provided care. The NAs were not documenting each time care was provided to Resident #60. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an infection control program. Staff were observed transporting soiled linen through the 100 Hallway while wearing soiled gloves. Trash Barrells sitting in resident a hallway full of soiled briefs were unable to be closed due to being so full. In addition, the 100 Hall Shower Room had a soiled washcloth, candy wrapper and open bottle of shampoo present. These were random opportunities for discovery that had the potential to affect more than an isolated number of residents. Facility Census: 59. a) 100 hall shower roomOn 12/15/25 at 11:44 AM, a tour of the shower room in 100 hall was completed. The tour found a soiled washcloth under the sink, a used hand wipe and candy wrapper on the floor, and an open bottle of soap sitting on the shower bar. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement the care plan for Resident # 2 regarding taking blood pressures in a restricted arm due to a mastectomy. This is true for one (1) of 11 residents reviewed during the survey process. Resident Identifier: #2. Facility Census: 59.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (2) two of 11 residents reviewed for medical record accuracy during the Complaint Survey process. Resident identifiers #49, #2. Facility Census 59. b) Resident #2 On 12/16/25 at 1:00 PM, a record review was completed for Resident #2. The review found a physician's order dated 08/28/25 stating, No B/P (blood pressure) or venipuncture to left arm related to malignant neoplasm of unspecified site of left female breast. The resident's left arm is restricted due to a mastectomy. The following dates the blood pressures were taken in the restricted arm: [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery, and had the potential to effect more than a limited number of residents during the complaint survey process. Facility Census 59. a) Packaged Terminal Air Conditioner (PTAC) unitsAn observation on 10/20/25 at 11:10 AM, revealed that the PTAC units in rooms 113, 125, 130, 131 and 132 had dirty filters that were covered with layers of dust. Additionally, room [ROOM NUMBER]'s PTAC unit had a dried, brown substance inside of the unit's vents. [...]

Inspectors wroteBased on record review, and staff interview the facility failed to provide a staff posting that was accurate with actual nurse staffing numbers. This failed practice was a random opportunity for discovery during the complaint survey. Facility Census 59.a) Nursing staff postingsA review on 10/21/25 at 2:00 PM, of the Nurse Staff Postings from 09/2025 to present, revealed that of the 50 days reviewed, 16 of those appeared to be under the staff minimum of 2.25 for the day. Further review on 10/22/25 of the staff punch forms for the days in question, revealed punches for all days in questions, that put the staffing above the minimum. During an interview on 10/22/25 at 9:30 AM, the Director of nursing confirmed that the staff punch forms were correct and accurate and that the staff posting for the 16 days was incorrect.

Inspectors wroteBased on record review, resident representative interview, and staff interview the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop an avoidable pressure ulcer during their stay. In addition the facility failed to identify and treat the pressure ulcer once it was developed. Resident #59 entered the facility without a pressure ulcer she was discharged back to her previous living arrangement and with in hours the nurse who worked for the behavioral health company discovered multiple wounds which required her to be sent to the hospital once discovered. The facility documentation mentioned no wounds and no treatments for the wounds were ever ordered. This resulted in actual harm for Resident #59. This was true for one (1) of three (3) residents reviewed for pressure ulcers during a complaint survey. Resident Identifiers: #59. [...]

Inspectors wroteBased on record review, family interview and staff interview the facility failed to notify the residents responsible party of a room change prior to moving the resident. This was a random opportunity for discovery during the compliant survey. Resident Identifier: #60. Facility Census: 58. Findings Include: a) Resident #60 During an interview with Resident #60's responsible party on 02/10/25 at 12:03 PM during a telephone interview , she stated, The last time they moved him they did not tell me. They just came in and packed up all his stuff and moved him. A review of the medical record on 02/10/25 in the afternoon found no indication the residents responsible party was notified of his room move. An interview with the Director of Nursing (DON) on the afternoon of 02/13/25 confirmed there was no evidence the residents responsible party was notified of his room move. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all allegations of abuse and/or neglect was thoroughly investigated. This was true for Resident #59 and was a random opportunity of discovery during a complaint survey. This was determined to be past non-compliance because the facility had identified the failure and implemented an effective plan of correction to correct the non- compliance prior to the first day of the complaint survey. Resident Identifier: #59. Facility Census: 58. Findings Include: a) Resident #59 A review of the facility's reportable incidents on 02/10/25 found a reportable incident dated 02/15/24 pertaining to Resident #59. A review of the report found the following under the brief description of the incident: [...]

