Bridgewood Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy and ensure timely and correct documentation of medication administration and pre-signed medication was administered prior to the medication being administered for two sampled residents (Resident #1 and Resident #5) of eight sampled residents. The facility census was 114 residents. Review of the facility's policy titled Medication Administration Policy, dated 06/26/24, showed:-It was the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines.-Staff were to ensure that the six rights of medication administration were followed:--Right resident.--Right medication.--Right dosage.--Right route.--Right time.--Right documentation.-Staff were expected to sign the medication administration record (MAR) after administering the medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's Crisis Prevention Institute (CPI) policy for one sampled resident (Resident #3) with a history of aggression towards staff out of eight sampled residents. On 07/20/26 around 8:30 A.M., Resident #3 became mad and impatient with Certified Medication Technician (CMT) related to a change in medication administration, resulting in the resident's medication administration being delayed. The resident demanded the CMT hurry up. CMT A told the resident he/she could wait or come back later, because the CMT was finishing a different resident's medication administration. The resident again demanded the CMT speed up and the CMT ignored the resident. The resident then walked up to the entrance door of the medication room, started to curse the CMT, and told CMT A that he/she was done. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep one sampled resident safe from resident-to-resident abuse when on 7/6/26 at approximately 6:55 P.M., Resident #1 struck Resident #2 with a closed fist causing a bruise to the eye out of three sampled residents The facility census was 115 residents. The facility Administrator was notified on 7/15/26 of the past non-compliance which occurred on 7/6/26. The residents were separated and root cause to the resident to resident abuse identified with intervention. Situational specific in-services regarding Abuse and Neglect including de-escalation techniques were conducted for all facility staff, beginning with the specific unit staff and including all facility staff. All in-servicing was completed by 7/8/26. The deficiency was corrected by 7/8/26. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that two sampled residents (Resident #1 and Resident #4) out of five sampled residents were free from abuse. On 5/8/26, Resident #2 struck Resident #1 on the face- resulting in a laceration to Resident #1's right eye requiring five sutures. On 5/17/26, Resident #5 kicked Resident #4 in the head resulting in a bump on Resident #4's forehead and a laceration on the scalp requiring two staples. The facility census was 121 residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent physical abuse for one sampled resident (Resident #1) out of 14 sampled residents. On 4/24/26, Resident #2 struck Resident #1 on the head and face. Resident #1 sustained facial injuries, including two black eyes, scratches under the eyes, injury/marking in the middle of the nose area, abrasion on the right forehead and red marks on both cheeks. Resident #1 was sent to the hospital. The facility census was 121. Review of the facility Abuse and Neglect Policy, dated 11/28/16 and revised on 06/12/24, showed:-Purpose:-Physical Abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal of inhumane manner. Handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent physical abuse of four residents (Resident #1, #4, #5, and #6) out of six sampled residents. On 4/14/26 Resident #5 kicked Resident #6 on the leg. Resident #6 struck Resident #5 with a closed fist on the right side of the head. Resident #5 sustained swelling to his/her head and Resident #6 sustained injury to his/her right knuckles. On 4/16/26, Resident #6 kicked Resident #4. On 4/17/26 Resident #2 struck Resident #1 resulting in a laceration to Resident #1's left eye. The facility census was 127 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect seven sampled residents (Resident #1, #2, #5, #6, #8, #12, and #16) out of 18 sampled residents from physical abuse between residents. On 3/23/26 at 7:30 P.M. Resident #2 approached Resident #1 and a verbal argument between the residents escalated into a physical argument with both Resident #1 and Resident #2 punching one another in the face and torso areas. Resident #1 then pulled a broken pair of scissors from his/her pants pocket and stabbed Resident #2 in the left forearm. Resident #2 was sent to the hospital and diagnosed with a concussion and received two sutures to the left forearm. On 3/25/26 at about 8:00 P.M., Resident #3 struck Resident #6 in the right eye which caused Resident #6 to fall and hit his/her head on the wall. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement facility practices and procedures to support behavioral health services when resident's had verbal altercations that lead to physical altercations for two sampled residents (Resident #1 and #2) out of 18 sampled residents. On 3/23/26 Certified Medication Technician (CMT) A witnessed a verbal argument between Resident #1 and Resident #2 and failed to initiate a Code [NAME] (a behavioral emergency or a request for immediate assistance to de-escalate a combative, aggressive, or out-of-control resident, often involving a specially trained response team) in a timely manner. Resident #1 and Resident #2 escalated into a physical argument where both Resident #1 and Resident #2 punched one another and Resident #1 stabbed Resident #2 in the left forearm with a pair of scissors. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy by not gathering witness statements when conducting an investigation of abuse for four sampled residents (Resident #3, #5, #6, and #18) out of 23 sampled residents. The facility census was 129 residents. Review of the facility policy for Abuse and Neglect, revised 6/12/24, showed the Administrator/Designee was to complete an administrative investigation to include personal statements from staff and residents involved in any situation that had any type of accusation of abuse including resident abuse. 1. Review of Resident #3's Facility admission Record showed he/she had a diagnosis of schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and behaviors, often causing a disconnection from reality). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect nine sampled residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #11, and Resident #17) from physical abuse out of 19 sampled residents. On 3/4/26, Resident #2 hit Resident #1 resulting in a lacerated lip with four stitches. On 3/18/26, Resident #3 pushed Resident #4 and Resident #4 hit Resident #3. On 3/8/26, Resident #5 and Resident #6 hit each other, resulting in Resident #5 sustaining a nasal fracture. On 3/12/26, Resident #10 pushed Resident #11 resulting in Resident #11 scraping his/her left hand on the brick wall. On 3/16/26, Resident #7 punched Resident #8 in the head. On 3/20/26, Resident #7 and Resident #17 hit each other. The facility census was 129 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of 14 sampled residents was free from abuse. On 03/06/26, the Director of Nursing (DON) placed his/her hand around the resident's neck area, and held the resident against a wall, resulting in a scratch on the resident's neck area. The resident expressed fear, flashbacks, nightmares of the DON coming back to strangle him/her, stating he/she did not feel safe living at the facility. The observed incident occurred at 7:40 P.M., and the DON continued to work his/her shift until 9:45 P.M. The employee was not removed from the facility or removed from contact with residents per facility policy. The facility census was 131 residents. The Administrator was notified on 03/10/26 at 3:24 P.M. of an Immediate Jeopardy (IJ) which began on 03/06/26. [...]

