Burlington Health and Rehabilitation Center

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that wound care was documented as completed according to physician's orders for 1 of 3 residents (R 2) reviewed for wound care out of a total sample of 27 residents. This has the potential to cause infection, prolonged healing, scarring, and in extreme or untreated cases, sepsis.

Inspectors wroteBased on facility document review, record review, and interviews, the facility failed to ensure a qualified social worker was employed on a full-time basis for a period of approximately two months. The facility, certified for more than 120 beds, did not have a qualified social worker to provide for and meet the needs of the 94 residents residing in the facility. This deficient practice had the potential to result in unmet resident psychosocial needs.

Inspectors wroteBased on record review, observations, interview, and review of the facility policy, the facility failed to ensure three residents (R2, R18, and R23) out of 18 residents in the sample who were reviewed for meal choices and alternates were regularly offered alternate meals of equal nutritional value when they declined to eat the meal they were originally served. This failure created the potential for residents to experience a poor overall dining experience and potential loss of weight. A total of 26 residents were reviewed in the sample.

Inspectors wroteBased on individual and group interviews, the facility does not always provide reasonable access to residents' mail. Mail that is delivered to the facility on Saturdays by the Postal Service is not delivered to the residents until the following Monday afternoon. This has the potential to affect 93 out of 93 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility did not ensure the kitchen was storing and preparing food in a safe and clean manner. This has the ability to affect all 93 residents. The walk-in freezer had buildup of thick ice on the floor, walls and ceiling including boxes of food in the freezer. Two fans in food prep area had buildup of red substance making the fan appear dirty and in disrepair. A bag of lettuce salad was opened with a date that was faded so it made the date unreadable. The lettuce was brown. The exhaust fan over the stove area had a buildup of dust. No beard restraint used for Dietary Staff (DS)-LL and Dietary Manager (DM)-MM.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect 93 of 93 residents residing in the facility. Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS triggering a one-star staffing rating for Quarter 2: January 1-March 31 of 2025.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained and the Enhanced Barrier Policy was implemented to help prevent the development and transmission of communicable diseases potentially affecting 93 of 93 residents. Enhanced Barrier Precautions (EBP) were not in place throughout the facility. Two of the six units provided signs and Personal Protective Equipment (PPE) for residents that required EBP; four of the six units did not implement EBP. *R3 was in Contact Isolation and observations were made of staff entering R3’s room without putting on PPE. *R1’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. *R16’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an effective pest control program to address the flies in the facility. *R15 and R16 informed Surveyor that the facility has a problem with flies and R15 uses items in the room to ‘swat’ at the flies. *Surveyor observed a fly flying around R34’s room during observation of a treatment to the right leg on 8/11/25. *Flies were observed around R8 at mealtime during the survey process and R10 informed Surveyor that R10 had killed 18 flies in 3 days. *R29 complained of so many flies they had to purchase fly strips to catch the flies in their room. *R8, R35, R49, and R78 informed Surveyor at resident council on 8/11/25 the concern of numerous flies throughout the facility. *Surveyors observed flies in resident unit hallways, the common dining room for residents, the conference room and in a resident's bathroom. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents were free from physical abuse for 1 (R59) of 5 residents reviewed for abuse. This has the potential to affect all residents who resided on the unit where R59 lives from 7/2/25 through 7/9/25 when CNA-FF continued working and had access to facility residents after an allegation of abuse.*R59 informed Surveyor that CNA-FF was rough with a transfer on 7/2/25, had been rough with cares in the past and that CNA-FF was bossy and made R59 feel intimidated. On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation of abuse was not reported to the Nursing Home Administrator (NHA)-A per the facility abuse policy. After the allegation of abuse, CNA-FF continued working at the facility from 7/2/25 through 7/9/25. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the Minimum Data Set (MDS) assessments accurately reflected residents' status for 4 (R33, R46, R53, and R10) of 4 residents reviewed for comprehensive MDS assessments. *R33 had behavioral symptoms not directed toward others, wandering, and elopement behaviors since the time of admission. R33's admission MDS assessment dated [DATE] documented R33 did not exhibit any behavioral symptoms or wandering. *R46 had a Preadmission Screening and Resident Review (PASARR) level 1 and level 2 completed. R46's Annual MDS assessment dated [DATE] documented R46 had not been evaluated by the Level 2 PASARR. *R53 had a PASARR level 1 and level 2 completed. R53's Annual MDS assessment dated [DATE] documented R53 had not been evaluated by the Level 2 PASARR. *R10 had a PASSAR level 1 and level 2 completed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 7 (R15, R16, R24, R27, R34, R81,and R6) of 8 Residents reviewed for ADLs (Activity of Daily Living). * R15, R16, R24, R27, R34, R81,and R6 did not receive showers at least one time a week.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 5 (R15, R16, R27, R34, and R8) of 20 residents received necessary care and treatment in accordance with professional standards of practice, a comprehensive person-centered care plan or facility policies and procedures. *R15 was observed not wearing compression stockings during the survey per physician orders and R15's plan of care. *R16 was observed not wearing compression stockings during the survey per physician orders and R16's plan of care. *R27 was observed not wearing compression stockings during the survey per physician orders and R27's plan of care. *R34 did not have a treatment completed to R34’s vascular/venous statis ulcer on 8/8/25. On 7/18/25, a physician order was obtained for R34 to receive an air mattress and R34 did not receive an air mattress until 7/21/24. [...]

