Bradley Estates Nursing and Rehab LLC

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one of three residents (Resident (R) 2) reviewed for abuse in a total sample of 11. R2 was the subject of physical abuse when Certified Nurse Aide (CNA) 5 poured coffee on R2. This had the potential to cause physical as well as psychological harm to the residents CNA5 provided care for.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a clean and homelike environment was maintained for eight of 31 sample residents (Resident (R) 20, R28, R14, R15, R18, R19, R16, and R17) reviewed for the environment. This had the potential to affect residents' well-being throughout the facility by not having a clean and homelike environment.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resident council grievances were resolved in a timely manner for three out of six monthly meetings, by three council members/attendees of the resident council meetings (Resident (R) 29, R15, and R31) of 31 sample residents. Failure to address and resolve grievances raised during resident council meetings in a timely manner has the potential to negatively affect residents' quality of life and satisfaction with care.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents. (Cross Reference F610)On 11/22/25 R7 was found by Certified Nursing Assistant (CNA)9 to be hitting R6 in the chest. R7 and R6 were roommates at the time. A reasonable person would not expect to be hit by their roommate in their own room/living space.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 6) reviewed for abuse/neglect was protected from physical abuse by R7 of 31 sample residents. This had the potential to cause emotional and/or physical harm.

Inspectors wroteBased on staff interview and record review, the facility did not monitor psychotropic medication use for 4 residents (R) (R3, R5, R94, and R104) of 5 sampled residents. R3 was prescribed antipsychotic, antianxiety, and antidepressant medications. The facility did not monitor R3 for adverse reactions to the medications. R5 was prescribed antipsychotic and antidepressant medications. The facility did not monitor R5 for adverse reactions to the medications. R94 was prescribed antipsychotic, antianxiety, and antidepressant medications. The facility did not monitor R94 for adverse reactions to the medications. R104 was prescribed antipsychotic and antidepressant medications. The facility did not monitor R104 for adverse reactions to the medications.

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R3, R5, R104, and R12) of 29 sampled residents. R3's Quarterly MDS assessment, dated 7/11/25, indicated R3 received hypnotic medication. R3 was not prescribed hypnotic medication. In addition, R3's Comprehensive MDS assessment, dated 10/8/24, indicated R3 did not have a serious mental illness. R3 had diagnoses including major depressive disorder and anxiety disorder. R5's Comprehensive MDS assessment, dated 7/28/25, did not indicate R5 received anticoagulant medication. R5 was prescribed anticoagulant medication. R104's Comprehensive MDS assessment, dated 8/5/25, indicated R104 did not have a serious mental illness. R104 had diagnoses including major depressive disorder and anxiety disorder. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 16 residents (R) (R97, R128, R81, R127, R136, R141, R78, R63, R118, R9, R124, R76, R72, R145, R165, and R35) in 4 of 6 medication carts were labeled or dated appropriately. In addition, the facility did not ensure expired medical supplies were removed from storage in 1 of 2 medication storage rooms. The 100, 300 and 400 unit medication carts contained insulin, inhalers, eye drops, and liquid medications that were not dated when opened. The 400 unit medication storage room contained expired medical supplies. The facility's Storage of Medications policy, revised [DATE], indicates: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R11, R13, and R132) of 29 sampled residents. During the provision of catheter care and peri-care for R11, CNA (Certified Nursing Assistant)-C did not wear a gown or complete appropriate hand hygiene. R13 and R132 had orders for doxycycline (an antibiotic medication). The facility did not include R13 and R132 on the infection control line list for antibiotic use. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 2 residents (R) (R5 and R116) of 3 sampled residents. R5 and R116 had legal Guardians. The facility did not ensure an annual review of court-ordered protective placement ([NAME] Reviews) was obtained for R5 and R116.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R3, R5 and R4) of 5 sampled residents had documentation that indicated the residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R3 was prescribed buspirone (an antianxiety medication), venlafaxine (an antidepressant medication), and trazadone (an antidepressant medication) for depression and anxiety. The facility did not ensure informed consent for the medications was completed timely with R3's Power of Attorney for Healthcare (POAHC). R5 was prescribed Seroquel (an antipsychotic medication) for anxiety, sertraline (an antidepressant medication) for adjustment disorder, mirtazapine (an antidepressant medication) for anxiety, and valproic acid (an anticonvulsant medication) for seizures. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure notification of coverage change and the financial liability for continued stay at the facility was provided timely when Medicare Part A benefits ended for 2 residents (R) (R22 and R113) of 3 sampled residents. The facility did not have documentation that an Advanced Beneficiary Notice (ABN) (which documents daily rate liability for continued cost of stay) or a Notice of Medicare Non-Coverage (NOMNC) form with appeal rights was provided to R22's representative when R22's Medicare Part A coverage ended and R22 remained in the facility. The facility did not have documentation that an ABN or NOMNC form was provided to R113's Guardian when R113's Medicare Part A covrerage ended and R22 remained in the facility.

Inspectors wroteBased on staff and resident interview and record review, the facility did not document, investigate, or thoroughly resolve a grievance for 1 resident (R) (R79) of 29 sampled residents. R79's reported missing clothing to staff. The facility did not appropriately document, investigate, or thoroughly resolve R79's grievance.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmittal of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 resident (R) (R105) of 29 sampled residents. R105 discharged from the facility on 5/7/25. R105's Discharge MDS assessment was not completed/transmitted as required.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 2 residents (R) (R5 and R94) of 5 sampled residents. R5 was prescribed Seroquel (an antipsychotic medication). The facility did not update R5's PASRR Level I Screen and submit for PASRR Level II reevaluation. R94 was prescribed Abilify (an antipsychotic medication) for major depressive disorder, buspirone (an antianxiety medication) for anxiety disorder, trazodone (an antidepressant medication), Lexapro (an antidepressant medication), and Wellbutrin (an antidepressant medication) for major depressive disorder. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R103) of 7 sampled residents. R103 had a diagnosis of schizophrenia. R103's PASRR Level I Screen indicated R103 did not have a mental illness. R103 did not have a PASRR Level II Screen. According to the State of Wisconsin Department of Health Services, PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or mental illness (MI). This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or MI. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 3 residents (R) (R5, R116, and R161) of 3 sampled residents who were unable to carry out activities of daily living (ADLs) were provided nail care, oral hygiene, or shower assistance. R5 and R116 did not receive consistent nail care or oral hygiene assistance. R161 did not receive showers per R161's request. In addition, R161's shower documentation was incorrect.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the provision of care and treatment to prevent pressure injuries from developing and/or promote healing for 2 residents (R) (R50 and R7) of 4 sampled residents. R50 had a history of facility-acquired pressure injuries. R50's plan of care indicated R50's heels should be floated. The intervention was not consistently followed. R7 had a history of a facility-acquired pressure injury due to a medical device. R7's plan of care indicated R7 should wear a left heel bootie at all times. The intervention was not consistently followed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neuro checks were completed after unwitnessed falls for 1 resident (R) (R42) of 4 sampled residents. R42 had unwitnessed falls on 6/12/25, 6/19/25, 6/27/25, 7/10/25 and 8/26/25. Following the falls, staff did not ensure neuro checks were completed in accordance with the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse reactions to high-risk medication was in place for 3 residents (R) (R3, R5 and R132) of 6 sampled residents. R3 was prescribed opioid and anticoagulant medication. The facility did not monitor R3 for adverse reactions to the medications. R5 was prescribed diuretic and anticoagulant medication. The facility did not monitor R5 for adverse reactions to the medications. In addition, the facility did not update R5's care plan to indicate R5 received diuretic and anticoagulant medication. R132 was prescribed antibiotic medication for osteomyelitis (a bone infection) on 9/5/25. The facility did not monitor R132 for adverse reactions to the medication.

Inspectors wroteBased on staff and resident interview and record review, the facility failed to prevent resident-to-resident abuse for 2 residents (R) (R8 and R4) of 13 sampled residents. On 7/6/25, R3 hit R8 in the face in the dining room. On 7/14/25, R2 held R4's arm down and punched R4 in the face and hand.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure an allegation of missing money was reported to the State Agency (SA) for 1 resident (R) (R10) of 3 sampled residents. R10 reported $650 was missing from a pill bottle in R10's dresser drawer. The allegation of misappropriation was not reported to the SA.