Inspectors wroteBased on interview and record review the facility failed to provide appropriate, necessary behavioral health services for one sampled resident (Resident #1) out of 14 sampled residents. On 03/26/26, facility staff failed to implement the resident's care plan for behavioral interventions and implement Crisis Prevention Intervention (CPI- behavioral techniques for de-escalation) techniques with the resident, when the resident became agitated on the smoke deck. The facility census was 130. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an employee to resident altercation with injuries and possible abuse immediately, but no later than two hours, after the altercation happened to the state survey agency. This deficient practice affected one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 131 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect seven sampled residents (Resident #1, Resident #13, Resident #6, Resident #5, Resident #2, Resident #9 and Resident #16) from physical abuse. On 1/18/26 Resident #1 punched Resident #13 in the back of the head. On 1/27/26 Resident #1 hit Resident #6 on the head with a mop stick after Certified Nurses Aide (CNA) E had asked Resident #6 to help. Resident #6 then punched Resident #1 multiple times in the face and head. Resident #6 had a bruise and raised area on the left side if his/her forehead. Resident #1 had scratches and red marks on his/her face. Resident #6 was upset CNA E had asked for his/her assistance and wanted this to stop. On 1/31/26 Resident #1 punched Resident #5 in his/her head. Resident #5 then punched Resident #1 in the face and head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #1) who had a known behavioral health history and mental health diagnosis. The facility staff failed to implement the resident's plan of care, administer psychotropic medications and tests as ordered by the physician, implement behavioral health techniques for de-escalation to reduce the resident's behavior and maintain residents safety. As a result, the resident was involved in multiple resident to resident altercations that resulted in physical injury. On 1/18/26 Resident #1 punched Resident #13 in the back of the head. On 1/27/26 Resident #1 hit Resident #6 on the head with a mop stick. Resident #6 then punched Resident #1 multiple times in the face and head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sufficient supplies of wash cloths, hand towels, bath towels, and sheets for five sampled residents (Residents #7, #22, #10, #23, and #14) out of 23 sampled residents. The facility census was 134 residents. The facility did not have a policy regarding maintaining sufficient supplies of washcloths, hand towels, bath towels, or sheets. 1. During an interview on 2/20/26 at 10:41 A.M., Resident #7 said (Review of his/her Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning showed the resident was cognitively intact) he/she started washing his/her own clothes, towels, and sheets so that he/she had some and that if he/she didn't wash them, he/she didn't get any. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary and functioning environment when the sink in rooms 215 had discolored water standing in the sink causing a bad odor, the bedroom and bathroom floors had brown grime built up, and the heating unit was pulled away from the wall which were both causing distress to one sampled resident (Resident #4), failed to have a sink installed in the 200 hall bathhouse #1 which resulted in two medal poles to protrude from the wall and create an unsafe environment for all residents who resided on the 200 hall, failed to maintain sanitation in the 200 hall bathhouse #2 by having a toilet that was filled with a dark brown substance, and failed to maintain a HVAC (heating, ventilation, and air conditioning) unit in the Main Dining room that had no cover on it exposing the metal edges around the opening's [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one sampled resident (Resident #4) from physical abuse. On 1/2/26 Resident # 3 punched Resident #4 twice in the face, staff intervened then later Resident #3 punched Resident #4 in the face two more times outside the nursing station. Resident #4 fell to the floor face down and Resident #3 then kicked Resident #4 in the head twice. Resident #4 had a bloody nose and a bruise under his/her left eye out of five sampled residents. The facility census was 138 residents. On 1/8/26 the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 1/2/26. All staff received education prior to working their next shift. The deficiency was corrected on 1/4/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient and competent staff to meet the behavioral health needs for two sampled residents (Resident #3 and #4). On 1/2/26 Resident # 3 punched Resident #4 in the face twice, staff intervened, and then later Resident #3 punched Resident #4 in the face two more times outside the nursing station. Resident #4 fell to the floor face down, Resident #3 then kicked Resident #4 in the head twice. Resident #4 had a bloody nose and a bruise under his/her left eye out of five sampled residents. The facility censure was 138 residents. On 1/8/26 the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 1/2/26. All staff received education prior to working their next shift. The deficiency was corrected on 1/4/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident#21) out of 16 sampled residents was free from abuse. On 12/7/25 Resident #22 assaulted Resident #21 while Resident #21 was sleeping with fingernails and a broken pen resulting in the left side of Resident #21 having multiple facial lacerations to varying depths. The facility census was 135 residents. The Administrator was notified on 12/22/25 of the Past Non-Compliance which occurred on 12/7/25. The facility immediately completed education for all employees on Abuse and Neglect and Customer Service. The deficiency was corrected on 12/9/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect Resident #1 from physical abuse when on the evening of 10/25/25, Certified Nurse Aide (CNA) A struck the resident with a closed hand and both fell to the floor. CNA A was on top of the resident with a closed fist swinging at the resident. The incident resulted in a fracture to the distal nasal bone. Seven residents were selected for sample. The facility had 139 residents. The Administrator was notified on 10/28/25 at 1:10 P.M., of an Immediate Jeopardy (IJ) which began on 10/25/25. The IJ was removed on 10/28/25, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective training program for all staff, which included training on behavioral health care and services as determined by staff need and the facility assessment. The facility identified 140 residents with behavioral health needs and 140 residents with long-term psychiatric management needs. Five out of 66 active employees did not have behavioral health training documented as completed. One previous employee, Certified Nurse Aide (CNA) A did not have training documented and was involved in an incident where he/she struck a resident with a closed hand. The facility had 139 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve the physician ordered diet in the correct consistency to meet the resident's need for one sampled resident (Resident #7) out of 8 sampled residents. The facility census was 151 residents. Review of the facility's Pureed Food Preparation policy and procedure dated 2016, showed pureed foods will be prepared using standardized recipes to ensure quality, flavor, and maximum nutritive value. It showed:-Standardized recipes will be used to prepare all pureed foods. The recipes will be adjusted to the number of pureed diets needed, including seasoning and technique to ensure the highest quality.-Recipes will not use water to thin pureed foods. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity and respect for two sampled residents (Resident #1 and Resident #5) out of five sampled residents when on 8/26/25, [NAME] A failed to maintain professional boundaries by hugging and kissing Resident #1 on his/her cheek and taking possession of Resident #1's spending card and taking the spending card off the premises of the facility. In addition, [NAME] A failed to maintain professional boundaries by hugging Resident #5, which made Resident #5 feel uncomfortable. The facility census was 154 residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep one sampled resident (Resident #3) free from physical abuse when on 8/1/25 Resident #4 then hit Resident #3 in the mouth and knocked out Resident #3's top two front teeth. Nine total residents were sampled. The facility census was 151 residents. The Administrator was notified on 8/22/25 of Past Non-Compliance which occurred on 8/1/25. An all-staff in-service on Abuse and Neglect was completed by 8/4/25. Resident # 3 and Resident #4 were separated. Resident #4 was placed on intensive monitoring with medication changes followed with psychiatric hospitalization. The deficiency was corrected by 8/4/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a full time qualified Licensed Social Worker (LSW) beginning 5/23/2525 affecting all residents who required services out of nine sampled residents. The facility census was 151 residents. Review of the facility Job Description for Licensed Social Worker (LSW) dated 2023 showed:-All facilities with more than 120 beds must employ a qualified social worker on a full-time basis.-The Social Services Department must be directed by a qualified professional LSW who had a minimum of a bachelor's degree in social work or another human services field to include but not limited to; sociology, gerontology, special education, rehabilitation, counseling or psychology. [...]

Inspectors wroteBased on interview and record review, the facility failed to adhere to resident's rights by not providing a safe way for sexual interactions for three sampled residents (Resident #4, #5 and #7) out of nine sampled residents whom were sexually active. The facility census was 151 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination through support of the resident's choice for one sampled resident (Resident #8) out of three sampled residents by not providing the resident with clean clothes which caused the resident to wear the same soiled clothing for two consecutive days. The facility census was 152 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident #8) the right to receive visitors. The facility further failed to have written policies in place for resident rights and visitation for the facility out of three sampled residents. The facility census was 152 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, comfortable, and homelike environment when hot water temperatures were not a minimum of 105 degrees Fahrenheit for rooms [ROOM NUMBER]; and the gender specific unit had dirt, debris and maintenance issues affecting 36 residents on the unit. The facility census was 151 residents. Review of the facility Resident Rights Policy dated 7/5/2023 showed:-Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility.-Resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the facility adhered to all the applicable components of the process for discharging a resident which included reassessment once the three sampled residents (Resident #1, #3, and #5) were found no longer a safety risk and were medically stable out of 25 sampled residents. The facility census was 151 residents. S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:-The location to which the resident is transferred or discharged .-The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . [...]