Inspectors wroteBased on observations and interviews the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 6 medication carts reviewed. Insulin vials and pens were not labeled, dated when opened and/or were expired.

Inspectors wroteBased on observation and interview the facility did not ensure 1 (R27) of 3 Residents reviewed for indwelling catheters were treated with dignity and respect.*R27's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors. Findings Include:R27's quarterly minimum data set (MDS) completed 5/31/25 documents R27 has an indwelling catheter. R27's comprehensive care plan documents:R27 has indwelling catheter due to diagnosis of Neurogenic BladderInitiated 11/23/24 Revised 6/11/25On 8/11/25, at 9:55 AM, Surveyor observed Certified Nursing Assistants (CNA) - X and (CNA) - Y bring R27 out of R27's room. R27 was in a wheelchair that was reclined. Surveyor observed CNA-X push R27 down the hall, turn left at the nurse's station, and continue pushing R27 down the hallway and placed R27 in the activity room. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not promote and facilitate 1 (R65) of 1 Resident's right to self-determination through support of R65's choice about an aspect of R65's life that is significant to R65. R65 changed rooms in the facility on 7/25/25. R65 had boxes with items important to R65 on R65's dresser and closet area. R65 went to a group activity in a common area on 8/4/25. When R65 returned to R65's room, R65's boxes and items important to R65 were gone. R65 informed Surveyor that Social Worker (SW)-J and Nurse Technician (NT)-BB entered R65's room without permission and removed R65's items.

Inspectors wroteBased on interview and record review, the facility did not ensure formulated advance directives were documented accurately for 1 (R3) of 20 residents reviewed for code status. Documentation in R3's medical record indicated R3 desired to be a full code (cardiopulmonary resuscitation to be administered) and a do not resuscitate (DNR).

Inspectors wroteBased on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 (R5, R34 and R65) of 3 residents. *R5’s wall and heat register in R5’s room was observed to be coated with dirt and a thick layer of dust. R5’s curtains hanging over the heat register was observed to be coated with dirt and black spots. *R34’s window in R34’s room was observed to have a thick white film and appears cloudy. The outside of the window was observed to be dirty. Near R34’s window, there is a cobweb with two dead flies hanging from it. R34’s window blinds appear to be broken and not functional. *R65’s air conditioning and heating unit on R65’s wall in R65’s room was observed to be disconnected and coming off the wall on the left side. On the left side of the unit, Surveyor observed an exposed metal pipe covered in dirt and cobwebs. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R53) of 2 residents with allegations of abuse were reported to the Nursing Home Administrator (NHA)-A per facility policy, the state agency and one or more law enforcement entities.*On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation was not reported to the Nursing Home Administrator (NHA)-A, the state agency and one or more law enforcement entities.

Inspectors wroteBased on interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 (R59) of 2 residents reviewed. R59 informed Surveyor that Certified Nursing Assistant (CNA)-FF was rough when caring for R59. On 7/2/25, R59 informed 3 different facility staff members of the alleged abuse incident. The allegation of abuse was not reported to Nursing Home Administrator (NHA)-A and the facility did not complete a thorough investigation into R59's allegation of abuse.

