Burgh Care Center

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to create an environment free of accidents when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke (a serious health condition when the body temperature rises to 104 degrees or more due to exposure to high temperatures) while out of the facility. This created an immediate jeopardy situation for one of 37 residents who was approved for a LOA- (leave of absence- when the facility allows a resident to leave the facility for a short period of time)

Inspectors wroteBased on review of Resident Council meeting minutes, and resident and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for two of two months (May, and June 2026).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to conduct ongoing clinical assessments to make certain that residents were provided appropriate treatment and care for two of two residents reviewed (Residents R2, and R3).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Former Nursing Home Administrator (FNHA) and the Director of Nursing (DON) failed to effectively manage the facility when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke (a serious health condition when the body temperature rises to 104 degrees or more due to exposure to high temperatures) while out of the facility. This created an immediate jeopardy situation for 37 residents who were approved for a leave of absence (LOA) .

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Director Manager to manage the daily operations of the Dietary Department for six months.

Inspectors wroteBased on a review of observations, and staff interviews, it was determined that the facility failed to properly monitor food temperatures creating the potential for cross contamination in the main kitchen of the facility, and failed to monitor refrigerator temperatures in one of three unit refrigerators (Ground Floor).

Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for three of five residents (Residents R4, R46, and R50).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R2, R7, R40, and R76), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of five resident hospital transfers (Residents R2), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for four of five resident hospital transfers (Residents R2, R7, R36 and R76).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of three residents (Resident R62, and R77).

Inspectors wroteBased on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of three residents (R25, R26, and R70).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide (NA) personnel records (NA Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for five of five residents (Residents R4, R9, R10, R46, and R50).

Inspectors wroteBased on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for five of ten residents (Resident R13, R34, R39, R53, and R72).

Inspectors wroteBased on review of facility policy, facility documentation, observations, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025), failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R19), and failed to prevent cross contamination during a medication pass for one of three resident's (Resident R67).

Inspectors wroteBased on review of the facility's infection control policies and procedures, facility documentation, and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10) and failed to ensure that three of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for five of five staff members (Licensed Practical Nurse (LPN) Employee E6, Registered Nurse (RN) Employee E7, Nurse Aide (NA) Employee E8, NA Employee E9, and NA Employee E10).

Inspectors wroteBased on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for two of five personnel files reviewed (Nurse Aide (NA) Employee E4 and NA Employee E5).

Inspectors wroteBased on review of facility policy, facility documents, clinical record reviews and staff interview it was determined that the facility failed to initiate a thorough investigation for injury of unknown origin for one of two residents reviewed (Resident R10)

Inspectors wroteBased on review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure residents had the capacity to understand the terms of the admission agreement for one of three residents (Resident R64).

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for two of six residents reviewed (Resident R36, R40).

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of three residents (Resident R6).

Inspectors wroteBased on review of facility policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter (a flexible tube inserted into the bladder to drain urine) for two of two residents (R1, and R73).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to create a care plan for the care and management of a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) for two of two residents (Resident R59, and R72).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of five residents (Resident R6).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication carts (Fourth Floor South Cart).

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not) for one of three residents (Resident R64).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that an influenza immunization was offered to one of five residents (Resident R26).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a COVID-19 vaccination was offered to two of five residents (Residents R26 and R48).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Fourth Floor) and one of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Fourth Floor).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post complete contact information for State Long-Term Care Ombudsman program, and accessible, and complete contact information for Adult Protective Services at the facility as required for three of three locations (First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to ensure postings of the location Department of Health most recent survey results were readily accessible to residents and visitors for three of three locations (First Floor, Nursing Unit Second Floor, and Nursing Unit Fourth Floor).

Inspectors wroteBased on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, where postings are available (First Floor, Nursing Unit Second Floor and Nursing Unit Fourth Floor).

Inspectors wroteBased on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for one of two nursing units (2nd floor). Findings Include: Review of the facility policy Safe and Homelike Environment, dated 7/24/25, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. During an interview and tour on 1/29/26, at 10:45 a.m., with the Nursing Home Administrator (NHA) the following areas indicated inadequate temperatures: [...]

Inspectors wroteBased on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Resident R1 and Closed Record Resident CR1).

Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two of three residents (Resident R2 and CR1).

Inspectors wroteBased on a review of regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to provide a bed frame, a mattress and functional furniture in resident rooms on one of three units (Third Floor).

Inspectors wroteBased on review of facility policy, job description, clinical record review, personnel records, resident and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of four residents reviewed which resulted in actual harm requiring a transfer to the hospital (Resident R1).