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a safe, sanitary and functioning environment when the sinks in rooms [ROOM NUMBER] had discolored water standing in the sinks and in rooms [ROOM NUMBERS] the sinks did not drain after water was ran for 2 minutes. This failure impacted nine residents living in those rooms. The facility census was 151 residents. S483.90(i) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain 12 months of infection control tracking with complete and accurate documentation of infections each month, the type of infection, signs and symptoms, and correct number of infections within the facility. This failure had the potential to affect all residents within the facility. The facility failed to ensure four sampled residents (Residents #149, #143, #3, and #128) and one supplemental resident (Resident #93) out of 28 sampled residents and five supplemental residents and seven staff (Employee #1, #2, #3, #4, #5, #8, and #9) out of 10 sampled staff were screened and/or tested for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) per policy; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for three out of five sampled Certified Nursing Assistants (CNAs) (Employee 13, 14, and 15). This had the potential to affect all of the residents residing in the facility. The facility census was 157 residents. 1. Review of the Facility Assessment, dated 3/26/24, showed: -Facility assessment would be used identify the type of staff members, other health care professionals, and medical practitioners that were needed to provide support and care for residents. -In-Service training. -All staff annual training was to include: --Compliance training one hour. --Health Insurance Portability and Accountability Act (HIPPA it is a federal law enacted in 1996 to protect the privacy and security of patient health information) one hour. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident wheelchairs were in good repair and in good working condition for two residents (Residents #123, and #31) out of 28 sampled residents. Additionally, the facility failed to ensure resident rooms and resident use areas were kept clean and free from soil and grime, and failed to ensure the resident-use kitchenette area, including a separate mini freezer and mini fridge with freezer was clean and free of pests. The facility census was 157 residents. Review of the Infection Prevention and control Program policy, dated 6/26/24, showed: -Equipment Protocol: --All reusable items and equipment requiring cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Aide Registry for federal indicators of abuse and failed to complete Criminal Background Checks (CBC) in accordance with facility policies and procedures to ensure employee eligibility to work in a long-term care facility. This affected 10 out of 10 sampled employees. The facility census was 157 residents. Review of the facility's Background Investigations policy, dated 12/27/24, showed: -The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough fall investigation, and update the care plans with new interventions to prevent further falls for two sampled residents who had unwitnessed falls (Resident #123 and #128). Additionally, and failed to ensure each residents environment was free of accident hazards when two residents (Resident #87 and Resident #109) had aerosol cans of bug spray and spray bottle of bug spray left in their room, out of 28 sampled residents and eight supplemental residents. The facility census was 157 residents. A policy for fall investigations was requested and not received at the time of exit. Review of the facility's Fall Prevention Policy, dated [DATE], showed: -When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least every 30 days for the first 90 days and then at least every 60 days thereafter for three sampled residents (Resident #123, #128, and #143) out of 28 sampled residents. The facility census was 157 residents. A policy for physician visits was requested but not received by the end of survey. 1. Review of Resident #128's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic (a substance used to treat moderate to severe pain) medications were stored securely under a double lock system on the medication cart, failed to ensure staff did not store their meals in the medication refrigerator, failed to ensure two nursing staff accounted for narcotics at the end of each shift, failed to ensure there were no loose pills in the medication carts, failed to ensure cleaning agents were not stored with the residents' medications, failed to document the disposition of medications for one closed record resident after his/her death (Resident #154), and failed to ensure medications that had been discontinued were promptly removed from the medication cart and sent back to the pharmacy or were destroyed. The facility census was 157 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the ceiling vents free of dust, rust, and other black substances potentially mold, and failed to repair the trim on the wall around the walk-in cooler and the back door next to the ice machine. The facility census was 157 residents. Review of the facilities Dietary-Equipment Operations, Infection Control, and Sanitation policy, revision dated 2/2/24 showed: The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager. Walls and Ceilings: -Walls and ceilings must be free of chipped and/or peeling paint. -Walls and ceilings must be washed thoroughly at least twice a year. -Heavily soiled surfaces must be cleaned more frequently and as required. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an antibiotic stewardship program to ensure the appropriate use of antibiotics within the facility when staff did not include the required information to track infections. This had the potential to affect any resident receiving an antibiotic medication. The facility census was 157 residents. Review of the facility's Antibiotic Stewardship Program (ASP) policy, dated 6/30/23, showed: -The purpose was to optimize antibiotic use in the nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach. -The facility will track and monitor antibiotic prescribing practices and resistance patterns among its residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Residents #149, #143, and #128) and one supplemental resident (Resident #93) were educated on, offered, and/or had the opportunity to decline Influenza and pneumonia vaccinations out of 28 sampled residents and five supplemental residents. The facility census was 157 residents. Review of the facility's Influenza and Pneumococcal Immunization policy, dated 6/30/23, showed: -All residents residing in the facility are offered Influenza and Pneumococcal immunizations to prevent infection and the spread of communicable diseases. -As part of the admission process, the resident or the resident's legal representative will be provided education on the benefits and potential side effects of both the Influenza and Pneumococcal immunization. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four sampled residents (Residents #149, #143, #3, #128) and one supplemental resident (Resident #93) were offered or had documentation of previous COVID (a new disease caused by a novel (new) coronavirus) vaccinations out of 28 sampled residents and five supplemental residents. The facility census was 157 residents. Review of the facility's Infection Prevention and Control Program, dated 6/26/24, showed: -Residents will be offered the COVID-19 vaccination when vaccine supplies are available to the facility. -Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives prior to offering the vaccine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident outside smoking area was free potential flammable hazard related to missing brick which had exposed exterior building structure and insulation material exposed, loose on the ground next to smoke bench, failed to ensure resident rooms and resident gathering areas were kept clean and free from caked on soil and grime for one supplemental resident (Resident #500); and the facility failed to ensure the medication room's sink and floors were clean out of the 28 sampled residents and eight supplemental residents. The facility census was 157 residents. Review of the Housekeeping-Deep Cleaning policy revised dated 12/27/24 showed: -All Areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free. -Residents Room Deep Clean: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident#64) out of 36 sampled residents was free from abuse. The resident sat next to Resident #92 on a bench when he/she was struck by Resident #92 several times in the head. The facility census was 157 residents. Review of the facility policy titled, Abuse and Neglect, revised 4/30/24, showed: -To outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. -To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a self-administration assessment, provide education, and obtain physician approval for one resident (Resident #143), out of 28 sampled residents, to complete his/her own wound care. The facility staff also failed to follow facility policy related to post fall assessments for two sampled residents who had unwitnessed falls (Resident #123 and #128). The facility census was 157 residents. Review of the Resident Self-Administration of Medication Policy, dated 5/18/24, showed: -It is the policy of this facility to support each resident right to self-administer medication. A resident may only self-administer medications after the facility interdisciplinary team (IDT) has determined which medications may be self-administered safely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on recommendations from occupational therapy to order and apply a left hand orthotic splint for Resident #72. Additionally, the facility failed to complete a physical therapy referral and assessment to determine Resident #31's mobility needs and the need for an assistive device (wheelchair) after recommended by the hospital orthopedist; failed to assess and document the resident's mobility status and continued need for a wheelchair; and failed to refer the resident to physical therapy for assessment and/or assistance with obtaining an operable wheelchair for the resident to use when mobilizing in the facility. This deficient practice impacted two out of 28 sampled residents. The facility census was 157 residents. Review of the facility's policy titled Therapy: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a competency assessment and provide self-care instructions for one resident (Resident #143) who completed his/her own colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) care out of 28 sampled residents. The facility census was 157 residents. 