Inspectors wroteBased on resident representative interview, staff interview, hospital staff interview, long term care ombudsman interview and record review the facility failed to ensure Resident #60 who was discharged from their facility and was expected to return was readmitted to the first available bed when medically stable. Resident #60 has remained in the hospital from [DATE] until the time of this survey. The facility has admitted other male residents instead of Resident #60 with claims they did not have suitable bed for him. Resident #60 has experienced actual psychosocial harm as a result of these failures. The resident has experienced anxiety, agitation, and feelings of despair thinking he has done something wrong to cause this. This was true for one (1) of three (3) facility residents whom were reviewed during this complaint survey. Resident Identifiers: #60. Facility Census: 58. [...]

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to provide services that are necessary to avoid emotional distress by transferring Resident #29 from the bed to a wheelchair via the mechanical lift on shower days, despite the resident being fearful of the lift. Multiple staff confirmed the resident would cry and scream. As soon as the transfer was complete, the resident would stop crying. This has resulted in psychosocial harm as evidenced by the mental anguish suffered by the resident while in the lift. The mental anguish was evidenced by the resident crying and yelling while in the lift. This has happened on multiple occasions and is not an isolated incident. This failed practice was true for (1) one of (3) three residents reviewed for abuse and neglect during the Long-Term Care Survey Process. Resident identifier: #29. Facility Census 58. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate facility assessment related to the overall acuity of care needed for its population. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process. Facility census 58. Findings Included: a) Facility Assessment (FA) A review on 01/14/24 at 11:30 AM of the Facility Assessment revealed the facility reviewed their FA on 10/24/24. Under over all acuity of residents the following calculations were determined: [...]

Inspectors wroteBased on resident interview, medical record review, staff interview and Resident Council Meeting discussion, the facility failed to ensure the resident shower room was at a comfortable temperature for resident use. This failed practice had the potential to affect more than a limited number of residents. Resident Census: 58. Findings Included: a) Resident Shower Room During an interview with Resident #26 on 01/07/25 at 11:39 AM, he stated he refused a shower the day before because the shower room was too cold. He stated one shower room was being renovated, and the other room is always too cold. [...]

Inspectors wroteBased on record review and interviews, the facility failed to revise care plan for Resident #40 for one (1) on one (1) activities and Resident #19 and Resident #29 for behaviors. This failed practice was found true for three (3) of 21 residents reviewed for the care planning care area. Resident identifiers: #40, #19, and #29. Facility census: 58.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided activities of interests that he/she was care planned for. This was found true for one (1) of six (6) residents reviewed for the activities care area. Resident identifier: #40. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of 21 residents in the long-term care survey sample. Physician's orders to obtain weights were not followed for Resident #26 and Resident #19. Insulin was held without physician orders or notification for Resident #32. Neurological checks were not completed after an unwitnessed fall for Resident #53. Resident identifiers: #26, #32, #53, and #19. Facility census: 58.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A storage room containing hazardous items was found to be unlocked. This was a random opportunity for discovery that had the potential to affect any resident able to access the closet. Facility census: 58.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure a licensed pharmacist completed a monthly drug regimen review, reported any irregularities to the attending physician and the attending physician responded to any recommendations within the time frame established by the facility policy. This was true for three (3) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident Identifiers: #30, #53, and #32. Facility Census: 58. Findings Included: a) Resident #30 A review of Resident #30's medical record on the morning of 01/13/25 found no evidence that the pharmacist had reviewed Resident #30's drug regimen in the months of 08/2024, 09/2024, and 10/2024. [...]