Inspectors wroteBased on staff and resident interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of missing money for 1 resident (R) (R10) of 3 sampled residents. R10 reported $650 was missing from a pill bottle in R10's dresser drawer. The allegation of misappropriation was not thoroughly investigated.

Inspectors wroteBased on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment for 4 (R2, R4, R5 and R6) of 6 residents reviewed for environment.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure all alleged violations of misappropriation were thoroughly investigated for 1 (R1) of 1 residents reviewed.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (R2) of 2 residents reviewed for falls.*R2 was observed not wearing non-slip footwear during a transfer from R2's wheelchair into R2's bed. *R2 was observed to not have a scoop mattress which was documented on R2's care plan as a fall prevention intervention.*R2's Certified Nursing Assistant informed Surveyor R2 requires the assist of 2 staff and a stand pivot transfer using a gait belt and was transferred the morning of 07/11/2025 using this technique. R2's care plan documents R2 requires the use of a sit to stand device for transfers.

Inspectors wroteBased on interview, record review, and review of resident council meeting minutes, the facility failed to act upon the grievances raised during resident council and demonstrate their response and rationale for such response. This failure had the potential to affect the quality of life of more than 4 of the 132 residents residing in the facility.

Inspectors wroteBased on observation, interview, facility policy review, and insulin pen manufacturer's instructions, the facility failed to ensure 2 residents (R) (R6 and R7) of 2 residents observed during medication administration were provided insulin from an insulin pen per the manufacturer's instructions. This failure had the potential for R6 and R7 to receive an incorrect dose of their insulin.

Inspectors wroteBased on observation, interview, facility policy review, and manufacturer's instructions, the facility failed to ensure multi-dose insulin pens were labeled with the date and time when first opened for 2 residents (R) (R6 and R7) of 2 residents observed during medication administration. This failure had the potential to expose R6 and R7 to expired medications.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to perform hand hygiene and administer medications in a manner to prevent cross-contamination for 1 resident (R) (R6) of 2 residents observed during medication administration. This failure had the potential to spread of pathogens in the facility.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified Dietary Manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 147 residents residing in the facility. Dietary Manager (DM)-I did not complete and was not enrolled in an approved dietary manager or food service manager certification course or other related education.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 9 residents (R) (R21, R24, R25, R18, R14, R17, R15, R16, and R9) of 11 sampled residents. R21, R24, and R25's controlled substance medications were not documented in the controlled substance log at the time the medications were administered on 3/31/25. R18, R14, and R17's 9:00 AM medications were not administered timely on 3/31/25. R21's tramadol was not administered in accordance with the physician order on 3/31/25. R14's bumetanide and carvedilol were not administered in accordance physician orders on 3/31/25. R15's Abilify, amlodipine, atorvastatin, lisinopril, sertraline, and hydralazine were not administered in accordance with physician orders on 3/31/25. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. The 100 wing medication cart was unlocked and unattended on 3/31/25. Medication stored in an unlabeled and uncovered medication cup was administered to R23 on 4/1/25.

Inspectors wroteBased on observation staff interview, and record review, the facility did not follow the menu for residents who ate in the dining room or follow serving sizes for residents who ate in their rooms. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. On [DATE], residents who ate in the dining room were not served cut potatoes that were on the lunch menu. On [DATE], residents who ate in their rooms on the first floor were not served the correct amount of potatoes.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. Dietary Aide (DA)-K did not follow hand hygiene and hairnet requirements while plating food on the second floor. Appropriate scoop sizes were not followed for residents residing on the first floor. Scoops were observed inside ice bin coolers on the first floor.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of pharmacogenomic testing for 1 resident (R) (R1) of 25 sampled residents. POAHC-M was not notified of pharmacogenomic testing that was completed for R1. In addition, R1 signed a consent form which was obtained by Lab Company (LC)-P without POACH-M's knowledge.

Inspectors wroteBased on staff interview and record review, the facility did not ensure activities of daily living (ADLs) needs were met for 1 resident (R) (R9) of 22 sampled residents. R9 did not receive weekly showers as specified in R9's plan of care and was not regularly transferred to the toilet. In addition, R9's medical record did not contain consistent ADL documentation.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 2 residents (R) (R22 and R23) of 3 residents observed during medication administration. On 4/1/25, staff did not complete hand hygiene during medication preparation and administration for R22 and R23.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R3) of 1 resident (with the potential to affect 26 of 141 other residents) when R3 obtained a loaded firearm from a staff's bag and carried it onto a secured memory care unit and for 1 (R2) of 1 resident who incurred a third degree cryogenic burn from a portable oxygen tank that was placed on the foot pedals of the resident's wheelchair. R3 was on 1:1 supervision related to wandering and aggressive behavior toward staff. Certified Nursing Assistant (CNA)-C was assigned to complete 1:1 supervision for R3 on the 1/22/25 PM shift. CNA-C brought a loaded gun into the facility in a purse and brought the purse into R3's room. R3 removed the gun from CNA-C's purse and carried the gun onto a secured memory care unit. [...]

Inspectors wroteBased on staff interview and record review, the facility did not notify a resident representative when 1 resident (R) (R3) of 1 resident accessed a loaded gun from a staff's purse and carried the gun onto a secured memory care unit. In addition, the facility did not notify the physician of a new skin concern for 1 (R2) of 1 resident R3 was on 1:1 direct supervision for aggressive behavior. On 1/22/25, R3 gained access to a loaded gun in a staff's purse and carried the gun onto a secured memory care unit. R3's Power of Attorney (POA) was not updated following the incident. On 12/20/24, a portable oxygen tank was placed on a blanket near R2's right leg while R2 was getting ready for dialysis. R2 complained of irritation to the right ankle. An assessment indicated a reddened area was present. R2's physician was not notified.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a bed hold notice was provided for 1 resident (R) (R1) of 6 sampled residents. R1 went to the emergency room (ER) with family on 1/8/25. The facility did not provide R1 with a bed hold notice.

Inspectors wroteBased on staff, resident, and family interview and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled resident was permitted to return to the facility after a hospital visit. R1's Family Member ((FM)-H) took R1 to the emergency room (ER) on 1/8/25. When R1 returned to the facility on 1/9/25, the facility informed R1 that R1 had been discharged and could not return. The facility then contacted R1 on 1/10/25 and indicated R1 could return, however, R1 was eating dinner and was settled at FM-H's for house for the night. R1 returned to the facility on 1/11/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents with an indwelling catheter received appropriate catheter care and services. R1 had a Foley catheter inserted on 11/21/24 due to urinary retention. From 11/21/24 to 12/7/24, staff did not monitor R1's urine output or assess for genitourinary changes. On 12/7/24, R1 complained of penile pain. Urinary and catheter assessments were not completed on 12/8/24 and 12/9/24. On 12/10/24, R1 had increased confusion, low urine output, and a large amount of pus at the catheter site. On 12/11/24, R1 was transferred to the hospital due to severe penile pain. R1's catheter was blocked and drained thick gray material. R1 returned to the facility on [DATE] with diagnoses of urinary retention, UTI, and acute kidney injury.

Inspectors wroteBased on staff interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 3 of 9 staff reviewed for caregiver background checks. This practice had the potential to affect more than 4 of the 141 residents residing in the facility. The facility did not ensure a thorough background check was completed for Dietary Aide (DA)-H who had substantiated findings of caregiver misconduct on DA-H's record and was prohibited from working as a caregiver in Department of Health Services (DHS) regulated facilities. In addition, DA-H did not report felony convictions on DA-H's Background Information Disclosure (BID) form. The facility did not have a completed Department of Justice (DOJ) letter or Government Findings Report for Certified Nursing Assistant (CNA)-J. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R3) of 9 sampled residents was free from verbal abuse. On 11/2/24, multiple staff witnessed Dietary Aide (DA)-H call R3 a derogatory name and threaten to take away and hit R3 with R3's walker. In addition, the facility did not ensure a thorough background check was completed for DA-H who had substantiated findings of caregiver misconduct and was prohibited from working as a caregiver in Department of Health Services (DHS) regulated facilities.

Inspectors wroteBased on observation and staff interview, the facility did not provide adequate supervision for 1 resident (R) (R2) of 1 resident who required direct supervision. R2 had a history of yelling, threatening, and hitting peers and staff. R2's care plan contained an intervention for 1:1 staff supervision. On 1/7/25, Surveyor observed R2 without 1:1 supervision on multiple occasions.