1. Review of Resident #143's admission Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's progress notes, dated 8/8/24, showed: -The resident had a colostomy in the right upper quadrant of his/her abdomen. -The resident requested to have colostomy bags in his/her room so he/she could change his/her colostomy. -Physician asked nursing staff to put some colostomy bags in the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #55) had a physician's order for a Continuous Positive Airway Pressure (CPAP) machine (a medical device used to deliver a continuous stream of pressurized air to the patient's airways through a mask, keeping the airway open), CPAP machine use was care planned, and failed to ensure the CPAP machine and face mask were kept off of the floor and covered when not in use. Additionally, the facility failed to properly store a respiratory nebulizer mask/mouthpiece (a medical device used to deliver medication in the form of mist) and tubing when not in use for one sampled resident (Resident #111) out of 28 sampled residents. The facility census was 157 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document completing intensive monitoring after a resident to resident altercation and to review and revise interventions after the altercation that occurred on 4/16/25 to support the resident's behavioral health needs for one sampled resident (Resident #209) out of 28 sampled residents and eight supplemental residents. The facility census was 157 residents. Review of the facility's Intensive Monitoring policy and procedure, dated 4/30/24, showed the purpose was to ensure a system was in place for residents who required increased monitoring for crisis, behavioral and psychiatric issues. -Intensive monitoring is defined as periodic (hourly, every two hours, or every shift) check by a facility staff member. One to one monitoring is a designated employee will monitor the resident at all times (within eyesight). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were followed up on in a timely manner for two sampled residents (Resident's #55 and #128) out of 28 sampled residents. The facility census was 157 residents. Review of the facility's Medication Regimen Review (MMR or Drug Regimen Review) policy and procedure, dated 6/26/24, showed the drug regimen of each resident is reviewed at least once per month by a licensed pharmacist and includes a review of the resident's medical chart. -The MMR or Drug Regimen Review includes a review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors or other irregularities. -The requirements associated with the MMR apply to all residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician/psychiatrist responded to the pharmacist's recommendation for gradual dose reductions of psychotropic medications in a timely manner for two sampled residents (Resident #31 and #128) out of 28 sampled residents. The facility census was 157 residents. Review of the facility's Medication Regimen Review (MMR or Drug Regimen Review) policy and procedure, dated 6/26/24, showed the drug regimen of each resident is reviewed at least once per month by a licensed pharmacist and includes a review of the resident's medical chart. -The MMR or Drug Regimen Review includes a review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors or other irregularities. -The requirements associated with the MMR apply to all residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Residents #49 and Resident #14) out of 17 sampled residents were free from abuse. On [DATE], Resident #49 was sexually abused by his/her roommate, Resident #50. Resident #49 reported to facility staff that Resident #50 fondled his/her private area over his/her underwear around 12:00 A.M. Facility staff failed to implement interventions to protect the resident, resulting in Resident #50 sexually abusing Resident #49 again at 1:00 A.M., and again at 2:00 A.M. Resident #49 told Resident #50 to leave and kicked the resident in the stomach. On [DATE], Resident #52 threw a hard plastic cup at Resident #14, hitting him/her in the mouth which resulted in the resident receiving two sutures to close a deep cut in his/her upper lip. The facility census was 153 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain resident dignity when Certified Medication Technician (CMT) E spoke to Resident #56 in an inappropriate manner, using foul language. This deficient practiced affected one sampled resident (Resident #56) out of seventeen sampled residents. The facility census was 153 residents. The Administrator was notified on 3/5/25 of the past noncompliance which began on 2/26/25. The facility immediately completed education for staff on the Dignity and Respect policy. The deficiency was corrected on 2/26/25. Review of the facility policy for Dignity and Respect, revised 6/29/23, showed: -The policy was created to ensure that all residents were treated with dignity and respect. -Every resident had the right to be treated with dignity and respect. Review of the facility policy for Customer Service, revised 7/31/23, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse timely for one sampled resident (Residents #49), out of seventeen sampled residents. On 2/25/25, Resident #49 told Certified Nurse Aide (CNA) R of the abuse and CNA R told Licensed Practical Nurse (LPN) D. CNA R and LPN D did not immediately report the allegation to administrative staff. The facility census was 153 residents. The Administrator was notified on 3/5/25 of the past noncompliance which began on 2/25/25. The facility immediately completed education for all staff on the Abuse, Neglect policy reporting procedures. The deficiency was corrected on 2/25/25. Review of the facility Abuse and Neglect Policy, dated 6/12/24, showed: -Sexual abuse was non-consensual contact of any type with a resident including any kind of unwanted touching of the genital area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #23, #28, #34, #44, and #46) were free from physical abuse. During a staff to resident abuse, Resident #44 was pushed to the corner of the wall, and held in place with a forearm against the resident chest area, resulting in bruising. During a resident to resident altercation, Resident #28 was attacked by Resident #23, ending up with both residents on the floor, hitting and pulling each other's hair and banging each other's head on the floor. Resident #23 sustained bruising to both eyes. Resident #28 was bit in the face, resulting in the resident's right upper cheek being punctured and a bump to the back right side and middle center of his/her head. On 1/12/25, Resident #34 was in the hallway, without his/her required 1-1 staff oversight. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation related to allegations of abuse for three resident (Resident #1, #7, and #28) out of 26 sampled residents. The facility did not investigate and did not have a system in place to ensure both residents had the capacity to consent to sexual activity when Resident #7 and Resident #28 were observed engaging in sexual activity. The facility also failed to investigate an allegation that Resident #7 gave Resident #28 a medication for anxiety he/she cheeked. The facility failed to complete an investigation and interview all potential witnesses when Resident #1 alleged Certified Nurses Assistant (CNA) B hit him/her in the face. The facility census was 161 residents. Review of the facility Sexual Activity Abuse and Neglect Policy, dated 5/14/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety for one sampled resident (Resident #34) when the facility staff did not maintain 1-1 supervision (one staff person to one resident) when designated to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Observations showed the facility not following their policy related to one on one staff oversight during the overnight shift for Residents #34, #24, and #47. Twenty six residents were sampled. The facility census was 161. Review of the facility Intensive Monitoring, dated 4/30/24, showed: -Intensive monitoring was defined as periodic checks by a facility staff member. -One to One (1-1) monitoring was a designated employee assigned by a facility supervisor. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident legal guardian for one sampled resident (Resident #1) of a change in condition out of 15 sampled residents. The facility census was 157 residents. Review of the facility policy for Notification of Changes revised 5/14/24 showed: -The purpose of the policy was to ensure the facility staff promptly notified the resident or resident's representative when there was a change requiring such notification. -Examples of situations requiring the notification of the resident's representative was any time the resident had a significant change in condition and any time the resident was transferred out of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one sampled resident (Resident #23) from restraint when on 12/22/24 Licensed Practical Nurse (LPN) E, Certified Medication Technician (CMT) D and Resident #29 held Resident #23 down on the floor by his/her arms and legs out of 15 sampled residents. The facility census was 157 residents. Review of the facility's undated Resident Rights information guide showed restraints were not to have been used for the purposes of discipline or staff convenience. 1. Review of Resident #23's Preadmission Screening and Resident Review (PASRR, a required assessment tool used to ensure individuals who have a mental disorder, or intellectual disabilities are not inappropriately placed in nursing homes for long term care), dated 12/10/20, showed: -He/She had the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/ the resident representative or legal guardian for three sampled residents (Resident #4, #5 and #7) who went without their medications out of 20 sampled residents. The facility census was 153 residents. Review of the facility When to Notify Management Policy dated 8/2/24 showed: -The purpose of this policy is to ensure that the facility management and regional director are notified for concerns related to the protective oversight of residents and facility operations. -The administrator and/or Director of Nursing (DON) will be responsible for notifying the Regional Management related topics, who will then notifies the Director of Operations for the following criteria: -Nursing related concerns including, but not limited to: medication unavailability and medication errors. [...]