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure food was served at a palatable temperature. This failed practice had the potential to affect more than an limited number of residents. Facility Census: 58. Findings Included: a) Grievance review A review of the grievances found the following grievances noted: Resident #13 and Resident #15, filed a grievance dated 03/22/24. The Residents stated the food is cool and they are not using the plate warmer. Resident #11 filed a grievance dated 08/21/24 and stated, when her tray is delivered it is cold almost every time at dinner time. Resident #1 filed a grievance dated 11/20/24 the resident indicated the pancakes were cold, not enough sausage, and the pancake was so hard she could not cut it. [...]

Inspectors wroteBased on observation and and staff interview, the facility failed to ensure food was stored and an served in a safe and sanitary manner. There were multiple items in the walk-in cooler that was either out of date or not dated to indicate when they had been opened. Additionally two (2) vents in the kitchen ceiling had a collection of dust around the vents on the ceiling. The vent on the HVAC unit in the kitchen had a collection of dust on the outer metal grate covering the filter. The filter itself was also completely covered in dust. This failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 58. Findings Included: a) Walk in cooler: An initial tour of the kitchen with the Dietary Manager (DM) on 01/07/25 beginning at 10:47 AM found the following food storage issues in the walk in cooler: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to follow proper infection control practices, by dropping cartons of milk on the floor and placing them back in the cart with clean cartons, by sending uncovered cups full of coffee out onto the floor from the kitchen, and by failing to ensure enhanced barrier precautions were followed and posted for Residents #20 and 58. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 20, 58. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to administer pneumococcal vaccines in accordance with Centers for Disease Control (CDC) guidelines. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #6 and #17. Facility census: 58.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to allow residents to make choices important to them. This deficient practice had the potential to affect one (1) of 21 residents in the long-term care survey sample. The facility did not honor Resident #49's choice as to when to have his dressing changed. Resident identifier: #49. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate bed hold notice was given to the resident representative when Resident #60 was transferred to the emergency room. This was true for one (1) of three (3) residents reviewed for the care area of hospitalizations during the long-term care survey process. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 A review of Resident #60's medical record on 01/08/25 found she was discharged to the emergency room on [DATE]. A copy of the resident's bed hold notice which was sent to the resident representative was requested on 01/09/24. The bed hold notice when provided was not complete. The notice contained the resident's name and medical record number and was signed by the nurse. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #60's and Resident #59's Minimum Data Set (MDS) were accurately completed. This was true for two (2) of 21 sample residents reviewed during the long term care survey process. Resident Identifiers: #59 and #60. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record on 01/14/25 at 10:00 AM, found the resident was discharged home on [DATE]. The son had asked the facility to prepare for the discharge on [DATE]. The facility made all arrangements for the discharge including a referral for home health. The Discharge MDS with and Assessment Reference Date (ARD) of 12/05/24 found the MDS identified the residents discharge as unplanned, even though the discharge was planned. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to identify medical diagnoses of Major Depressive disorder on the Preadmission Screening and Resident Review (PASARR). This was found true for one (2) of three (3) residents reviewed under PASARR care area. Resident identifiers: #40 and #30. Facility census 58.

Inspectors wroteBased on record review and staff interview, the facility failed to implement the care plan for Resident #19, by failing to identify triggers for behaviors. This was true for one (1) of twenty-one (21) resident care plans reviewed during the survey process. Resident identifier: #19. Facility census: 58.