Inspectors wroteBased on staff interview, resident interview, and record review, the facility did not allow 1 resident (R) (R1) of 1 resident to remain in the facility after the resident returned from the hospital and planned to move into an apartment 11 days later. R1 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. R1 planned to discharge to an apartment that was undergoing renovation and would be ready for move in on 10/20/24. Following an argument with staff on 10/9/24, R1 was told R1 had to leave the facility and was discharged to a relative's home without medication and a discharge plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 1 resident received assistive devices to maintain vision. The facility did not ensure R2 obtained replacement glasses after R2's glasses were lost in the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R4 and R13) of 27 residents. On 10/28/24, Certified Nursing Assistant (CNA)-O carried clean towels against CNA-O's scrub top and delivered the towels to R4. In addition, CNA-O carried clean towels into 2 residents' rooms before delivering them to R13.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R607 & R605) of 3 residents were free of significant medication errors. * R607 did not receive Lacosamide for seizures 11 times in July. In August R607 did not receive Lacosamide 2 times & Keppra 3000 mg one time. On 9/1/24 & 9/4/24 R607 did not receive the 7:00 a.m. dose of Divalproex Sodium 1500 mg. On 9/8/24 R607 did not receive the 7:00 a.m. dose of Keppra 3000 mg and on 9/9/24 R607 did not receive the 7:00 a.m. dose of Lacosamide 200 mg & Keppra 3000 mg. On 9/9/24 R607 was transferred to the hospital for seizures. On 9/10/24 R607 did not receive the 7:00 a.m. dose of Lacosamide 200 mg. * R605's physician order includes with an order date of 7/30/24 documents Clobazam oral tablet 10 mg (milligram) with directions to give one tablet by mouth two times a day for seizures. [...]

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 2 (R600 and R601) of 3 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R600 and R601 in the care planning process. *R600 was admitted on [DATE], and there is no documentation in R600's electronic medical record that R600 and/or representative participated in the development and implementation of R600's person-centered plan of care. *R601 did not have a care conference, that included R601 or R601's representative, in order to develop, implement, or revise a plan of care between 3/19/2024 and R601's discharge on [DATE]. Findings Include: The facility's undated policy Care Management Guideline documents: .Guideline: [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R600) of 1 Resident's representative was notified when there was a need to alter treatment. R600's electronic medical record (EMR) has no documentation that R600's representative was notified of R600's colonoscopy being rescheduled to 1/3/25. On 8/28/24, R600 was sent to the emergency room (ER) for leg swelling and R600's representative was not notified. On 9/10/24, R600's physician was updated due to lab results and new order to discontinue Levothyroxine re-check TSH (thyroid stimulating hormone) and T4 (Thyroxine) in 5 weeks and Start Potassium (K+) 40Meq (milliequivalents) daily for 4 days due to decreased K+ re-check BMP (basic metabolic panel) and Mg in one week. On 9/12/24, R600's physician ordered new Lab TSH AND T4 and new orders for Levothyroxine 25 Mcg Daily. [...]

Inspectors wroteBased on observation, interviews and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R609) of 1 residents reviewed for grievances. On 9/3/24 a grievance was initiated for R609 related to wanting a comfortable mattress and/or a recliner for sleeping. The facility indicated the grievance was resolved when R609 was told the facility does not provide recliners for residents, but the resident could bring one from home and she could not have an air mattress because of a lack of wounds and R609 accepted the explanation. Part of the resolution of the grievance was telling R609 to pursue an air mattress on their own by contacting the Physician. The facility did not attempt to come up with an alternative option or resolution other than stating R609 does not have wounds, therefore, they cannot have an air mattress. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 2 allegations of injuries of unknown origin involving 2 Residents (R603 and R606) were reported immediately to the State Survey Agency. *R606 was noted to have bruising and swelling to right eye on 8/20/24. The injury of unknown origin was not immediately reported to Nursing Home Administrator (NHA)-A and to the State Survey Agency. *On 7/27/24, R603's x-ray results showed a left hand fracture which was not reported immediately to the State Survey Agency. Findings Include: The facility's Abuse, Neglect and Exploitation policy implemented 9/2020 and last revised on 1/5/24 documents: .III. Prevention of Abuse, Neglect and Exploitation B. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 1 allegation of injury of unknown origin involving 1 Resident (R606) of 2 allegations of injury of unknown origin reviewed were thoroughly investigated. *R606 was noted to have bruising and swelling to R606's right eye on 8/20/24. The injury of unknown origin was not thoroughly investigated including obtaining statements from staff. Findings Include: The facility's Abuse, Neglect and Exploitation policy implemented 9/2020 and last revised on 1/5/24 documents: .III. Prevention of Abuse, Neglect and Exploitation B. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R602 & R606) of 9 residents care plans were revised. * On 7/30/24 at 5:56 a.m. R602 was observed on the floor. The IDT (interdisciplinary team) determined an intervention of: If resident is awake offer resident to get up and dressed for the day. This intervention was not added to either R602's at risk for falls or had an actual fall care plan. * R606's care plan and Kardex were not individualized to address R606's care needs. Additionally, items on the comprehensive care plan were not included on the Kardex. R606's care plan was not updated with fall interventions including crawling on a mat.

Inspectors wroteBased on interview and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R601) of 1 residents reviewed for weight loss. R601 sustained severe weight loss over a period of 7 months. The Physician was not notified, weight loss was not prescribed and no new interventions were implemented.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R606) of 3 Residents reviewed who was receiving a psychotropic medication, was free from unnecessary medications. * R606 has a PRN (as needed) order for Ativan, an anti-anxiety medication that did not have a documented rationale in R606's medical record that indicated the duration for the PRN order beyond 14 days. Findings Include: The facility's policy 14 Day PRN Psychotropic Medication Guideline Effective 11/28/17 documents: .A psychotropic medication order with instructions for PRN dosing shall be discontinued after 14 days. For PRN non-antipsychotic psychotropic orders: The PRN order may be extended beyond 14 days if the prescriber believes it is appropriate to extend the order. The Prescriber must document the rationale for the extended treatment in the medical record and indicate a specific duration of therapy. [...]

Inspectors wroteBased on observation, interviews and record review the facility did not provide functional furniture appropriate to the resident's needs in each resident's room to attain or maintain his or her highest practicable level of independence and well-being, including a clean, comfortable mattress for 1 of 1 (R609) residents reviewed. R609 was not provided a comfortable mattress.

Inspectors wroteBased on record review and interviews, the facility did not comprehensively provide medically related social services, to attain the highest psychosocial well-being, of a resident for 1 (R124) of 30 residents reviewed. *R124 verbalized, and attempted, to leave the facility to go home. The facility did not look at whether R124 still needed activation of power of attorney for health care and could, thus make own health decisions, did not look at alternatives to Sertraline, an antidepressant that R124 refused to take, did not look at discharge alternatives, and did not develop a plan of care for supervising R124 when agitated and expressing a desire to leave. On 6/23/24 R124 verbalized a desire to leave the facility and kept setting off alarms on the unit trying to leave, R124 was not permitted to do so. R124 then utilized their bed sheets to climb out a second-story window. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R109) of 5 residents reviewed for pressure injuries. On 05/29/2024, R109 developed a Deep Tissue Injury (DTI) and did not receive the care and treatment necessary for the healing of a pressure injury.

Inspectors wroteBased on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 148 residents. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: ~Reflect changes in program members. ~Include water management team members who were knowledgeable about the facility's water system. ~Identify control measures based on where Legionella could grow and spread and identify how to monitor the control measures and risks. ~Identify acceptable ranges of control limits (temperature ranges) and corrective actions to take when control limits are not met. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain mechanical and/or electrical equipment in safe operating condition. Surveyor observed the following: * A leaking, full grease tank from the kitchen next to the dryers in the laundry area. * Dryer vent with copious amounts of lint. * Washer for residents personal clothing leaking water. This deficient practice has the potential to affect all 148 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 2 of 5 sampled Certified Nursing Assistants (CNAs). This has the potential to affect the148 Residents who reside at the facility and have the potential to receive care from both CNAs. Findings Include: On 07/12/24 at 3:16 PM, Surveyor reviewed CNA-II and CNA-JJ's completed trainings for the past year and noted there was no documentation that CNA-II and CNA-JJ's received wertraining on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 of 5 sampled Certified Nursing Assistants (CNAs received annual training on the facility's compliance and ethics program. This has the potential to affect the148 Residents who reside at the facility and have the potential to receive care from both CNAs. Findings Include: On 07/12/24 at 3:16 PM, Surveyor reviewed CNA-II and CNA-JJ's completed trainings for the past year and noted there was no documentation that CNA-II and CNA-JJ's received training of the facility's compliance and ethics program. On 7/12/24 at 4:02 PM, Surveyor requested documentation from NHA (Nursing Home Administrator)-A for CNA-II and CNA-JJ that included training of the facility's compliance and ethics program. [...]