Inspectors wroteBased on interview, and record review, the facility failed to protect four sampled residents (Resident #6, #7, #8 and #9) from abuse when on 12/3/24 Resident #7 went into Resident #6's room and began hitting Resident #6, Resident #6 then began hitting Resident #7 prompting staff to intervene to separate the residents. Resident #7 was sent to the hospital for psychiatric evaluation. On 12/3/24 Resident #9 went to Resident #8's room and struck Resident #8, then Resident #8 began hitting Resident #9 prompting staff to intervene to separate the residents. Resident #8 sustained bruising to his/her the face and was sent to the hospital for medical evaluation, and Resident #9 was sent to the hospital for psychiatric evaluation out of 20 sampled residents selected for review. The facility census was 153 residents. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate the transfer of three sampled residents (Resident # 17, #18 and #19) after a hospital visit back to the facility; and the facility failed to send transfer paperwork with Resident #17 and Resident #18 to coordinate care out of 20 sampled residents. The facility census was 153 residents. Review of the facility policy dated 11/6/23 Access to Medical Records and Medication in an Emergency showed: -If the resident is transferred to a facility not managed by the transferring facility, the current facility can print all needed records through the use of printer connected to the system. -If the facility has no working printer capability the user can remotely print all records including the physician orders. -The paper records should be provided to the transferee facility. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to effectively manage behaviors for three sampled residents (Resident #4, #5, and #7) by not administering medications for specific mental health diagnoses and behaviors related to those diagnoses, resulting in sexually charged behaviors on 12/3/24 between Resident #4 and #5 in the community shower room; and an altercation and psychiatric evaluation on 12/3/24 involving Resident #7 out of 20 sampled residents. The facility census was 153 residents. Facility assessment dated pending 12/27/24 was incomplete and unable to review. Review of the facility Behavioral Health Services Policy dated 10/31/24 showed: -It was the policy of the facility to ensure all resident receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident #4, #5 and #7) received medications for chronic medical and mental health diagnosis resulting in exacerbation of behaviors for all three residents out of 20 sampled residents. The facility census was 153 residents. Review of the facility Medication Administration Policy dated 6/26/24 showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -It is the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practiced guidelines. Review of the facility medication Orders Policy dated 5/18/24 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were securely stored for two medication carts when on 11/2/24 and 11/3/24 staff left two medication carts unlocked and unattended and four residents (Residents #1, #2, and #3, and #4) were able to obtain medications from the carts. Residents #1, #2 and #3 accessed the unlocked cart obtaining Metformin (a drug for diabetes), Seroquel (a drug for psychiatric disorders), and Buspirone (a drug used to treat anxiety). Resident #4 accessed the narcotic box and took sixteen 5 milligram (mg) tablets of Oxycodone (narcotic). Resident #4 said he/she ingested 11 tablets. The facility census was 154 residents. The Administrator was notified on 11/13/24 at 4:45 P.M., of the Past Non-Compliance Immediate Jeopardy (IJ) which began on 11/3/24. Upon discovery, all staff were in-serviced on medication storage. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services for one out of 16 residents (Resident #19) with behavioral health needs and a history of post-traumatic stress disorder (PTSD), who displayed self-harming behaviors. On 9/1/2024, the resident was hospitalized due to his/her psychiatric needs after using a disposable razor blade to cut his/her forearm. The resident returned to the facility on 9/11/24, requiring one on one supervision. The resident was taken off one-on-one supervision and it was restarted again on 9/24/24 after he/she had an increase in behaviors. The facility did not have a system in place to ensure the interdisciplinary team was involved in assessing the resident's needs related to supervision and participating in decision making prior to implementing changes in the resident's care related to supervision. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two residents (Resident #11 and Resident #12) from physical abuse. On 9/9/24 about 3:00 A.M., Certified Nurse Aide (CNA) F punched Resident #12. The resident and CNA F fell and rolled on the floor punching each other. CNA D and CNA G watched and did not attempt to separate Resident #12 and CNA F. A Code [NAME] (emergency response) was called and staff separated the resident and CNA F. Licensed Practical Nurse (LPN) D assessed Resident #12 and noted redness. CNA F pushed past the LPN D and other staff going toward Resident #12 and CNA F punched Resident #12 in the face three times. Resident #12 sustained a cut above the left eye, bruising under and around the left eye and brow, and a broken nose. On 9/8/24 about 7:00 P.M., Hall Monitor (HM) C hit and punched Resident #11. The facility census was 166. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate discharge location on the immediate discharge letter for one sampled resident (Resident #11) out of 20 sampled residents. The facility census was 160 residents. Record review of the facility's policy entitled Resident Transfer/Discharge, Immediate Discharge and Therapeutic Leave Policy, revised 5/14/24, showed: -A discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other appropriate location in the community when return to the original facility was not expected. -The facility could have discharged a resident as a Facility-Initiated Discharge if the welfare and needs of the resident could not have been met; the resident no longer needed the services provided by the facility; the safety of individuals in the facility was endangered; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one resident, (Resident #19) free from self harm by not following the facility protocol for signing out disposable razors with the charge nurse, supervising the resident while he/she was shaving and then returning the disposable razor to the charge nurse for safe disposition, when on 9/1/24 the resident presented to staff with a superficial cut on his/her left forearm where he/she stated he/she had cut himself/herself with a broken disposable razor where the protective plastic covering had been broken off exposing the blade. 20 residents were sampled. The facility census was 166 residents. Review of the facility policy for Sharps and Hazardous Waste, revised 6/26/24, showed: -The purpose of the policy was to ensure that sharp objects and contaminated objects were disposed in a safe manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed implement interventions for dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) care to promote the highest possible level of well-being for one sampled resident (Resident #3) with dementia which negatively affected sampled Residents #2, #4, #9 and #10 out of 10 residents sampled. The facility census was 162 residents. Review of the facility's Elopements and Wandering Residents policy dated as revised 6/12/24 showed: -Wandering was defined as random or repetitive locomotion that may be goal-directed (such as searching for something like an exit) or non-goal directed, or aimless. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity of one sampled resident (Resident #4) out of 10 sampled residents. The facility census was 162 residents. Review of the facility's policy titled Dignity and Respect, revised on 6/29/23 showed: -Every resident had the right to be treated with dignity and respect. -All staff would speak to and treat all residents with dignity and respect. 1. Review of Resident #4's care plan dated as revised on 3/20/24 showed: -The resident was at risk for: -Fatigue. --Activity intolerance due to Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -The resident: --Refused to get out of bed. --Had bowel incontinence with instructions for staff to assist the resident as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's guardian (a person who looks after and is legally responsible for someone who is unable to manage their own affairs) of changes in the resident's condition for one sampled resident (Resident #6) out of 10 sampled residents. The facility census was 162 residents. Review of the facility's policy titled Residents' Rights dated as revised on 7/5/23 showed the facility must immediately inform the resident and notify the resident's legal representative when there was a change in the resident's condition. 1. Review of Resident #6's care plan dated 2/9/24 showed the resident had a guardian to assist in decision-making due to mental illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to maintain a secure environment for one sampled resident (Resident #1) out of six residents sampled for resident safety, who was allowed to leave the facility without guardian permission on 8/3/24 and as of 8/15/24 had not returned to the facility. The facility census was 162 residents. The Administrator was notified on 8/15/24 of Past Non-Compliance which occurred on 8/3/24. On 8/3/24 facility administration identified the resident left the facility without permission, began the facility investigation, made necessary notifications and facility staff were in-serviced on 8/3/24 and 8/4/24. On 8/3/24 the receptionist received corrective action and on 8/4/24 the receptionist received training. Review of the facility's Resident Outside Pass policy dated as revised on 6/29/23 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) was free from abuse when on [DATE], the resident was struck in the face by Resident #2 which resulted in Resident #1 having a broken nose. The facility census was 165 residents. The Administrator was notified on [DATE] of Past Non-Compliance which occurred on [DATE]. An all staff in-service was completed on resident abuse and neglect by [DATE]. The deficiency was corrected [DATE]. Review of the facility's Abuse and Neglect policy, updated [DATE], showed: -Physical abuse was defined as purposely beating, striking, wounding, or injuring another resident or mistreating or maltreating a resident in a brutal of inhumane manner. Physical abuse included hitting, slapping, punching, biting and kicking, and also included corporal punishment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment by not maintaining the indoor air temperatures of resident rooms in the facility between 71.0 °F (degrees Fahrenheit) and 81.0 °F for 20 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, and #22) with room temperatures ranging from 82.0 degrees Fahrenheit (°F) to 86.7 °F. Resident #1 reported he/she had to sleep in the common area due to the discomfort of her personal room. Resident #2 said he/she felt his/her heart was in distress. Resident #3 said he/she had hot sweats when trying to nap during the day and has had to go sleep in the TV room twice because of the heat. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services to deescalate one sampled resident (Resident #2) out of 22 sampled residents, who was displaying emotional and behavioral adjustment difficulty. The facility census was 164 residents. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, a federally required assessment to ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care), dated 6/4/10, showed the following diagnoses: --Schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self). --Psychosis (a mental disorder in which there is a severe loss of contact with reality). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain one sampled resident's (Resident #1) dignity, when staff made light of the resident being upset, not using appropriate de-escalation techniques, touching the resident on the back while following the resident into the unit, causing the resident to further escalate his/her behaviors out of six sampled residents. The facility census was 162 residents. Review of the facility policy for Dignity and Respect revised 6/29/23 showed: -The policy was created to ensure that all residents were treated with dignity and respect. -Every resident had the right to be treated with dignity and respect. Review of the facility policy for Customer Service revised 7/31/23 showed: -The purpose of the policy was to set expectations for customer service and professional behavior expected of all facility staff. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure temperatures inside Resident #6 and 7's room were maintained between 71 and 81 degrees Fahrenheit (ºF) when the outside temperature rose to 82.1 degrees ºF, and to follow its policy for maintaining room temperatures at a comfortable level while the air conditioning system in the resident's room was not appropriately functioning affecting two sampled residents out of seven sampled residents. The facility census was 162 residents. Review of the facility's undated policy for Utility Failure showed: -The policy was in place to ensure that resident comfort remained paramount in the operation of the facility and that plans for utility failure were in place to ensure equipment was maintained. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one sampled resident (Resident #6) from physical abuse when on 4/23/24 about 8:30 P.M., Certified Nursing Assistant (CNA) A grabbed, shoved, and pushed the resident down the hall and then up against the wall. Hall Monitor (HM) A and CNA C watched the physical abuse and did not intervene. CNA A continued to work his/her shift until 7:00 A.M., on 4/24/24. The sample was 16 residents. The facility census was 163 residents. The Administrator was notified on 4/29/24 at 4:45 P.M. of the past noncompliance Immediate Jeopardy (IJ) which began on 4/23/24. The facility completed education for all staff on the Abuse, Neglect policy. Involved staff were suspended and terminated. The IJ was corrected on 4/26/24. Record review of the facility's Abuse and Neglect policy, updated 1/5/23, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff (Certified Nursing Assistant (CNA) A, CNA B, CNA C, Hall Monitor (HM) A, and the Night Shift Supervisor A) failed to report allegations of abuse to the facility Administrator as instructed by the facility policy resulting in a delay of an investigation. On 4/23/24 about 8:30 P.M., CNA A grabbed Resident #6, shoved and pushed him/her down the hall and then up against the wall. Hall Monitor A and CNA C watched the abuse occur. CNA B came around the corner intervened and separated the resident from CNA A and then reported the incident to the evening administration. The facility census was 163 residents. The Administrator was notified on 5/3/24 of the past noncompliance which began on 4/23/24. The facility inserviced all staff on the reporting policy and made notifications to appropriate agencies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #8, #22, #26, #37 and #53) were free from abuse when on 1/6/24, Resident#8 and Resident #22 hit each other resulted in Resident #8 having an injury to his/her left shoulder and Resident #22 an injury to his/her left eye. On 1/14/24, Resident #26 and Resident #3 hit each other without any injury and Certified Nurses Aide (CNA) E inappropriately called, texted and video chatted with Resident #53 out of 11 sampled residents. The facility census was 152 residents. Review of the facility's Abuse and Neglect policy, updated 1/5/23, showed: -Physical abuse was defined as purposely beating, striking, wounding, or injuring another resident or mistreating or maltreating a resident in a brutal of inhumane manner. [...]