Inspectors wroteBased on record review and interview, the facility did not accurately screen residents for a mental disorder for 2 (R4 and R9) of 2 residents reviewed for Preadmission Screen and Resident Review (PASARR) Level I and requiring a Level II screening. R4 was admitted to the facility with diagnoses of mental disorders and was not evaluated on the PASARR Level I screen as having any mental disorders. The Level II PASARR was never completed due to the inaccurate PASARR Level I screen. R9 was admitted to the facility with diagnoses of mental disorders and was evaluated as having a serious mental disorder on the PASARR Level I screen. R9 did not have a completed Level II PASARR screen when identified as having a positive Level I PASARR screen.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R1, R16 and R53) of 5 residents reviewed for pressure injuries. *R53 developed a facility acquired, Suspected Deep Tissue Injury (DTI) on 7/22/25. The pressure injury was incorrectly staged on 7/29/25 when it developed slough and continued to be staged as a DTI. The wound treatment was recommended to be changed but facility staff continued treating the wound with skin prep as previously ordered. On 8/5/25, the facility documented the same measurement of an unstageable wound and documented an area of DTI with a new measurement. With the changes in R53’s wound, R53’s care plan was not updated. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R24) of 4 Residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R24 was not wearing R24's right hand splint/ right elbow brace during the survey. There was no documentation R24 was provided with physician ordered neck exercises. Surveyor did not observe any range of motion being performed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (R8, R24 and R81) of 5 residents reviewed for falls. *R8 requires the assistance of 2 with a toilet transfer. R8 was transferred to the toilet on 4/8/25 and left alone in the bathroom. R8 sustained an unwitnessed fall 2 minutes later. In interviews with Director of Rehab, Director of Nursing and other staff members, facility staff indicated R8 should not be left alone in the bathroom. R8’s care plan was not updated with a resident specific intervention after this fall. *R24’s fall interventions were not in place during Surveyor observations. *R81’s fall interventions were not in place during Surveyor observations.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R34) of 2 Residents receiving oxygen (O2) therapy.*On 8/7/25, Surveyor observed R34's humidifier bottle completely empty and the humidifier bottle should have been changed on 8/6/25 per physician orders. Findings Include:The facility's Oxygen Administration policy and procedure reviewed and revised 1/8/24 documents:Policy:Oxygen is administered to Residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the Resident's goals and preferences. Policy Explanation and Compliance Guidelines:1. O2 is administered under orders of a physician, except in the case of an emergency. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R9) of 3 residents was provided pain management consistent with professional standards of practice. R9 reported being in constant pain that frequently affected sleep and day to day activities. R9 was consistently receiving Oxycodone for pain management, which was prescribed on [DATE], and later discontinued on [DATE]. R9 was documented as having pain 10 out of 10 and went without Oxycodone pain medication on [DATE] and [DATE], after Oxycodone was discontinued on [DATE], which resulted in R9 going to the emergency room (ER) for pain management on [DATE].

Inspectors wroteBased on observation, interview and record review, the facility did not assess the risk for possible entrapment, the continued need, review the risks & benefits, and obtain consent on a quarterly basis for 3 (R24, R27, and R81) of 8 Residents reviewed having enabler bars. Findings Include:The facility's Proper Use of Bed Rails/Enabler Bars/Assist Bars reviewed/revised 3/14/25 documents:.Guideline:It is the guideline of this facility to utilize a person-centered approach when determining the use of bed rails (may also be referred to side rails, safety rails, grab bars, assist bars, transfer bars). Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Informed Consent .7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were followed and served as posted for 2 (R65 and R59) of 2 residents reviewed. *R65’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray, 8/11/25 breakfast tray and 8/11/25 lunch tray. *R59’s food preferences were not followed. On 8/6/25 Surveyor observed white bread on R59's tray when white bread is one of R59’s dislikes. R59’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray and 8/11/25 lunch tray.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R8) of 3 residents reviewed for hospice. R8's hospice visit documentation, hospice plan of care, hospice responsibilities and services being provided, and hospice daily nursing visit notes, were not kept in R8's facility's electronic medical record or in R8's hospice binder.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing a pressure ulcer dressing change for one Resident (R) 6 out of three reviewed for enhanced barrier precautions (EBP). This had the potential for cross contamination and risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Dietary Manager (DM) was designated to act as the director of food and nutrition services, when the DM position was vacant. This had the potential to affect 89 of 89 residents in the facility.