Inspectors wroteBased on record review, the facility did not properly complete a BID (Background Information Disclosure) form, DOJ (Department of Justice) form, and IBIS (Integrated Background Information System) form for 2 of 8 employees reviewed for the sufficient and competent staffing tasks. This has the potential to affect a pattern of residents whom may recieve care from both staff members.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent further potential abuse for 1 (R118) of 2 residents reviewed. On 6/9/24, R118 was discovered with his hands down R73 pants. R118 and R73 are roommates. Med tech- R separated both residents and reported the incident immediately. The facility moved R73 to a different room and placed a different resident in the room with R118. NHA-A stated the reason for placing a different roommate with R118 is because the new roommate was more verbal and able to voice if R118 would touch him. R118's care plan was not updated to reflect the inappropriate sexual behavior. The facility did not have structured monitoring of R118 and no evidence of supervision of R118 after discovering his hands down R73 pants. [...]

Inspectors wrote4.) R106 nurses notes dated 6/22/24 documents R106 was sent to the hospital due to an unresponsive episode and seizure like activity. There is no evidence, in the medical record, of a transfer notice completed for R106. On 6/27/24 at 3:00 p.m. during the daily exit meeting with NHA-A and DON-B, Surveyor asked for the transfer notice for R106's transfer to the hospital on 6/22/24. As of 7/1/24 Surveyor did not receive any additional information regarding R106 transfer notice. Based on record review and interview, the facility did not ensure residents received the required transfer notices, in writing, with a transfer from the facility. This was observed with 10 (R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81) of 10 resident transfer's reviewed. * R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81, were transferred from the facility to a hospital. [...]

Inspectors wrote4.) On 6/22/24, R106 was sent to the hospital due to an unresponsive episode and seizure like activity. There is no evidence, in the medical record, of a bed hold notice completed for R106. On 6/27/24 at 3:00 p.m. during the daily exit meeting with NHA-A and DON-B, Surveyor asked for the bed hold policy for R106's transfer to the hospital on 6/22/24. As of 7/1/24 Surveyor did not receive any additional information regarding why R106 did not recieve a bed hold notice on 6/22/24 when he was transfered to the hospital. Based on record review and interview, the facility did not ensure residents received the required bed-hold information, in writing, with a transfer from the facility. This was observed with 10 (R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81) of 10 resident transfer's reviewed. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure Preadmission Screening was completed or accurate for individuals with a mental disorder for 6 (R102, R140, R31, R47, R54, and R91) of 9 residents reviewed for PASARR (Preadmission Screening and Resident Review). *R102, R140, R31, R47, R54, and R91 had diagnoses mental disorders and medications to treat those disorders. A Level I PASARR should have triggered a Level II PASARR to be completed by the State Agency, but no Level II PASARRs were completed for these residents.

Inspectors wroteBased on interview and record review, the facility did not ensure comprehensive care plans were implemented and included participation by the resident or resident representative for 2 (R102 & R124) of 32 resident care plans reviewed. *R102 did not have any documented care conferences since admission on [DATE] and did not have a care plan developed that included R102's preferences. *R124 did not have any care conferences to discuss discharge planning and the care plan was not revised after elopement attempts or refusals to take antidepressant medication.

Inspectors wroteBased on interview and record review the facility did not ensure resident was free from misappropriation of property for 1 (R64) of 1 residents reviewed for misappropriation. * R64 had eight (8) oxycodone tablets go missing when facility staff did not complete a shift change narcotic count on 6/10/2024. The facility did not thoroughly investigate the missing narcotic tablets and the investigation did not include a conclusion of where the missing 8 oxycodone tablets went.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R499 and R118) of 3 abuse allegations reviewed were reported to the State Agency. * On 4/16/2024, R499 filed a grievance indicating she did not receive care. R499 alleged she did not receive cares overnight on 4/16/2024. The facility did not report this allegation to the State Agency. * On 6/9/24, R188 was found with his hand down R73's pants. The facility failed to submit the initial self-report within the 2-hour timeframe for an allegation of sexual abuse to the state agency and the police were not notified of this allegation of sexual abuse until the next day.

Inspectors wroteBased on record review and interview, the facility did not document in a resident's medical record the reason for a transfer to the hospital for 1 (R124) of 9 resident hospital transfers from the facility that were reviewed. * R124 was transferred to the hospital on 3/3/24. There is no documentation in the medical record, of reason and location of what hospital R124 was transferred to.

Inspectors wroteBased on observation and staff interview the facility did not develop and implement a comprehensive person-centered care plan for 1 (R72) of 29 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. *R72 was assessed to be at high risk for falls and only had one intervention on his care plan to prevent falls.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R10) of 4 residents reviewed received ADLs (Activities of Daily Living) including personal hygiene per plan of care. *R10 was observed to be disheveled, having a strong body odor and untrimmed fingernails with a brown substance underneath R10's nails throughout the survey. Findings Include: R10 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident and left upper and lower extremity contractures. Surveyor reviewed R10's Quarterly MDS (Minimum Data Set) dated 5/15/24. R10 is rarely to never understood. R10 has limitations in range of motion to their left upper and lower extremities. R10 requires total assistance with personal hygiene and bathing. On 6/25/24 at 9:25 AM, Surveyor observed R10 in bed in a hospital gown. R10 was positioned on their back. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not assess the risk of entrapment and review the risk & benefits for 1 (R10) of 1 residents observed having bilateral half bed rails.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medication for 1 (R54) of 2 Residents reviewed. * R54 received an antibiotic but did not meet the facility's criteria for the administration of the antibiotic. R54 also did not receive final dose of an antibiotic after returning to the facility from the hospital.

Inspectors wroteBased on interview and record review, the facility did not ensure coordination of care and the hospice communication process was followed for 1 (R119) of 4 residents reviewed for hospice services. The facility did not ensure hospice required documentation was maintained in R119's medical record. The facility did not have R119's hospice plan of care with the delineation of hospice's responsibilities and services provided, and communication process between the facility and hospice.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R499) of 32 residents reviewed based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. R499 developed Moisture Associated Skin Disorder (MASD) while residing in the facility. The facility did not perform skin checks throughout R499's stay from 4/15/24 through 5/3/24.

Inspectors wroteUNCORRECTED AT REVISIT Based on interview, observation and record review, the facility did not ensure 4 (R24, R27, R20 and R4) of 7 residents reviewed for quality of care, received treatment and care in accordance with professional standards of practice and a comprehensive plan of care. ~ R24 was a borderline diabetic with a HgA1c of 6.2 taken [DATE]. On [DATE] R24 was prescribed 60 mg Prednisone for scleritis for 4 weeks and then 6 weeks of tapering. (Prednisone raises blood glucose levels and should be monitored in long term use.) On [DATE] R24 was prescribed Seroquel for behaviors. R24 did not have an appropriate diagnosis for the medication, was not properly monitored for specific behaviors and did not have a care plan that address the psychotropic medication or any interventions for R24's behaviors. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that 1 (R25) of 1 Residents reviewed received appropriate treatment and services to increase mobility and/or to maintain current mobility and/or prevent further decrease in mobility. *R25 was walking 10 feet with a walker and transferring from bed to chair with a walker in the hospital, prior to admission to the facility. R25 did not receive physical therapy (PT) and occupational therapy (OT) at the facility, which resulted in R25 being completely dependent for mobility and being transferred by a Hoyer lift from bed to chair. R25 was not placed in a restorative program to maintain mobility status while waiting for authorization for PT and OT. R25 became depressed with feelings of hopelessness. R25 was unable to tolerate being up in a wheelchair for more than 1/2 hour without getting dizzy. [...]