Inspectors wroteBased on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for two of two residents. This failure resulted in an Immediate Jeopardy situation for Resident R32 and R34 who had a tracheostomy obstruction, experienced respiratory and emotional distress and potential death. (Resident R34)

Inspectors wroteBased on review of facility policy, facility documents, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of five residents (Resident R32), which resulted in actual harm requiring a transfer to the hospital for evaluation of head trauma that resulted in an acute minimally depressed right orbital floor fracture for one of five residents (Resident R32).

Inspectors wroteBased on a review of facility policies, four week cycle menu, and staff interviews it was determined that the facility failed to have a Registered Dietitian review and approve the four week cycle menu and nutritional substitutes prior to implementation for ten out of ten months (June 2024 to December 2024; January 2025 to March 2025).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined the facility failed to properly monitor essential equipment and log dish machine temperatures per shift in the main kitchen for ten of ten months (June 2024 to December 2024; January 2025 to March 2025).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R22) failed to prevent cross contamination during a medication pass for two of three residents (Resident R9 and R12) and failed to ensure an infection control surveillance plan was implemented and staff and residents were tested in accordance with national standards.

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for ten of ten months (June 2024 through February 2025).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (January 2025 to March 2025).

Inspectors wroteBased on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Employee E21, E26, E27, E28, and E29).

Inspectors wroteBased on review of facility documentation, interview with residents and observations the facility failed to implement an activites program that met residents needs for four of six residents (Resident R300, R301, R302 and R303).

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to employed a qualified activities director from October of 2024 to April of 2025.

Inspectors wroteBased on review of facility policy, clinical record, and staff interviews, it was determined that the facility failed to maintain a complete record of pre and post dialysis assessments for three out of five sampled resident records (Resident R20, R38, and R233).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two of two residents (Residents R20 and R77). Findings Include: The job description for the Nursing Home Administrator dated 10/29/24, specified the primary purpose of the job is to manage the facility in accordance with current applicable, federal, state, and local standards, guidelines, and regulations the govern long-term care facilities. It is the NHA job to follow all facility policies and to ensure the highest degree of quality care is provided to the residents at all times. [...]

Inspectors wroteBased on review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide tracheostomy care for four of four staff members (Licensed Practical Nurse, Employee E1, Registered Nurse Supervisor E2, LPN, Employee E9 and LPN, Employee E11).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of five nurse aides (NA) (NA Employee E26, E27, and E29).

Inspectors wroteBased on review of facility documentation, clinical records and staff interview it was determined that the facility failed to correctly label medication for two of four residents (Resident R2 and Resident R17) and failed to implement pharmaceutical services to ensure accurate provision of medications for two of four residents (Resident R4 and Resident R77).

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of seven sampled residents (Resident R71).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and resident staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of five residents (Resident R34).

Inspectors wroteBased on review of facility policy, resident record, investigation documents and staff interview, it was determined that the facility failed to report an allegation of neglect failed to report an allegation of neglect for one of five sampled residents (Resident R70).

Inspectors wroteBased on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of four sampled records (Resident R69).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R281).

Inspectors wroteBased review of facility policy, clinical records, smoke observations and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for one of two sampled residents (Resident R283).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for two of four residents (Resident R4 and R77).

Inspectors wroteBased on review of facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of two residents reviewed (Resident 34).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received the necessary services and ensure wound care recommendations were implemented timely for one of four residents (Resident R16).

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to have physician order specifications relating to size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R48).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration and health for one of four residents (Residents R20) and address a significant weight loss for one of four residents (Resident R68).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (PEG - a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Residents R281).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement a care plan for intravenous therapy for one residents of two residents (Resident R24).

Inspectors wroteBased on review of facility policy, resident record review, and staff interview, it was determined that the facility failed to develop care plans with identified triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) to prevent re-traumatization for three of three sampled residents (Resident R33, R38, and R42).

Inspectors wroteBased on review of the pharmacy recommendations, clinical record, and staff interview, it was determined that the facility failed to act on the pharmacy medication recommendations in a timely manner for one of five sampled residents (Resident R38).

Inspectors wroteBased on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for one of five residents (Resident R12), failed to identify a diagnosed specific condition for treatment, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of five residents (Resident R82) reviewed. Findings Include: Review of facility policy Psychotropic Medication Use dated 9/18/24, indicated residents will not recieve medications that are not clinically indicated to treat a specific condition. As needed (PRN) psychotropics will be limited to 14 days. PRN orders cannot be reordered unless the physican pr prescirber evaluates the resident and documents the appropraiteness of the medication. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of six residents (R6 and R77).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to properly store medical supplies and biologicals in one of four medication carts (4th floor north hall medication cart) and one of two medication rooms (4th floor medication room).

Inspectors wroteBased on review of facility policy, meal tray observations, staff and resident interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for one of seven sampled residents (Resident R56).

Inspectors wroteBased on review of facility policy, facility scheduled mealtimes, meal delivery observations, resident council group interviews, resident and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for one of three meal observations (4/1/25-breakfast).

Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for two of two residents reviewed (Resident R34 and R77).

Inspectors wroteBased on review of facility documentation and previous surveys and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1). This failure created an immediate jeopardy situation.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R1), which created an immediate jeopardy situation for one of five residents.

Inspectors wroteBased on review of facility documents, and staff interviews it was determined the facility failed to designate a physician to serve as medical director. Findings Include: Review of the facility's medical director contract dated 12/1/23, signed by Doctor of Osteopathic Medicine (DO), Employee E14 indicated a medical group is to provide medical directorship and oversight services for the facility and to provide clinical medical services to the patients on each unit as medically necessary. It was stated the medical group agrees to assign physicians to provide such services. Review of information submitted to the Department of Health, on 3/12/25, at 1:30 p.m. revealed Medical Director, Employee E16 was the designated Medical Director of the facility since 1/1/20. During an interview on 3/12/25, at 2:47 p.m. [...]

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of three residents (Resident R1).

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial visit for one of three residents (Resident R2).

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for two of four residents (Residents R2 and R3).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of a change in condition for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia protocol and failing to notify the physician timely of a change in condition for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined that the facility failed to ensure infection control and prevention practices were implemented on one of two nursing units observed (3rd floor).

Inspectors wroteBased on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect a resident from neglect by not providing appropriate assistance with transfers using a mechanical lift for one of four residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, investigation documentations, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. [...]

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the elopement of a resident and effectively manage the facility to ensure that proper supervision, assessments, and interventions were provided to ensure safe smoking for residents as required.

Inspectors wroteBased on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of three residents (Resident R1).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label and date food products in the walk in cooler creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen.

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, resident clinical records, and staff interview, it was determined that the facility failed to make certain that Minimum Data Set assessments were completed accurately for three out of six sampled resident records (Resident R20, R39, and R40).

Inspectors wroteBased on review of facility policy, clinical records, medication administration records, resident and staff interview it was determined that the facility failed to provide glucose monitoring as per physician's order for two out of four sampled resident records (Resident R40 and Resident R53) and failed to have a physician orders to provide pacemaker monitoring for one of two sampled resident records (Resident R32).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for three of six residents reviewed (Resident R7, R274, and R30) and failed to obtain physician orders for one resident with a tracheostomy (Resident R30).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide care and treatments related to dialysis care for one of six residents (Resident R22) and failed to provide consistent and complete communication with the dialysis center for four of six residents (Resident R20, R22, R32, and R61).

Inspectors wroteBased on review of facility policy, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for five of five nursing personnel (Nurse Aide (NA) Employees E13, E14, and E15, Licensed Practical Nurse (LPN) Employee E16, and Registered Nurse Supervisor (RN) Employee E17).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for two of three sampled records (Nurse aide (NA) Employees E13 and E14).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 11 of 12 months (June 2023 - May 2024), and failed to implement enhance barrier precautions for five of five residents (Residents R3, R20, R22, R32, and R61 ) and failed to disinfect equipment, failed to perform hand hygiene between care for one of three residents (Resident R24), and failed to prevent cross contamination during a dressing change for one of three residents (Resident R17).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 11 of 12 months (June 2023 - April 2024).

Inspectors wroteBased on review of facility records and staff interviews, it was determined that the facility failed to have a designated qualified Infection Preventionist (IP) working at least part time in the facility for six of 12 months June 2023 to November 2023 .

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R58).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interview it was determined that the facility failed to properly screen an employee by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E6).

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incidents or accidents for two of three residents (Residents R71 and R4).

Inspectors wroteBased on facility policy, observation, clinical record, and staff interview it was determined that the facility failed to ensure that residents receive necessary treatment and services to promote healing of a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R17).

Inspectors wroteBased on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for two of two residents (Residents R39 and R58).

Inspectors wroteBased on review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for one of three residents with a urinary catheter (Resident R3).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist at least monthly for one out of six sampled resident records (Resident R14).

Inspectors wroteBased on review of facility policies, observations, and staff interviews it was determined that the facility failed to accurately label and date open medications for one of two medication carts (third floor medication cart) and failed to properly store medical supplies and biologicals in one of two medication rooms (third floor medication room).

Inspectors wroteBased on menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for one of one lunch meal (lunch meal Monday 5/20/24).

Inspectors wroteBased on review of facility policy, clinical records, incident reports and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of eleven residents (Closed Record Resident CR1).

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to ensure the presence of necessary documentation supporting the specific reason for discharge of one of six residents reviewed (Resident R1).

Inspectors wroteBased on a review of facility policies, documents, observations, and resident and staff interviews, it was determined that the facility failed to follow a physician order, provide comprehensive skin assessments for a resident with sutures, and failed to coordinate post surgical appointments for one of three residents with skin impairment (Resident R1).