Inspectors wroteBased on observation, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food substitutions and ensuring recipes were followed for 89 out of 89 residents. This failure had the potential to cause residents to lose weight.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness. This had the potential to affect 89 of 89 residents. Specifically, the facility failed to label, date, and store food properly.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R6) who were observed with medications at the bedside for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the residents' bedside where other residents could access them.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure documentation of pre- and post-dialysis assessments and failed to ensure communication occurred between the facility and the dialysis center for one of two residents (Resident (R) 17) reviewed for dialysis out of total sample of 18. This had the potential to affect the health of residents receiving dialysis.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have medications available to administer as ordered for three of four residents (Resident (R) 7, R18, and R2) reviewed for medication availability out of a total sample of 18. This had the potential to result in adverse health outcomes.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 7) reviewed for medications was free from significant medication errors when medications were not available and/or were not administered per physician orders. This had the potential to result in adverse health outcomes.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure care and services were documented for four Resident (R)1, R4, R5, and R9) of 11 residents reviewed for documentation of treatments as ordered by the physician. Failure to document medication administration and treatments to residents does not ensure the treatment or medication has been completed, and could cause a delay in treatment or medication. Findings Include: Review of the facility's policy titled, Documentation in Medical Record dated [DATE], revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 5 (R11, R15, R16, R3, and R7) of 12 Residents reviewed received a prompt resolution to grievances. *On 5/17/24, it is documented R11 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved. *On 5/17/24, it is documented R15 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved. *On 5/17/24, it is documented R16 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of abuse for 2 of 5 investigations reviewed, included steps that were taken by the facility to ensure safety of the facility residents. * Visitor-HH alleged facility housekeeper-N was sexual inappropriate to the visitor when visiting a resident in the facility. The facility did not complete a thorough investigation of the allegation/actions of housekeeper-N by ensuring current facility residents were interviewed to determine if they had concerns or similar allegations regarding housekeeper-N. *R10 made an allegation of rough care that was reported to a registered nurse. This was not thoroughly investigated by the facility. This deficient practice had the potential to affect 73 of 73 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility did not provide pharmaceutical services to assure accurate dispensing and administering medications to meet the needs of each resident. This has the potential to affect R3, R7, 17 residents who reside on the 400 unit & R17. * R3's Bisacodyl (Dulcolax) 10 mg (milligram) suppository was transcribed incorrectly on 8/20/24 when R3 was readmitted from the hospital. *The Facility did not provide R7 with the ordered Coban wraps, per the physician's order. * Medications were left on top of medication cart unattended. * R17's glucose monitor was not labeled to identify it was R17's glucose monitoring device. 1.) R3 was readmitted to the facility on [DATE] with diagnosis which includes C Diff (clotridoides difficile). [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R3) of 1 Resident's resident representative was notified when there was a need to alter treatment. R3's POA (Power of Attorney) was not notified when occupational therapy was discontinued on 6/26/24 and physical therapy was discontinued on 7/2/24.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 1 allegations of abuse involving 2 Residents (R10 and R8) of 5 allegations of abuse were reported immediately. *On 5/16/24, Certified Nursing Assistant (CNA)-V notified Registered Nurse (RN)-S that R10 voiced an allegation that CNA-V was rough with cares. RN-S informed CNA-V that was R10's behavior. CNA-V went back and continued cares for R10 and other Residents on CNA-V's assignment. On 5/17/24, Social Services notified Nursing Home Administrator (NHA)-A of the allegation. Findings Include: The facility's policy Abuse, Neglect, and Exploitation implemented 9/18/23 documents: .Policy: [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R10) of 2 Residents reviewed for discharge received a complete discharge summary. *R10 was discharged to an adult living home on 6/4/24 without a completed discharge summary and list of medications to allow for coordination of care and to effectively transition R10 to post-facility care. Findings Include: The facility's policy Transfer and Discharge implemented 10/26/2022, and last revised on 1/2024 documents: 14 Anticipated Transfers or Discharges -Resident -initiated discharges a. Obtain physicians' for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team(IDT) completes relevant sections of the Discharge Summary. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (R3 & R7) of 16 residents. * Staff did not place tubi grips on R3's bilateral lower extremities on 10/1/24 & 10/2/24. * R7's non pressure wounds were not comprehensively assessed for 7 days. There is no order for R7's PICC (peripherally inserted central catheter), the PICC dressing, & care of PICC line. Facility staff were wrapping R7's legs with ace bandages when the physician's orders documented Coban.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate assistance with devices to prevent accidents for 1 (R5) of 1 resident observed for accidents. R5 required assistance of 2 staff to be transferred using a Hoyer lift. Facility staff were observed walking away from R5 during the transfer process to address other issues leaving R5 suspended in the sling and creating a potential unsafe transfer.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R3) of 1 resident was provided with appropriate food items for a renal/LCS (low concentrated sweets) diet as prescribed by the physician. R3 was served french fries and a tomato slice on 10/1/24.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R3) of 1 residents with a tracheostomy. The facility did not change R3's HME (heat moisture exchanger) trach valve daily according to physician orders.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R6) of 5 Residents reviewed for antibiotic use. *R6 began having Urinary Tract Infection (UTI) symptoms on 7/16/24. R6 had a urinalysis (UA) and culture lab test collected by the facility staff on 7/17/24 and Rocephin (an antibiotic medication) was ordered to start on 7/18/24. R6 requested to go to the emergency room (ER) on 7/17/24 due to R6's UTI symptoms. The ER doctor prescribed Bactrim (an antibiotic medication) to start on 7/18/2024. On 7/19/24, R6 received Rocephin and Bactrim for R6's UTI symptoms. On 7/20/24, R6's urinary culture results came back and Macrobid (an antibiotic medication) was ordered to start on 7/20/2024 by the on-call Medical Doctor (MD). On 7/20/24, R6 received Rocephin, Bactrim and Macrobid for R6's symptoms of UTI. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 20%. *R14 received crushed Depakote (delayed release) and administered 8AM scheduled medications, including Carbidopa-levodopa, at 10:04 AM. *R8 received 8AM scheduled Gabapentin and Tramadol medications at 10:26 AM. *On 10/1/24 R3 did not receive Complex B-100 extended release with biotin & folic acid per physician orders and did not receive the correct dosage of Carvedilol.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R3) of 1 residents were free of significant medication errors. R3 was readmitted to the facility on [DATE] with discharge medications to include Carvedilol 25 mg every 12 hours. The facility did not change the dosage when R3 was readmitted and continued the previous dose of 12.5 mg. R3 received the incorrect dosage from 8/20/24 until 10/3/24 when DON (Director of Nursing)-B spoke with R3's physician on the telephone. R3 received the incorrect dose of Carvedilol 69 times during August and September 2024.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 2 Residents. * Appropriate hand hygiene was not observed during trach & incontinence cares for R3 who is on contact isolation for C diff (Clostridioides difficile).