Inspectors wroteUNCORRECTED AT REVISIT Based on observation, record review, and interview, the facility did not ensure adequate supervision and assistance devices, or ensure the environment remained free of accident hazards to prevent accidents for 3 (R30, R29, and R22) of 6 residents reviewed for accidents. *R30 had multiple falls where the root cause of the fall was not determined, and interventions were not observed to be in place to prevent future falls. R30 sustained a laceration to the scalp that required staples. The example regarding R30 rises to the scope and severity of actual harm. *R29 did not have a Smoking Care Plan in place until after multiple incidents of smoking in bed. R29 was observed to not have a smoking apron on per care plan when smoking in the designated smoking area. *R22 was observed to be transferred without the use of a gait belt as per care plan.

Inspectors wroteBased on interview and record review the Facility did not ensure 2 (R32 & R23) 6 Residents were free from significant medication errors. * R32 missed 15 doses of Divalproex Sodium during December 2023 and 5 doses during January 2024. On 1/3/24 the Facility was notified R32's Valproic acid level was low at 17 (reference range 50-100). On 1/4/24 R32 experienced two seizures and was transferred to the hospital. R32 did not return to the Facility. * R23 has a diagnosis of Crohn's disease. Crohn's disease causes inflammation in the digestive tract with symptoms that include diarrhea and cramping & pain in the abdomen. R23 missed 42 doses of Diphenoxylate-Atropine 2.5-0.025 mg (milligram), a medication to treat diarrhea, during October 2023 and 38 doses during November 2023.

Inspectors wroteBased on observations, interview, and record review, the facility did not help prevent the transmission of COVID-19, that had the potential to affect 161 of the 161 residents at the facility. The facility had a COVID-19 outbreak [DATE] to 3/2/ 2024 that caused positive test results for 40 residents and 8 staff members with one resident, R33, testing positive and passing away during the outbreak. Agency staff members were not fit-tested for N95 masks, and 57 agency staff members provided services at the facility from [DATE] to [DATE]. Residents that were COVID-19 positive continued to congregate in the smoking area, passing through the hallways with face masks not worn appropriately or at all per interview.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure 1 (R24) of 1 residents reviewed for planning and implementing care were given the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care and treatment. R24 had an activated Healthcare Power of Attorney (POA) for decision making. R24 was prescribed Seroquel (Antipsychotic medication) in December 2023 and R24's activated POA was not made aware of the prescribed medication and a consent for the medication was not signed by the activated POA.

Inspectors wroteBased on record review and interview the Facility did not ensure 2 (R32 & R23) of 4 Resident's reviewed had consultation with a physician when a change in treatment and care occurred. * R32's physician was not consulted with when R32 missed multiple doses of Divalproex Sodium during December 2023 & January 2024. On 1/3/24 the Facility was consulted with R32's Valproic acid level was low at 17 (reference range 50-100). There is no evidence R32's physician was consulted with regarding this lab and on 1/4/24 R32 experienced two seizures and was transferred to the hospital. * R23's diagnosis includes Crohn's disease. R23's physician was not consulted with when R23 missed multiple doses of Diphenoxylate-Atropine, a medication to treat diarrhea, during October 2023 & November 2023. On 11/23/23 R23 was vomiting all evening shift and into the night shift. R23's physician was not consulted with.

Inspectors wroteUNCORRECTED AT REVISIT Based upon observation, interview, and record review, the facility did not ensure a grievance submitted for 1 (R24) of 16 residents reviewed was resolved and the resolution was implemented. A grievance was filed on behalf of R24 indicating the facility staff do not get R24 out of bed. R24 was to be up and out of bed by 8:00 am. During the survey R24 was observed to not be up and out of bed throughout the day, including by 8:00 am. Facility staff indicated R24 refuses to get up, there is no indication this has been assessed as part of the grievance process or care planned if the behavior occurs.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R23) of 1 Residents discharged to the community received a completed discharge summary. R23 was discharged on 11/24/23. The Facility did not complete a discharge summary including a recapitulation of R23's stay.

Inspectors wroteUNCORRECTED AT REVISIT Based on observation, interview, and record review, the facility did not ensure 1 (R4) of 4 residents reviewed for Activities of Daily Living who was unable to conduct activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene . R4 was not provided oral care while at the facility.

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R16 & R4) of 3 residents reviewed for pressure injuries. * The weight for R16's air mattress was not set according to physician orders. Treatment to R16's heel was not completed on 3/2/24 & 3/3/24. R16 developed a pressure injury above the right heel which was identified in a picture on 3/4/24. As of 3/7/24, this area was not comprehensively assessed and there was no treatment until 3/7/24. R16's sacrum pressure injuries were not comprehensively assessed individually but measured and assessed as one area. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R23) of 1 Residents reviewed for an indwelling catheter had a valid medical justification for continued use of the indwelling catheter and received the necessary services for monitoring of the indwelling catheter. R23 was originally admitted to the Facility with a Foley catheter on 10/19/23 & upon return from the hospital on [DATE]. There is no medical justification for the continued use of the indwelling catheter as Facility documentation indicates R23's Foley catheter is in place for healing of excoriation buttocks due to Crohn's disease. R23 had MASD (moisture associated skin damage) and did not have any pressure injuries. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 2 (R23 & R21) of 4 Residents reviewed for nutrition maintained acceptable parameters of nutritional status. * R23's nutritional needs were not assessed while R23 resided in the Facility, weights were not obtained per Facility guidelines and a nutritional care plan was not developed. * R21's weights were not obtained per Facility guidelines.

Inspectors wroteBased on interview, and record review, the facility failed to ensure hemodialysis care and services were provided consistent with professional standards of practice which included the development of policies and procedures, development of a comprehensive dialysis care plan, ongoing assessments, monitoring for complications before & after dialysis treatments received at a certified dialysis center, and ongoing communication and collaboration with the dialysis center for 2 (R4 & R21) of 2 Residents reviewed for dialysis. *R4 receives dialysis 3 times a week and did not have completed communication reports by the facility prior to going to dialysis. R4 does not have a person-centered focused care plan addressing then need for dialysis. *R21 received dialysis 3 times a week and did not have completed communication reports by the facility prior to going to dialysis. [...]

Inspectors wroteBased on interview, and record review the facility did not ensure the physician wrote, signed, and dated progress notes at each visit for 2 (R24 and R4) of 2 residents reviewed for Medical Doctor (MD) visit notes. Resident visit notes for R24 and R4 were not available in Electronic Medical Records (EMR) for Nurse Practitioner (NP)-D.

Inspectors wroteBased on interview and record review the facility did not ensure that 3 ( R21, R31 and R25) of 15 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. *R21 and R31 engaged in a Resident to Resident altercation on 1/13/23. The facility did not initiate behavior monitoring, psychiatric evaluations, follow up after the incident, or create person-centered care plans with individualized interventions keep all Residents in the facility safe. *The facility did not ensure R25 received therapy services upon admission, initiate ancillary referrals, initiate and update discharge planning which included options counseling for R25. The facility failed to monitor R25's mood status which includes updates to R25's care plan with person centered interventions. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R24, R27 and R20) of 6 residents reviewed for medications were not adequately monitored for insulin administration. ~ R24 was receiving fast acting insulin prior to meals. The facility was not checking for therapeutic blood glucose (BG) levels before administering the fast acting insulin per documentation. Surveyor observed staff providing a meal prior to administration of insulin. ~ R27 had orders for 4 times daily BG monitoring. This was not completed per order. On discharge from the hospital, it was recommended R27 have Sliding Scale (SS) insulin ordered until diabetes was controlled which was not completed. ~ R20 was admitted with orders for three times daily blood glucose levels. The order was not transcribed into the orders and was not completed. ~R20 returned to the facility from a hospital stay on 2/14/24. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that 1 (R24) of 6 sampled residents reviewed for medications were free from unnecessary psychotropic medications. R24 was prescribed Seroquel for behaviors. R24 did not have an appropriate diagnosis for the medication, was not properly monitored for specific behaviors, did not have a care plan addressing the psychotropic medication or any interventions for R24's behaviors.