Inspectors wrote2. Review of Resident #22's PASRR dated 7/14/23 showed: -Was diagnosed with: --Schizophrenia: (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self). --Adjustment Disorder: (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). --Post Traumatic Stress Disorder. --Antisocial Personality Disorder: (a condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' environment was free from accident hazards when one sampled resident (Resident #48) accessed an opened medication cart and obtained an unspecified amount of medication and ingested the medication out of 11 sampled residents. The census was 152 residents. Review of the facility Medication Administration and Monitoring, dated 9/20/23, showed no instruction for the safeguard of medications on the facility unit. 1. Review of Resident #48's facility Face Sheet, dated 2/1/24, showed he/she admitted [DATE] with the following diagnoses: -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six sampled residents (Resident #29, #35, #26, #25, #33, and #44) were free from abuse. On 12/14/23 Resident #1 with known aggressive behaviors struck Resident #29 multiple times on the top of his/her head and torso with a metal chair causing multiple contusions to the right side of his/her head and above the hairline. He/she also sustained bilateral rib fractures to ribs 2 through 8, deep defensive wounds to both hands and a left hip red contusion with indentation. Also, on 12/1/23, Resident #36 punched Resident #35 in the mouth resulting in Resident #35 needing two stitches in his/her lower right lip. On 12/10/23, Resident #31 punched Resident #26 in the mouth resulting in Resident #26's lip to be split. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a discharge notice for one sampled resident (Resident #36) out of 26 sampled residents. The facility census was 163 residents. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 7/12/22, showed: -A facility-initiated transfer or discharge was a transfer or discharge which the resident objected to, which did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community when return to the original facility was not expected. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident #36) to return to the facility after a hospital admission out of 26 sampled residents. The facility census was 163 residents. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 7/12/22, showed: -A facility-initiated transfer or discharge was a transfer or discharge which the resident objected to, which did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community when return to the original facility was not expected. [...]

Inspectors wroteBased on interview and record review, the facility failed to make a referral to the state mental health authority for a Level II Preadmission Screening and Resident Review (PASRR) evaluation when Resident #1 experienced a significant change in behavioral health needs requiring a 38-day stay in inpatient psychiatric treatment and when the resident did not respond to current care plan/treatment measures, requiring physical and chemical interventions and multiple hospitalizations related to behaviors. The facility policy did not include when a referral should be made for a Level II evaluation. This deficient practice effected one out of 25 sampled residents. The facility census was 163 residents. Review of the facility PASRR Assessment & DA 124 A & B policy, dated 4/6/17 and reviewed on 7/9/21, showed: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the resident environment remains as free of accident hazards as is possible. The facility failed to maintain proper storage of medication for one sampled resident (Resident #32) when on 12/8/23, a bottle of Melatonin (a medication used to help induce sleep) 3 milligrams (mg) was left on top of the medication cart and the resident took the bottle and ingested 5 tablets. The facility census was 163 residents. Review of the facility policy for Medication Storage and Destruction, revised 10/20/22, showed: -The purpose of the policy was to ensure that all medication were properly stored. -All medications used for residents were to be kept locked in the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one sampled resident (Resident #14) out of 15 sampled residents from physical abuse, when on 11/26/23 about 12:30 A.M., Administrator in Training (AIT) C punched the resident in the stomach and forcibly took the resident to the ground, held the resident on the ground while on top of the resident, resulting in the resident having a scrape on the right knee and a closed fracture to the seventh rib on the left side. The facility census was 159 residents. The Administrator was notified on 11/29/23 at 1:20 P.M., of an Immediate Jeopardy (IJ) which began on 11/26/23. The IJ was removed on 11/30/23, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, updated 1/5/23, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide privacy to one sampled resident (Resident #/14) of 15 sampled residents, when on 11/26/23 Administrator in Training (AIT) C sat in the resident's room in the middle of the night, and further failed to protect the resident's privacy on 11/27/23 when visitation with the resident's guardian was in an open public lobby area. The facility census was 159 residents. The facility policy titled, Resident Rights, dated 7/5/23, showed: -Privacy and Confidentiality of Resident and Medical Records: --Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require Facility to provide a private room for the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one sampled resident (Resident #1) out of 12 sampled residents from physical abuse when on 11/10/23 about 2:30 A.M., Licensed Practical Nurse (LPN) A, Certified Nurses Aide (CNA) A, and Administrator in Training (AIT) A forcibly took the resident to the ground, kicked the resident, drug the resident by his/her legs and arms from the common dining area into the hallway resulting in the resident's pants being pulled down around his/her ankles, and then continued toward the resident's room. Once in the resident's room, AIT B physically broke the resident's bed and hit the resident in his/her face with a fist. The facility had 161 residents. The Administrator was notified on 11/14/23 at 12:45 P.M., of the Immediate Jeopardy (IJ) which began on 11/10/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to report physical abuse for one sampled resident (Resident #1) out of 12 sampled residents. On 11/10/23 about 2:30 A.M., Licensed Practical Nurse (LPN) A, Certified Nurses Aide (CNA) A, and Administrator in Training (AIT) A forcibly took the resident to the ground, kicked the resident, drug the resident by his/her legs and arms from the common dining area into the hallway resulting in the resident's pants being pulled down around his/her ankles, and then continued toward the resident's room. Once in the resident's room AIT B allegedly stomped the resident in the face, threw the resident's bed on top of him/her, and AIT B and CNA A kicked the resident while he/she was under the mattress. LPN A, AIT A, AIT B and CNA A continued to work until their shift ended. [...]