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure 1 of 3 residents (R1) reviewed for potential sexual abuse was provided medically related social services to assist R1 in attaining or maintaining their mental and psychosocial health. * On 5/18/24, R1 was approached by her spouse to have sexual relations while R1 resided at the facility. The facility was made aware of R1's spouse's intentions to have sexual relations with R1 prior to 5/18/24 but took no steps on 5/18/24 to ensure that R1 could consent to having sexual relations.

Inspectors wroteBased on observation, interview, and a comprehensive record review, the facility did not ensure that a resident with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new injuries from developing for 1 of 3 (R13) residents reviewed for pressure injuries. R13 developed a facility acquired Suspected Deep Tissue Injury (SDTI) on the left heel. Subsequent staging of the pressure injury included staging of the pressure injury as unstageable and a stage 3. While on survey, Surveyor had observations of R13's care plan interventions not implemented, including offloading of R13's heel.

Inspectors wroteBased on record review, observation and interview the facility did not distribute and serve food in a manner that prevents foodborne illness to 74 out of 74 (census 76, 2 NPO) residents who receive their meals from the main serving kitchen. *Cook-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. *Dietary Aide-M was observed touching nose with gloved hands while transferring yogurt from large container to individual service containers.

Inspectors wroteBased on interview and record review the facility did not ensure that 6 (R2, R12, R33, R35, R39, & R46) of 13 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R2 transferred to another room on 4/12/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. There is no documentation that R2's guardian was provided written notice. *R12 transferred to another room on 2/28/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. There is no documentation that R12's guardian was provided written notice. [...]

Inspectors wrote4.) R52 was re-admitted to the facility on [DATE] with diagnosis that included Cerebral palsy, asthma, blindness right eye, major depressive disorder, bipolar disorder, developmental disorder, anxiety, seizures. R52 was originally admitted to the facility on [DATE]. Surveyor conducted a review of R52's plan of care that indicates R52 has the potential for falls, accidents and incidents due to immobility, impaired cognition, unaware of safety needs. Interventions included padded side rail to prevent bruising to extremities from swatting/ hitting when anxious. The need for padded side rail was added on 8/10/23. The plan of care also states that R52 has self- care deficit due to cognitive deficits, disease process/ progression due to his cerebral palsy, blind in both eyes. Interventions include that R52 needs the assist of 1 for bed mobility. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 2 (R47 &R322) of 7 facility reported incidents investigations reviewed were reported to the State Survey Agency, within 5 working days of the incidents, after the initial reporting and with the results of the investigations of each alleged violation.

Inspectors wroteBased on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R52) of 1 Resident reviewed with PASARR level 2 recommendations. *R52's PASARR dated 7/21/21 determination states R52 needs specialized services to address R52's developmental disability needs. Findings Include: Policy Review: Specialized Rehabilitative Services ( date implemented- blank, Date reviewed- blank, Date revised- blank) Policy: [...]