Inspectors wroteBased on interview and record review the facility did not ensure that Residents received specialized rehabilitative services that were ordered upon admission to the facility for 2 (R21 and R25) of 2 Residents reviewed for rehabilitation services. *R21 had physician orders upon admission dated 11/22/23 for physical (PT), occupational (OT), and speech (ST) therapy. R21 was admitted to the facility on [DATE] and discharged from the facility on 2/16/24 and did not receive PT, OT, and ST during their stay at the facility. *R25's hospital Discharge summary dated [DATE] documented R25 was to receive PT and OT and to be up in chair 3 times daily. On 2/21/24, ST was to evaluate R25 for potential difficulty with chewing and/or swallowing. R25 has not received PT, OT, or ST since their 12/29/23 admission. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use for 1 (R24) of 1 resident reviewed for antibiotic use. R24 was prescribed Rocephin IM (intramuscularly) antibiotic for an infection without verification that the infection met McGeer's criteria per protocol.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 (R1 and R4) of 18 residents reviewed for accidents. R1, who is severely cognitively impaired, was assessed to be at risk for wandering/elopement upon admission to the facility. The facility implemented the use of a wander guard and R1 was placed on a secure unit on the second floor upon admission. R1 eloped from the facility on 9/30/20. R1 again eloped from the facility on 10/29/2023 around 3:28 AM. R1 was found outside the facility around 4:26 AM. When the door alarm sounded, staff did not immediately search the stairwell, even though it led to a area with an unsecured/unalarmed door to the outside. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure they provided care and treatment, based on a comprehensive assessment and professional standards of practice, to 2 (R2 and R6) out of 18 residents who experienced changes in their condition and needed further evaluation. R2 began to experience symptoms of a cold with productive cough, secretions and wheezing. R2 began to have swallowing difficulties as a result and refused medications on 3 medication passes. The facility did not notify the Physician and did not provide further assessment of R2 until 4 days later when R2 requested to be sent to the hospital after having trouble breathing. R2 was diagnosed with Pneumonia. R6 tested positive for COVID-19 on 11/14/23. There was no monitoring of vital signs or lung assessments on subsequent days. On 11/20/23, R6's family transferred R6 to the hospital. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure 1 (R15) of 5 residents reviewed for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. R15 was admitted to the facility with a stage 3 pressure injury to their sacrum. admission orders included to assess R15 using a Braden Scale to assess for risk for developing pressure injuries. This was indicated as completed on the treatment administration records but there was not consistent indication this was completed. The facility assessments of R15's pressure injury did not include all details to show actual percentages of the wound bed tissue to help monitor for improvement or deterioration. [...]

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure they provided proper pain management for 1 (R16) out of 3 residents reviewed for pain management. The facility did not ensure that they developed and implemented a plan of care, based on a comprehensive assessment, to assist in managing R16's pain during daily wound treatments and movement during cares. Staff was aware R16 experienced pain with movement but the plan of care had not been updated to reflect possible interventions to reduce or eliminate pain during treatments and cares and while moving R16. The plan of care did not indicate what is the level of pain that R16 can tolerate, what provides relief for the pain and if there is any non-pharmacological intervention to help with pain relief.

Inspectors wroteBased on record review and interviews with staff and residents, the facility did not always ensure that they made prompt efforts to resolve grievances brought forward by residents or family members for 2 (R4 and R5) of 5 residents reviewed for grievances. The facility does not follow grievance policy and procedures to document, investigate and resolve grievance promptly. Grievance signage on first and second floor have incorrect contact information for the Grievance Official. R4 expressed concerns to Scheduler-H that they did not want to work with Certified Nursing Assistant (CNA)-Q anymore due to an incident that occurred on 11/2/23. This care concern was not documented, investigated and not resolved promptly by the facility. R3 has had missing clothing since admission. There is no documented grievance for R3 and the missing clothes. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure training to their staff that at a minimum educates staff on- Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Dementia management and resident abuse prevention. During review of the facility's staff training, 1 of 5 Certified Nursing Assistants (CNAs) did not complete dementia training and 3 of 5 CNAs did not complete Abuse training. This had the potential to affect a pattern of the 155 residents in the facility based upon unit assigned.

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 5 of 5, CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours.

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately (but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury) to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures and report the investigation results within 5 working days of the incident. R9 and R10 were involved in an allegation of sexual assault on 12/18/23. The Director of Nursing was made aware of the incident and did not report the incident to administration. Multiple staff heard rumors of the incident and did not report it to the administration. [...]

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate 2 of 6 reportable incidents reviewed for abuse and misappropriation. R9 and R10 were alleged to have been involved in a sexual assault on 12/18/23. The Director of Nursing was made aware of the incident and did not notify Facility Administration or the State Agency and the incident was not investigated. R2's Power of Attorney reported R2 was missing eighty eight dollars and soda and the alleged misappropriation of resident property was not thoroughly investigated.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure 1 (R16) out of 4 residents, who are unable to carry out activities of daily living, received assistance to maintain grooming and personal hygiene.

Inspectors wroteBased on observation, staff and resident interview, and record review the facility did not provide a safe, clean, comfortable home-like environment which had the potential to affect all 167 residents residing in the facility. The 100, 200, 300, 400 unit hallways and multiple resident rooms contained damaged and missing ceiling tiles, dusty fans, dirty bedside tables, soiled privacy curtains, dirty wheelchairs, sticky floors, and urine odors. In addition, the floors in multiple hallways and resident rooms contained debris, clutter, used linens, and bags of garbage. Common areas on the first and second floors contained missing and stained ceiling tiles, bags of garbage, and clutter. Multiple staff and residents reported the facility did not have enough supplies, including Styrofoam cups, briefs, wash cloths, towels, and soap. The facility had extra supplies in a supply cage downstairs; [...]

Inspectors wroteBased on observation, staff and resident interview, and record review the facility did not ensure meals were served at regular times. This practice had the potential to affect all 167 residents residing in the facility. On 10/16/23 and 10/17/23, the facility began the breakfast and lunch meal service more than 30 minutes after the posted meal time. On 10/17/23, the facility began the dinner meal service more than 40 minutes after the posted meal time.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure staff wore name badges to identify themselves. This had the potential to affect multiple residents residing in the facility. On 10/16/23, 10/17/23, and 10/18/23, multiple facility, agency, and contracted staff were observed on resident units, in resident rooms and/or providing care without name badges.

Inspectors wroteBased on staff interview and record review, the facility did not ensure grievances were documented, thoroughly investigated, and resolved for 4 Residents (R) (R19, R18, R21, and R20) of 4 sampled residents. The facility's monthly grievance logs contained three grievances for R19 between 5/2/23 and 7/28/23. The grievances were not thoroughly investigated. The facility's monthly grievance logs contained two grievances for R18 between 7/6/23 and 8/1/23. The grievances were not thoroughly investigated. The facility's monthly grievance logs contained two grievances for R21 between 6/13/23 and 9/18/23. One grievance was not documented on a grievance form, and both grievances were not thoroughly investigated. The facility's monthly grievance logs contained one grievance for R20, dated 6/14/23. The grievance was not thoroughly investigated.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure residents received treatment and services in accordance with professional standards of practice for 4 Residents (R) (R8, R28, R29, and R4) of 7 sampled residents. R8's Treatment Administration Record (TAR) did not indicate surgical wound care was provided for 5 of 12 scheduled treatments. R28's and R29's blood pressure was not assessed in accordance with the facility's standard of practice. R4's TAR did not indicate wound care was provided for 11 of 50 scheduled treatments between August and September of 2023. In addition, R4's right lower extremity drainage was not documented for 49 of 105 shifts between August and September of 2023.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure there was adequate supervision to prevent accidents and the environment was as free of accident hazards as possible for 1 Resident (R) (R25) of 5 residents reviewed as well as 29 out of 29 residents who resided on the secured dementia unit. R25 had a diagnosis of congestive heart failure (CHF) and used oxygen via nasal cannula. On 10/16/23 and 10/17/23, cigarettes, lighters and a vape pen were observed in R25's room which was not in accordance with the facility's smoking policy. The facility did not ensure 29 of 29 residents on the secured dementia unit were supervised at all times.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide services to prevent a urinary tract infection (UTI) for 5 Residents (R) (R2, R38, R39, R46, and R21) of 7 sampled residents. R2's urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) tubing was draped over R2's mattress and above the level of R2's bladder. On 10/16/23, 10/17/23, and 10/18/23, R38, R39, R46, and R21's catheter bags were uncovered, in contact with the floor, and visible from the hallway.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for 6 Residents (R) (R21, R19, R22, R29, R28, R50) of 18 sampled residents reviewed for medications. On 10/16/23 at 9:15 AM, Surveyor observed an uncapped insulin pen on R21's bedside table which staff indicated was left there on the previous PM shift. On 10/16/23, Surveyor observed Licensed Practical Nurse (LPN)-KK administering AM medications on the 200 unit at 10:25 AM. LPN-KK indicated 4 residents on the unit had not yet received their AM medications. On 10/16/23, R19's AM and 12:00 PM medications were administered late and/or not provided with breakfast and lunch as indicated. In addition, LPN-H left the room before R19 took the 12:00 PM medications. R19 did not have a physician's order to self-administer medication. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure menus and dietary instructions were followed for 6 Residents (R) (R21, R22, R36, R19, R56, and R26) and multiple residents who were prescribed carbohydrate-controlled diets. On 10/16/23 at 9:25 AM and 10/17/23 at 9:08 AM, Surveyor observed R21's breakfast room tray and noted R21's meal ticket was not followed. On 10/17/23 at 12:33 PM, Surveyor observed R22's lunch tray and noted R22's meal ticket was not followed. On 10/17/23 at 1:35 PM, Surveyor observed R36's lunch tray and noted R36's meal ticket was not followed. On 10/17/23 at 1:42 PM, Surveyor observed R19's lunch tray and noted R19's meal ticket was not followed. On 10/17/23 at 9:23 AM, Surveyor observed R56's breakfast tray and noted R56's meal ticket was not followed. [...]