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (5) five residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier #34. Facility Census 58. Findings Included: a) Resident #34 During the initial observation and interview on 01/07/25 at 2:15 PM, Resident #34's teeth were covered with a white substance with some black spots. Resident #34 stated, I can not tell you when the last time they brushed my teeth. I cannot do it myself. I do have a tooth brush in here, but I cannot tell you where it is. A record review on 01/08/25 at 1:30 PM, of Resident #34's Brief Interview for Mental Status (BIMS) score, dated 12/17/24 revealed a BIMS score of 14. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to prevent, identify, assess, and treat pressure ulcers in accordance with professional standards of treatment. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #6. Facility census: 58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. This was true for one (1) of two (2) residents reviewed for the care area of tube feeding during the long term care survey. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 1. Residual Order A review of Resident #60's medical record on the morning of 01/14/25 found the following physician order: Enteral Feed Order: every shift Check feeding tube residual every (provider please specify) Hold tube feeding if residual is greater than (provider to specify). This order had a start date of 01/08/25 and was the current order at the time of this review. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement non-pharmacological interventions for behaviors exhibited by Resident #19. This was true for one (1) of one (1) residents reviewed for behaviors during the survey process. Resident identifier: 19. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor Resident #53 for psychotropic medication side effects in November of 2024, during which time, the resident had an unwitnessed fall. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 53. Facility census: 58.

Inspectors wroteBased on record review, observation, and resident and staff interview, the facility failed to accommodate Resident #36's food preferences by serving her eggs. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records for two (4) of 21 residents in the long-term care survey sample. Resident #49 had an incomplete Physician Orders for Scope of Treatment (POST) form. Resident #6 had an inaccurate medication order and care plan. Resident identifiers: #49, and #6. Facility census: 58.

Inspectors wroteBased on observations and staff interview, the facility failed to establish and 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 with regards to the water management program to reduce Legionella growth and spread in the facility. This practice had the potential to affect all residents that reside in the facility. Facility census: 52.

Inspectors wroteBased on observation and staff interview, the facility failed to promote dignity during dining. Residents were not served lunch trays at the same time as roommates for dining within the residents' room. This was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifiers: #14, #45. Facility census: 55.

Inspectors wroteBased on observation and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature for Resident # 54. This was a random opportunity for discovery. Resident identifier: 54. Facility census: 55.

Inspectors wroteBased on record review and staff interview the facility failed to complete infection surveillance for residents who are actively being treated for Multidrug-resistant organisms (MDRO.) In addition, the facility failed to track and trend other infections. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 48.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure resident privacy was available during the delivery of personal care. Windows were not covered and a resident's room door was not closed during care.

Inspectors wroteBased on Observation, record review and staff interview the facility failed to develop a comprehensive person-centered care plan in the care area of pressure injury preventions, privacy cover on a Foley catheter collection bag, and having a resident placed in contact isolation. This was true for three (3) out of 16 residents reviewed for care plans. Facility census 48.

Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to hold a care plan meeting and involve R #17 in his individual care planning process. This was true for one (1) of 16 Residents reviewed for care plans. Resident identifier: #17. Facility census: 48.

Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to provide appropriate care for elevated blood glucose levels for one (1) of one (1) Resident reviewed for unnecessary medications. Resident identifier: #21. Facility census: 48.

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents receive care, consistent with professional standards of practice, for care of pressure ulcers. This was true for one (1) of one (1) resident reviewed for pressure ulcer care. Resident identifiers: Resident identifier: # 107. Facility census 48.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the environment is free from accident hazards. This was true for one (1) of one (1) resident reviewed for the care area of accidents related to smoking and one (1) was a random act of discovery. Resident identifiers: #11 and #3. Facility Census: #48 Findings Included: a) Resident #11 On 04/24/23 at 2:55 PM records revealed Resident #11 is a smoker. Further record review found the following: 06/15/22 Quarterly Tobacco Use Observation assessment, Description: Annual Assessment 10/11/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment 11/22/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment The next Quarterly Tobacco Use Observation assessment was due 02/22/23 and had not performed. The care plan reflects the following: Approach: [...]

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to follow physicians' orders for ensuring the Foley Catheter collection bag was covered at all times. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #107. Facility census 48.

Inspectors wroteBased on record review and staff interviews the facility failed to offer pneumococcal immunizations to all residents. This was true for two (2) out of five (5) reviewed for immunizations. Resident Identifiers: #107, and #41. Facility census 48.