Inspectors wroteBased on record review, observation and interview, the facility did not ensure a complete baseline care plan was developed and addressed all of the resident's needs within 48 hours of admission for 1 (R371) of 2 sampled residents for new admission. R371's baseline care plan did not address R371's enabler bar usage on the baseline plan of care.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure 1 (R32) of 1 Resident reviewed for communication with the use of hearing aides, received proper treatment and assistive device to maintain R32's hearing abilities. Findings Include: R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Hypo-osmolality and Hyponatremia, and Gastro-Esophageal Reflux Disease. R32 has an activated health care power of attorney(HCPOA). R32's Significant Change Minimum Data Set(MDS) dated [DATE] documents R32's Brief Interview for Mental Status(BIMS) score to be a 0 indicating R32 demonstrates severely impaired skills for daily decision making. R32 has no behaviors documented. R32's Patient Health Questionnaire(PHQ-9) score is 8 indicating mild depression. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that , based on a comprehensive assessment, provided the appropriate treatment and services to restore continence , to the extent possible, for 1 out of 2 residents ( R19) reviewed for bowel and bladder incontinence. This is evidenced by: Policy Review: Incontinence Date implemented: ( blank), Date Reviewed/ Revised ( blank). Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: ( includes) 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 4. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure a Resident with a gastrostomy tube received the appropriate care and services for 1 (R60) of 3 Residents with gastrostomy tubes. *R60's water flush bag and tube feeding was not labeled for two days during the survey process. R60's tube feeding pump had not been calibrated to ensure proper flow rate. Findings Include: Surveyor reviewed the facility's undated Care and Treatment of Feeding Tubes policy and procedure and notes the following: 10. Direction for staff regarding how to manage and monitor the rate of flow will be provided: a. Use of gravity flow b. Use of a pump c. Periodic evaluation of the amount of feeding being administrated for consistency with practitioner's orders d. [...]

Inspectors wroteBased on interview and record review, the Facility did not provide dialysis services consistent with professional standards of practice for 1 (R321) of 1 Residents reviewed for dialysis. * R321 receives dialysis three times per week. R321's dialysis center communication records are not being completed by Facility nurses.

Inspectors wroteBased on interview and record review the pharmacist recommendations made during the monthly record review were not reported to the attending physician and were not acted upon for 1 of 5 (R37) residents reviewed for unnecessary medications. R37's pharmacy recommendations were not acted upon by the physician.

Inspectors wroteBased on interviews and record review the facility did not ensure that residents are free of any significant medication errors for 2 of 2 (R3 and R37) residents reviewed. Morning medications are not administered within timeframe specified and are often administered after 11 AM along with noon medications. The facility policy titled Medication Administration (not dated) documents (in part) . .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 3 of 3 medication carts had insulin vials dated with the open date and insulin pens that have expired after being open removed from the medication cart. This affected 4 residents (R35, R30, R56 and R29) On [DATE] Surveyor observed medication carts from 200, 300, and 400 hall. The 200 hall had insulin vials opened and not dated. The 300 hall had an insulin pen that expired after it was opened on [DATE]. The 400 hall had an insulin pen that expired after it was opened on [DATE].

Inspectors wroteBased on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R32) of 3 sampled Residents receiving hospice services. *R32 was admitted on hospice on 4/8/24. R32's hospice binder did not have a physician certification of terminal illness, physician orders, documentation of visits, schedule of hospice visits with hospice team listed, and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider. Findings Include: Surveyor reviewed the facility's Hospice Program policy and procedure and notes the following applicable: .Policy Interpretation and Implementation 9. In general, it is the responsibility of the hospice to manage the Resident's care as it relates to the terminal illness and related conditions, including: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement effective infection prevention measures. This included observation of a nurse touching medications with bare hands during medication pass on two occasions. Observation of two residents having their catheter bag on the floor multiple times during the survey affecting 2 of 4 residents sampled with catheter bags. * The facility did not ensure R371 and R372's catheter bags were maintained in a sanitary manner.

Inspectors wrote2) R4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus, Anxiety Disorder and Major Depressive Disorder. R4 is his own person. Surveyor reviewed R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score to be a 15 which indicates that R4 is cognitively intact for daily decision making. R4's Patient Health Questionnaire(PHQ-9) score of 5 indicates that R4 has mild depression present and R4's MDS does not document any behaviors. R4's MDS documents that R4 requires limited assistance for bed mobility, transfers, dressing, and toileting and has range of motion impairment on both upper and lower of 1 side. R4 is mobile with an electric wheelchair. [...]

Inspectors wroteBased on interview and record review, the Facility failed to utilize the services of the Facility's Medical Director to ensure 1 (R2) of 1 Residents received the appropriate behavioral health services, including ensuring R2 received medications and health services as assessed. R2 had been receiving Clonazepam since being admitted in 2020. In May of 2023, the facility became aware that the psychiatric nurse practitioner (psych NP) that was seeing R2 and actively prescribing R2's antianxiety medication would no longer see R2. The psych nurse practitioner did not help refer R2 to an alternate provider and the psychiatrist supervising the psych nurse practitioner did not step in to assess R2 or help refer R2 to an alternate provider. The facility's medical director did not communicate with the behavioral practitioners to facilitate services for R2. [...]