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure food was palatable and served at an appetizing temperature for 6 Residents (R) (R37, R19, R40, R42, R41, and R52) of 20 residents reviewed. R37, R19, R40, R42, R41, and R52 indicated the food was not palatable, appetizing, or served at a temperature they preferred.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of water in a timely manner for 6 Residents (R) (R22, R27, R25, R18, R33, and R40) of 13 sampled residents. Staff did not ensure R22, R27, R25, R18, R33, and R40 were provided water in a timely manner.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide a sanitary environment to help prevent the transmission of communicable disease and infection for 4 Residents (R) (R55, R51, R2, and R19) as well as multiple other residents residing on the first floor of the facility. From 10/16/23 through 10/18/23, fruit flies were observed on multiple items in common areas, including trays of uneaten food and a bucket of snacks. In addition, fruit flies were observed on multiple items in R55, R51, and R2's rooms. On 10/16/23, Surveyor observed Licensed Practical Nurse (LPN)-H check R19's blood sugar with a glucometer. Following the accucheck, LPN-H placed the glucometer on R19's bedside table without a barrier and then placed the glucometer in the medication cart. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R2) of 1 resident who had a Guardian received services to ensure court-ordered protective placement was obtained. R2's medical record indicated R2 was under guardianship. The facility did not ensure R2 had a court-order to be protectively placed at the facility.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R19) of 6 sampled residents had a self-administration of medication assessment, or a physician's order to self-administer medication and keep medication at the bedside. R19 kept an inhaler and nasal spray on R19's bedside table and stated R19 self-administered both medications. R19 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R19 could safely and accurately self-administer medication.

Inspectors wroteBased on observation, resident and staff interview, and record review, staff did not ensure call lights were within reach for 3 Residents (R) (R25, R18, and R2) of 7 sampled residents. On 10/16/23, Surveyor observed R25's call light on the floor and not within reach. On 10/17/23, Surveyor observed R18's call light on the floor and not within reach. On 10/17/23, Surveyor observed R2's call light on the floor and not within reach.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for background checks. Licensed Practical Nurse (LPN)-Z's last completed background check forms were dated 4/13/18. Certified Nursing Assistant (CNA)-K's last completed background check forms were dated 6/11/19.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R5) of 22 sampled residents. R5 alleged a staff member hit R5 and stomped on R5's foot in March of 2023. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R14) of 1 resident reviewed for hospitalization received written information regarding the facility's bed hold policy, including the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. R14 was transferred to the hospital on 7/10/23 and was not provided a bed hold notice upon transfer. In addition, R14 could not return to R14's original room when R14 returned to the facility on 7/19/23.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not follow an intervention on a skin integrity care plan for 1 Resident (R) (R19) of 6 sampled residents. R19 was at risk for impaired skin integrity. A care plan intervention indicated linens should not be creased or folded under R19 and staff should keep R19's bedding as smooth as possible. The intervention was not consistently implemented.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not review and revise the plan of care for 2 Residents (R) (R21 and R25) of 6 sampled residents. R21's plan of care indicated R21 had an unstageable pressure injury on the left heel and contained interventions for a left heel boot and to elevate heels while in bed. R21's right and left lower extremities were amputated. R25's plan of care indicated R25 had a pressure injury on the sacrum. R25's pressure injury was healed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure call lights were answered and/or care was provided timely for 3 Residents (R) (R52, R34, and R28) of 4 sampled residents. On 10/16/23 at 6:02 AM, Surveyor noted R52's call light was activated. Staff answered the call light 30 minutes later at 6:32 AM and responded to R52's needs. On 10/17/23 at 9:09 AM, Surveyor noted R34's call light was activated. Staff entered the room and shut off R34's call light multiple times before care was provided 65 minutes later at 10:14 AM. On 10/16/23 at 12:31 PM, Surveyor noted R28's call light was activated. Staff answered the call light 27 minutes later at 12:58 PM and responded to R28's needs.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide nephrostomy care consistent with professional standards of practice for 1 Resident (R) (R28) of 1 resident who required nephrostomy care. Staff did not follow R28's physician orders related to nephrostomy care which resulted in one missed left and right nephrostomy dressing change. In addition, staff incorrectly measured R28's left and right nephrostomy output.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 8 errors occurred during 32 opportunities which resulted in a 25% medication error rate affecting 1 Resident (R) (R29) of 5 residents observed during medication pass. On 10/17/23, R29's 9:00 AM medications were administered at 1:15 PM.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a safe and comfortable environment for multiple residents residing on both floors of the facility. The second floor common area near the elevator contained missing ceiling tiles and two large biohazard pails with water in the middle of the hallway. The area was used by multiple residents to access the first and second floors of the facility.

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure 4 (R66, R88, R69, R43) of 5 residents reviewed for accidents received care and services to prevent accidents. * On 3/24/23, R66 fell out of bed and suffered a fractured right hip. R66's care plan intervention dated 2/11/23 indicated her bed should be in the low position and at the time of the fall her bed was not in the low position. A thorough investigations as to why her bed was not in the low position was not conducted. Interviews were not conducted with staff or the resident after the fall to see why her bed was not in the low position at the time of the fall. In addition the post fall report indicated it was possible R66 was playing with the bed controller and no intervention was provided to prevent this in the future and no evidence was provided this was a problem before the fall on 3/24/23. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility did not store food in accordance with professional standards for food service safety. This deficient practice had the potential to effect 161 of the 166 residents who receive food from the facility kitchen. Facility kitchen observations include: Food in unsealed bags in which the food item was exposed to the air, and without an open or use by date label on bag. Packages of food that ripped open and debris fallen onto floor. Food in bags that had mold on it. Open cans of soda mixed in with facility food. Staff coat hanging on a rack with facility food. Shiny wet substance on floor under rack.

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 5 Residents (R128, R17, R66, R151) reviewed for hospitalizations received a notice of transfer which includes, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R128 was transferred to the hospital on 2/13/23, 2/22/23, 3/19/23 and 4/13/23. R128 and the legal representative was not provided with the transfer notice. R17 was transferred to the hospital on 3/2/23 and R17 and the legal representative was not provided with a transfer notice. R66 was transferred to the hospital on 3/24/23 and R66 and the legal representative was not provided with a transfer notice. R151 was transferred to the hospital on 4/4/23 and R151 and the legal representative was not provided with a transfer notice. This is evidenced by: Surveyor reviewed the facility policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 5 Residents (R17, R66, R151, R128) reviewed for hospitalizations received a written notice of the bed hold policy upon transfer to the hospital. R128 was transferred to the hospital on 2/13/23, 2/22/23, 3/19/23 and 4/13/23. R128 or the legal representative was not provided with a written copy of the bed hold notice. R17 was transferred to the hospital on 3/2/23 and R17 or the legal representative was not provided with a written copy of the bed hold notice. R66 was transferred to the hospital on 3/24/23 and R66 or the legal representative was not provided with a written copy of the bed hold notice. R151 was transferred to the hospital on 4/4/23 and R151 or the legal representative was not provided with a written copy of the bed hold notice. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not develop and implement a comprehensive person-centered care plan for 4 (R43, R81, R25 and R95) of 33 residents reviewed. * R43 did not have a comprehensive plan of care addressing smoking. * R81 did not have a comprehensive plan of care addressing hospice services. * R24 did not have a comprehensive plan of care addressing the use of anticoagulant medication. * R95 did not have a comprehensive plan of care addressing pain.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 7 out of 11 residents (R95, R93, R130, R76, R140, R90, R15) reviewed for potential weight loss, received treatment and services to maintain acceptable parameters of nutritional status. R95, R93, R130, R76, R140, R90 and R15 were assessed to be at nutritional risk and had documented weight loss. The facility did not provide additional assessment or care plan interventions to assist in residents maintaining their nutritional status. This is evidenced by: Policy review: Weight Monitoring Guideline. Effective date 4/6/2018. Revised 7/1/2019. Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters. [...]