Inspectors wroteBased on interview the facility failed to treat one resident with respect and to care for the resident in an environment that enhanced his/her quality of life. Facility staff refused to allow Resident #1 to utilize a resident common area after 10:00 P.M. and to have the light on in the common area. This affected one of 12 residents were sampled. The census was 161 residents. Review of the facility undated Covenant Guidelines showed: -Residents are not allowed in other resident's rooms unless the other resident invited them. -Residents are not allowed to be in other resident's rooms between 10:00 P.M. to 10:00 A.M. Sunday through Saturday. Residents may visit in the common area after 10:00 P.M. if they are not disrupting others. 1. Review of the resident face sheet, dated 11/10/23, showed he/she admitted to the facility 7/28/23 and had the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate their abuse and neglect policy to prevent further potential physical abuse for one sampled resident (Resident #1) out of 12 sampled residents after an allegation of abuse was made. On 11/10/23, around 6:00 AM, AIT A told Receptionist A and the Dietary Manager of the alleged abuse. Counselor A and the Staffing Coordinator were also made aware of the alleged abuse during the day on 11/10/23. On 11/10/23 about 10:00 A.M., AIT A reported to the Administrator during a telephone call that CNA A and AIT B had kicked and hit the resident. Both employees were not removed from contact with residents per the facility policy and returned for their next shift from 6:00 PM on 11/10/23 to 6:00 AM on 11/11/23. Additionally, the facility failed to notify Resident #1's legal guardian of the allegations of abuse and injuries sustained. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from abuse when Resident #1 repeatedly struck Resident #2 from behind on the face and back of head with a closed fist, resulting in Resident #2 receiving an acute non-displaced right zygomatic arch fracture, (a fracture of the bony structure in the face that connects the cheekbone to the temporal bone of the skull) , acute minimally displaced right orbital floor fracture, (a fracture of the facial bone involving the floor of the eye socket), extending into the posterolateral wall of the right maxillary sinus, (right side rear and side boundary of the sinus within the upper jaw) out of six sampled residents. The facility census was 160 residents. On 10/18/23, the Administrator was notified of the past noncompliance which occurred on 10/8/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep residents separated or call for assistance when one sampled resident (Resident #5) began showing increasing agitation due to Resident #4 pacing repeatedly in an area Resident #5 felt was his/her space, resulting in Resident #5 striking Resident #4 on the head with his/her walker. The facility census was 160 residents. On 10/18/23, the Administrator was notified of the past noncompliance which occurred on 10/13/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on resident intervention and behaviors before the start of the next shift. Resident care plans were updated. The residents' room placement was changed to separate hallways, and staff were instructed to always be present if either resident were in the common area. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one sampled resident (Resident #1) with respect and dignity when staff held the resident's room door forcibly shut, to prevent him/her from repeatedly slamming his/her room door out of three sampled residents. The facility census was 160 residents. On 10/6/23, the Administrator was notified of the past noncompliance which occurred 10/4/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on Customer Service Policy, Abuse/Neglect Policy and Behavioral Emergency Policy, including resident interventions and behaviors before the start of the next shift. Resident care plans were updated. The deficiency was corrected on 10/4/23. Review of the facility policy titled Abuse and Neglect Policy, dated 1/5/23 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to hold monthly Resident Council meetings and to respond to all concerns, recommendations from the monthly Resident Council meetings and provide written documentation of responses and/or rationale related to the concerns and recommendations. The facility census was 147 residents. A policy was requested for Resident Council meetings and was not received by the facility. 1a. Record review of the facility's Resident Council Minutes dated 2/1/23 showed: -Maintenance issues: toilets continue to run. -Housekeeping/laundry issues: clothes do not come back and it takes too long to wash clothes. Concern has been brought forward before but not resolved. -Dietary issues: The residents would like more salads, more vegetables, and more choices. -Activity issues: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR-a federal program implemented in 1987 to: Prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) recommendations and to integrate the recommendations into the care plan for three sampled residents (Resident #75, #112, and #20) out of 32 sampled residents. The facility census was 147 residents. A PASRR policy was requested but not received from the facility. 1. Record review of Resident #75's PASRR dated 5/2/16 showed: -The resident had the following diagnoses: --Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop comprehensive care plans for four sampled residents (Resident #11, #101, #127, and #114) out of 32 sampled residents. The facility census was 147 residents. Record review of the facility's Care Assessment Summary and Individualized Care Plans policy revised 2/26/21 showed: -Areas that trigger on the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) should be care planned. -The care plan should be individualized and all areas triggered should be in the residents' care plan. 1. Record review of Resident #11's significant change MDS dated [DATE] showed the resident: -Was cognitively intact. -Received hospice (end of life) services. Record review of the resident's care plan revised 11/13/22 showed no care plan related to hospice services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful activities to meet the interests of and support the physical, mental, and psychosocial well-being of three sampled residents (Resident #599, #127 and #101) out of 32 sampled residents. The facility census was 147 residents. Record review of facility policy entitled Activities dated 1/1/17 revised 2/26/21 showed: -The purpose of this policy was to ensure that all residents in the facility were provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interest and their physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for two sampled residents (Resident #75, #20, #132, and #77), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 32 sampled residents. The facility census was 147 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide nurse aides competency skills training and techniques necessary for resident care for four out of four Certified Nurse Assistants (CNA). This practice had the potential to effect all residents. The facility census was 147 residents. A policy regarding Nurse Aide training was requested from the facility. No policy was received prior to exit. 1. Record review of the facility's Facility Assessment Tool, dated 5/1/23, showed: -The facility had an Annual Training requirement of: --1 hour compliance training. --1 hour Health Information Portability and Accountability Act (HIPAA federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) training. --0.75 hours of Preventing, Recognizing and Reporting Abuse. --0.5 hours Resident Rights. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 12 hours of annual in-service training for nurse aides employed by the facility for two out of four Certified Nurse Assistants (CNA) (CNA A and CNA C) for the months of January through [DATE]. This practice had the potential to effect all residents. The facility census was 147 residents. A policy regarding Nurse Aide training was requested from the facility. No policy was received prior to exit. 1. Record review of the facility's Facility Assessment Tool, dated [DATE], showed: -The facility had an Annual Training requirement of: [...]