Inspectors wroteThis is an uncorrected deficiency from survey event: VLJH12. Based on interview and record review, the facility did not ensure that 1 of 1 allegations of abuse involving R32 was reported immediately to the State Survey Agency. On 10/2/23, it is documented that a male Resident who was monitored to not be on R32's wing was found in R32's bed. Findings Include: Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented 9/18/23 and notes the following in regards to reporting requirements: .Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. [...]

Inspectors wroteThis is an uncorrected deficiency from survey event: VLJH12 Based on record review and staff interview, the facility did not ensure an allegation involving potential sexual abuse was thoroughly investigated for 1 of 1 Resident (R32) reviewed for allegations of abuse. Findings Include: Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented on 9/18/23 and notes the following in regards to reporting requirements: .Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. [...]

Inspectors wrote2) R2 was originally admitted to the facility on [DATE] with a readmission date of 10/19/23. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus, and hypertension. R2 does not have an activated power of attorney for healthcare. The resident requires assistance with discharge planning care plan created 2/5/20 and initiated & revised on 10/19/23 documents the following interventions: * Assist resident with adjustments to the residential setting so that he has a sense of control that is maintained throughout. Created 2/5/20 and initiated & revised 10/19/23. * Consult with the physician, therapy, and other disciplines regarding progress toward discharge goals. Make arrangements for appropriate placement and update. Created 2/5/20 and initiated & revised 10/19/23. [...]

Inspectors wroteBased on record review and interview, the facility did not have an effective system to ensure residents' advanced directives for emergency end-of-life care/code status were accurate and carried out as the resident wished and did not follow facility policies to call a Code Blue when a resident was found pulseless and non-breathing. This affected 1 of 1 residents (R1) who expired while at the facility and 11 of 16 sampled residents (R11, R30, R27, R28, R29, R20, R7, R22, R23, R24, R25) whose code statuses identified delays in obtaining resident/responsible party signatures, witness signatures, signatures of the physician/nurse practitioner and at times issues with code status orders. R1's code status election forms were documented as follows: The first one was for a full code status election signed by R1 on [DATE] and Nurse Practitioner (NP)-FF on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to protect 1 of 6 residents (R10) right to be free from sexual and mental abuse by Dietary Aide (DA)-O. (DA)-O failed to maintain caregiver boundaries by engaging in a personal/sexual relationship with R10. DA-O became overly involved with R10 which included spending inappropriate amounts of time while off duty with R10, directing staff that she was providing 1:1 supervision and cares of R10, such as doing dressing changes, allowing R10 to call her for support when R10 wanted to get high, allowing R10 to watch movies at her home, assisting R10 with detoxing by providing R10 with narcotics (such as Heroin and/or Fentanyl). The facility was aware of the relationship and dynamics that were developing between DA-O and R10. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R10, R11 and R8) of 7 sampled residents' environment was as free as possible of accident hazards and provided with the supervision necessary to prevent accidents. * R10 was admitted to the facility with a history of drug abuse. On [DATE], [DATE], [DATE] and [DATE], R10 overdosed on drugs and had to have Narcan administered. The facility did not investigate or monitor the resident and did not put effective interventions, including increased supervision, in place to prevent subsequent overdoses. On [DATE], the facility did not notify the MD or call 911 after administering Narcan for R10's overdose. * R11 was admitted to the facility with a history of drug abuse. On [DATE] and [DATE], R11 overdosed on drugs and had to have Narcan administered. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R11) of 3 residents reviewed received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. R11 was admitted to the facility with a history of Substance Use Disorder (SUD). On 11/19/22, 3/17/23, 5/4/23 and 8/3/23 R11 overdosed on drugs and had to have Narcan (Naloxone) administered. There is no indication if care planned interventions were followed through on, and whether they were evaluated for effectiveness. [...]

Inspectors wroteBased on observation, interview, and record review 1 of 1 (R1) resident's employed by the facility did not have a care plan or appropriate job description before employment at the facility began. This deficient practice has the potential of affecting all 97 residents in the building. * R1 has a history of resident-to-resident abuse and excessive alcohol consumption while in the facility. Before employment, the facility had R1 sign a job description for a Certified Nursing Assistant (CNA) and a policy that indicated R1 would answer call lights of other residents.