Inspectors wroteBased on observation and interview the facility did not ensure drugs and biological's used in the facility were stored with currently acceptable principles, including proper temperature controls. This deficient practice has the potential to affect 83 of 83 residents residing on the 400, 500 and 600 unit. The facility did not ensure drugs and biological's used in the facility were labeled with an applicable expiration date and not used past the expiration date. This deficient practice affected 11 residents (R121, R92, R36, R32, R89, R87, R131, R2, R31, R136, R173). *The medication refrigerator in the second floor medication room did not have a thermometer or a temperature log. * R121, R92, R31, R87 and R36 had open and used eye drops which had expired. * R92, R131, R136, R173, R2, R32, and R89 had open and used eye drops that were not dated when opened. [...]

Inspectors wroteBased on observations, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of commuicable disease and infection such as COVID-19, when facility staff did not follow standards of practice in the sanitizing a shared glucometer and when staff were not either wearing the appropriate Personal Protective Equipment (PPE) and/or was not wearing PPE correctly. This deficient practice had the potential to affect the 8 residents who share the glucometer on the 300 and the 2 residents who share a glucometer on the 500 unit, as well as those residents residing on the 300 and 600 units. *Surveyor noted facility staff not disinfecting shared glucometers at the facility for obtaining resident blood sugars. [...]

Inspectors wroteBased on observation, interview and record reviewthe facility did not ensure 2 (R2 and R66) of 2 residents with catheters were treated with dignity and respect. * R2's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors for 3 days of the survey. A strong odor of urine was smelled in R2's room on 4/24/23. * R66's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors for 3 days of the survey.

Inspectors wroteBased on record review and interview, the facility did not include resident participation in the development and implementation of the person-centered plan of care for 1 (R112) of 33 sampled residents. R112 did not have a care conference, that included R112 or R112's representative, in order to develop, implement, or revise a plan of care since 2/11/2022 (over a year ago), the day after R112 was admitted to the facility.

Inspectors wroteBased on record review and interview, the facility did not formulate an advanced directive that the resident requested for 1 (R112) of 33 sampled residents. R112's Care Plan stated R112 had an advanced directive of being a full code; the electronic medical record indicated R112 had a status of Do Not Resuscitate (DNR). No DNR form had been completed with a physician signature indicating R112 was a DNR.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that they implemented their abuse policies by permitting 3 out of 8 employees reviewed, to work without being properly screened by passing the criminal background check. In addition, the facility did not implement its abuse policies by conducting an updated background check on employees every four years. CNA- AA was originally hired on 3/1497. The facility did not complete all 3 components of an updated, every four-year, background check by obtaining Background Information Disclosure (BID) form from CNA- AA in 2021 or thereafter. CNA- BB was hired on 2/14/23. The facility did not obtain the BID form prior to CNA- BB being permitted to work with residents at the facility. CNA- CC was hired on 8/3/22. [...]

Inspectors wroteBased on record review and interview, the facility did not report an allegation of misappropriation to the police for 1 (R228) of 1 Facility Reported Incidents reviewed. R228 alleged $120 was missing and the police were not called to investigate the allegation.

Inspectors wroteBased on observation, record review and interviews, 1 Resident (R107) of 33 sampled residents reviewed did not receive required assistance with Activities of Daily Living (ADLs). * On 4/23 and on 4/24/23, R107 appeared disheveled, with unkempt hair, long facial hair and body odor. There was no indication R107 receive a shower in the past 30 days or that R107 was provided with services that maintained good grooming and personal hygiene.

Inspectors wroteBased on observation, record review and interviews, 1 Resident (R478) of 33 sampled residents reviewed did not receive quality of care in accordance with their physician orders * R478 was not provided with elastic tubi-grip stockings to treat their lower extremity edema per physician orders.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure pressure injury preventive measures were implemented. This was observed with 2 (R49 and R151) of 6 residents reviewed for pressure injury. * R49 was observed with their heels against the mattress and not off-loaded. * R151 was observed to have her air mattress at an improper setting for effectiveness. On 4/23 and 4/24/23, R151's air mattress was set incorrectly at 210 mm/hg (millimeters/mercury) rather than in accordance with manufacturer instructions which would have been according to R151's weight and which should have been set at 120 mm/hg.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure a resident with a limited range of motion received appropriate equipment to maintain or improve mobility with the maximum practicable independence for 1 (R53) of 4 residents reviewed for limited range of motion. R53 had contractures to both hands and Occupational Therapy had recommended the use of a palm protector to the left hand, a rolled washcloth to the right hand, and red foam built up on feeding utensils to promote independence with eating. A palm protector, a washcloth, and the red foam adaptive device was not in use by R53 as recommended.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure pharmaceutical services including accurate acquiring and timely administering of medications to meet the needs of each Resident for 1 (R130) of 33 Residents reviewed and 1 (R51) supplemental resident. *R130 did not receive their morning medications until 1:30pm on 04/24/2023 which resulted in a missed dose of at least one medication. *R51 returned from the hospital on [DATE] with an order for Hydralazine. The Medication Administration Record indicated the medication was administered on 4/23 and 4/24/23 at 12:00 am, 8:00 am and 4:00 pm however, the pharmacy never dispensed the medication due to a listed allergy which needed clarification, and the medication was not in contingency. R51's physician was not notified until 04/25/23.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 1 out of 3 residents (R69) reviewed for the use of psychotropic drugs was assessed for adverse drug reactions and side effects. * R69 has received antipsychotics on a routine basis. The facility did not regularly conduct an AIMS (Abnormal Involuntary Movement Scale) assessment to measure for involuntary movements known as tardive dyskinesia, a possible side effect for the use of psychotropic medication. This is evidenced by: Review of facility policies; Behavior Management Program, effective date 11/28/2017 Purpose: The purpose of the Behavior Management Program is to promote and provide the highest practicable quality of life and a safe environment for residents and staff. Responsible party: Nursing, Social Services, Activities, Therapy, Pharmacy. Procedure: (includes) 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure medical records were complete, and accurately documented for 1 (R175) of 36 residents sampled. * On [DATE] R175 had a change in condition while at the inhouse dialysis. R175 coded while in dialysis with both dialysis and facility staff responding and providing CPR. The paramedics arrived and while in transport to the hospital, R175 expired. R175's medical record was not complete in that the facility staff did not document on R175's change of condition and their involvement with R175's change in condition prior to expiring on [DATE].

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure collaboration with hospice representatives and facility staff to coordinate the care planning process and did not ensure hospice was notified of a significant change in the resident's physical status for 1 (R81) of 3 hospice residents reviewed. * R81 did not have any care conferences with the facility and the hospice agency to coordinate a plan of care between the two entities and when R81 developed COVID-19, no documentation was found showing the hospice agency was notified of the change in condition.

Inspectors wroteBased on record review and interview, the facility did not offer the influenza and/or pneumococcal immunizations for 3 (R53, R93, and R24) of 5 residents reviewed for immunizations. * R53 was not offered the influenza immunization on admission to the facility and did not document if the immunizations were offered and declined. * R93 was not offered the influenza immunization for the 2022 influenza season and did not document if the immunizations were offered and declined. * R24 was not offered the Prevnar 13 immunization on admission to the facility and did not document if the immunizations were offered and declined.