Inspectors wrote4. Record review of Resident # 85's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life). -Major Depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). -Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). Record review of the resident's Order Summary Report dated 12/7/21 showed an order to monitor him/her for behaviors every shift. Record review of the resident's care plan dated 1/3/23 showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident's prescribed narcotic medications were documented as counted and the narcotic count was verified to be accurate at the beginning and end of each shift by two nursing staff. The facility census was 147 residents. Record review of the facility's policy, Medication Storage and Destruction Policy, dated 2023 showed: -A manual end of shift narcotics count must be completed with the on-coming nurse counting and the out-going nurse verifying. -Any nurse leaving the facility without properly conducting the narcotic count would receive disciplinary action, up to and including termination. -The Director of Nursing (DON) must ensure the end of shift narcotic count was occurring, and the records of all items dispensed was current, with no missing signatures, and correctly counted. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts which included narcotics were locked when not within sight of the nursing staff, failed to ensure staff did not keep their personal belongings in the medication carts, failed to ensure there were no loose pills in the drawers of the medication carts, and failed to ensure cleaning products were not in the same drawer as the residents' medications. Three of the six medication carts were sampled. The facility census was 147 residents. Record review of the facility's policy, Medication Storage and Destruction Policy, dated 2023 showed: -Controlled medication were to have been kept in the medicine cart's special secure drawer with a double locking system. 1. Observation of a medication pass on 5/4/23 at 8:30 A.M. with RN A showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure all residents were tested and/or screened for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function). The facility failed to ensure five residents (Residents #57, #66, #85, #138 and #142) were tested for TB upon admission to the facility out of 32 sampled residents. The facility census was 147 residents. Review of the facility policy entitled Tuberculosis Testing, dated 4/6/17 revised 2/26/21, showed: -Ensured each resident of the facility was tested for TB after entering the facility to prevent the spread of infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered the Influenza vaccine (vaccines that protect against the four influenza viruses that research indicates will be most common during the upcoming season) in a timely manner and provide documentation the resident or representative had refused, or provide a medical reason the immunization would not be given for five sampled residents (Resident #57, #66, #85, #138, and #142) out of 32 sampled residents. The facility census was 147 residents. Record review of facility Policy entitled Influenza and Pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia, or pneumococcus) Immunizations (the action of making a person or animal resistant to a particular infectious disease or pathogen, typically by vaccination) dated 4/6/17 and revised 3/18/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were offered the COVID (an infectious disease caused by the SARS-CoV 2 virus) vaccine, failed to obtain a declination if the resident refused the COVID vaccine, failed to obtain documentation a resident had a contraindication to the COVID vaccine, and failed to ensure there was documentation the residents or guardians had been provided with education on the COVID vaccine for five supplemental residents (Resident #28, Resident #144, Resident #65, Resident #10, and Resident #89) out of 32 sampled residents and 28 supplemental residents. The facility census was 147 residents. Record review of the facility's policy, COVID-19 Vaccine Mandate, dated 2023, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required nurse aide in-services that included dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) training for two out of four sampled Certified Nurse Assistants (CNA) (CNA A and CNA C) for [DATE] through [DATE]. This had the potential to effect the residents in the medical care unit. The facility census was 147 residents. A policy regarding Nurse Aide training was requested from the facility. No policy was received prior to exit. 1. Record review of the facility's Facility Assessment Tool, dated [DATE], showed: -The facility had an Annual Training requirement of: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents and/or family/representative of care plan (written out plan for the care of the resident) meetings for two sampled residents (Resident #60 and #18) out of 32 sampled residents. The facility census was 147 residents. Record review of the facility's policy titled Individualized Care Plans dated 2/26/21 showed no policy for invitation to care plan meetings. 1. Record review of Resident #60's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Congestive Heart Failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). -Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Residents #116 and #126) out of 32 sampled residents were free from verbal and physical abuse. Resident #116 had a history of verbal and physical aggression toward other residents and Resident #126 had a history of physical aggression and poor coping skills when agitated. Resident #116 started a verbal altercation with Resident #126, positioned himself/herself in Resident #126's personal space and threatened to hit the resident as he/she had done in the past, resulting in Resident #126 hitting Resident #116. The facility census was 147 residents. Record review of the facility's Abuse and Neglect policy, updated 1/5/23 showed: -Physical abuse was defined as purposely beating, striking, wounding, or injuring another resident or mistreating or maltreating a resident in a brutal or inhumane manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were carried over for colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen stoma) care to include the type of appliances, skin barriers and skin care, and to document a detailed assessment of the colostomy site for one sampled resident (Resident #61) out 32 sampled residents. The facility census was 147 residents. A policy and procedure on colostomies requested and was not provided prior to exit on 5/5/23. 1. Record review of Resident #16's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Colostomy. -Hypertension (high blood pressure). -Anxiety Disorder (a feeling of worry, nervousness or unease). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were detailed for a tracheostomy (trach - an incision in the windpipe made to relieve an obstruction to breathing) to include care, compressor (a machine that pushes air through a bottle of water to provide fine mist moisture through tubing into trach) orders, and maintenance; to obtain physician orders for self-care of the resident's tracheostomy; to complete a self-care assessment for the resident's ability to perform his/her own trach care; and to document detailed respiratory assessments for one sampled resident (Resident #114) out of 32 sampled residents. The facility census was 147 residents. A policy and procedure for Resident self-care/self-administration requested was not provided by facility prior to exit on 5/5/23. [...]

Inspectors wroteBased on interview and record review, the facility, failed to ensure residents' monthly Drug Regimen Review (DRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were reviewed and acted upon for two sampled residents (Resident #60 and #18) out of 32 sampled residents. The facility census was 147 residents. Record review of the facility's Monthly Drug Regimen Review policy revised 7/5/22 showed: -The consultant pharmacist will provide the Director of Nursing (DON) each month a written report with a statement about each resident any irregularities found. -The nurse/DON will forward the pharmacist's recommendations to the attending physician within 48 hours of receiving the recommendations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff members were fully vaccinated for COVID-19 or had a medical or religious exemption. Out of 71 sampled employees, five did not received their second vaccine in a two series vaccine and two staff did not receive the vaccine or have an exemption. There were no positive COVID resident in the facility the last four weeks. The facility census was 147 residents. Record review of the facility's policy, COVID -19 Mandate, dated 2023 showed: -Staff refers to individuals who provide any care, treatment, or other services for the facility and its residents, including employees. -Clinical contraindications refer to conditions or risks that preclude the administration of a treatment or intervention. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain in good repair and in good sanitary condition the residential flooring, sinks, walls and ceilings throughout the residential rooms and corridors as well as in the common areas such as the dining room and dining room chairs. These deficient practices provide opportunities for contact microorganisms to harmfully affect all of the residents who use these areas and the furniture. The facility's census was 162 residents. 1. Observations on 5/18/21 between 9:40 A.M. and 3:15 P.M., during a segment of the facility's environmental/life safety tour with the Maintenance Director (MD), showed several penetrations and holes in the walls and ceilings in the following locations: [...]

Inspectors wroteBased on interview and record review the facility failed to act upon the residents' drug regimen reviews and/or to ensure the physician documented the rationale when there was no change in the medication in response to the pharmacist's recommendations for four sampled residents (Residents #34, #40, #53 and #74) out of 32 sampled residents. The facility census was 162 residents. Record review of the facility's Monthly Drug Regimen Review policy dated 2/26/21 showed: -The nurse/Resident Care Coordinator (RCC)/Director of Nursing (DON) forward the monthly pharmacist's recommendations to the attending physician within 48 hours of receiving the recommendations. The nurse/RCC/DON documents the date and time that the physician was notified of the recommendation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed, during medication pass, to ensure medications were securely locked in one of the two sampled medication carts for three sampled residents (Residents #150, #52, and #119) out of 32 sampled residents. The facility census was 162 residents. Record review of the facility's policy titled Monthly Inspections - Medications, dated 2/26/21 showed: -The purpose was to ensure that the facility was monitoring the storage of all medications within the facility on a routine monthly basis. -The medication carts were in good repair and locked without difficulty. -Controlled medications were locked and counted. 1. Observation on 5/21/21 at 7:00 A.M. of the morning medication pass with Registered Nurse (RN) A showed: -There were two locks on the cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used during a medical emergency was checked monthly and failed to have all supplies necessary for the equipment to be fully functional for three out of the four Automated External Defibrillator (AED- a portable medical device that analyzes the heart rhythm of a person in sudden cardiac arrest(a sudden cessation of the heart) which was able to deliver a shock to return a person into a normal heart rhythm) machines. The facility census was 162 residents. Record review of the [NAME] AED PLUS Administrator's Guide dated [DATE] showed: -If more than three years have elapsed since the issue date, contact [NAME] Medical Corporation to determine if additional product information updates were available. -This product guide provides information about the operation and care of the AED Plus unit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for residents who were wearing a seat belt restraint and were not able to remove it for themselves for two sampled residents (Resident #57 and #98) out of 32 sampled residents. The facility census was 162 residents. Record review of the facility's policy titled Restraints - Physical, dated 4/6/17 showed: -The policy should be reviewed annually. -Restraints shall only be used for the safety and well being of the residents and only after other alternatives have been tried unsuccessfully. -Restraints will only be used after other alternatives have been tried unsuccessfully, and only with informed consent from the resident, physician, and or legal guardian. -Physical restraints includes soft ties that the resident cannot remove. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury acquired during a resident to resident altercation to the Department of Health and Senior Services (DHSS) for one sampled resident (Resident #74); and to report an allegation of alleged rape, and to report the results of the investigation within five working days of the incident, for one sampled resident (Resident #136) out of 32 sampled residents. The facility census was 162 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on the interests, preferences, comprehensive assessment and care plan of the resident including group and individual activities for one sampled resident (Resident #53) out of 32 sampled residents. The facility census was 162 residents. Record review of the facility's activities policy dated 2/26/21 showed: -The facility would ensure that all residents were provided an ongoing program of activities designed to meet the residents interests based on a comprehensive assessment. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the pharmacist's recommendation for gradual dose reduction for psychotropic medications for one sampled resident (Resident #26), who had a history of falls, out of 32 sampled residents. The facility census was 162 residents. 1. Record review of Resident #26's face sheet showed he/she admitted to the facility on [DATE] with the following diagnosis Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). Record review of the resident's pharmacy consultant notes dated 5/8/20 showed: -The resident recently had a fall. [...]