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate 4 of 7 reportable incidents reviewed for abuse and misappropriation involving R10 and R15. * R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A was made aware of inappropriate incidents on 6/28/23 and 7/22/23 between DA-O and R10 that were not fully investigated. NHA-A was also aware that R10 had been to DA-O's home and did not investigate the incident. * On 8/9/23 R15 reported missing $30.00. The facility's investigation did not include interviews with direct care staff to see if they had any knowledge of R15's missing money. The facility's investigation did not include interviewing other residents on R15's unit to see if any other resident may have had missing money/items.

Inspectors wroteBased on interview and record review, the facility did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 85 residents who reside in the facility as the 5 CNA's work throughout the building as needed.

Inspectors wroteBased on record review and interview, the facility's assessment, last updated 8/8/23, indicates the number/average range of residents the facility can care for with active or current substance use disorders is 15 residents. The facility's assessment was not specific in regards to residents with substance abuse disorders and the level of care they are able to provide for those residents. The facility assessment does not include available resources for narcotic substance abuse that is available to the residents for support services. The facility assessment does not indicate if the facility has a professional in substance abuse with drug and treatment expertise who would be able to assist with resident support and facility resources. This deficient practice has the potential to affect the 15 residents (per facility assessment) who are active with or experience substance disorders.

Inspectors wroteBased on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition for 1 (R11) of 4 residents reviewed for change of condition. R11 had a history of drug and alcohol abuse and had an order to update the MD if any signs and symptoms were noted of drug use. The facility did not update the MD on 9 different occasions when staff documented R11 had overdose signs and symptoms.

Inspectors wroteBased on interview and record review, the facility did not report 3 of 7 reportable incidents (involving R10), reviewed for abuse to the State Agency. * R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A interviewed DA-O on 6/28/23 and 7/22/23 and asked questions about the relationship. NHA-A was also aware that R10 had been to DA-O's home; that was confirmed during an interview on 8/8/23. The facility did not investigate these allegations and did not report any of the allegations of abuse to the State Agency.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure injuries for 2 (R7, R29) of 6 residents reviewed for pressure injuries. * R7 developed a facility acquired, Stage 4 pressure injury with an exposed tendon under a splint that had been applied to R7's hand. There was not a doctor order for R7's splint. The splint did not appear to have been removed for cares to check R7's skin impairment, the splint was not on the care plan or care delivery guide. Facility failure to obtain a doctor's order, care plan, and provide care for R7's splint caused R7 to develop a Stage 4 pressure injury with exposed tendon created a finding of immediate jeopardy that began on 1/6/2023. [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not store food in accordance with professional standards for food service safety. This has the potential to affect all 108 residents. * Surveyor observed 18 unopened boxes on the floor of the freezer. Boxes were there for two days of the survey. * Surveyor observed large amounts of ice buildup in the freezer. Ice buildup was scattered across the ceiling, down the walls and on boxes of food. * Food brought in by residents and family members were stored in a refrigerator in the shared activity and dining room and food items were not discarded by the use by date of the food.

Inspectors wroteBased on interview and record review, the facility did not ensure a facility-wide assessment was conducted to determine what resources were necessary to competently care for its residents during both day-to-day operations and emergencies. This had the potential to affect all 108 residents residing at the facility. *The Facility Assessment Tool, dated 1/7/2023, did not identify the facility's need for the Infection Preventionist role or the designated hours per week necessary to perform their duties. An Infection Preventionist is responsible for managing the facility's Infection Prevention and Control Program. *The Facility Assessment Tool, dated 1/7/2023, did not include a completed facility-based and community-based risk assessment, utilizing an all-hazards approach to create an emergency preparedness plan, including a water management plan, that met current standards of practice. [...]

Inspectors wroteBased on interview and record review the facility did not ensure as part of their infection prevention and control program they had an effective water management plan based upon the individual characteristics of the facility. The facility failed to implement a Water Management program to prevent the transmission of Legionnaires Disease which has the potential to affect all 108 residents residing in the facility. Based upon observation and interview, the facility failed to provide infection control measures according to professional standards of practice for 1 (R29) of 4 Residents reviewed for wound care. The facility did not disinfect a scissors used during wound care when transitioning from dirty to clean supplies.

Inspectors wroteBased on record review, interviews, and observations, the facility did not implement their abuse policy in regards to screening 3 of 8 employees (Certified Nursing Assistant(CNA)-AA, Licensed Practical Nurse (LPN)-J and CNA-BB. * CNA-AA was hired on 6/14/22. Caregiver and criminal background checks were not completed until 3/1/23. The Background Information Disclosure (BID) was not completed by CNA-AA until 3/1/23. * LPN-J was hired on 4/22/22. Caregiver and criminal background checks were not completed until 3/1/23. * CNA-BB was hired on 7/27/16. Caregiver and criminal background checks were not completed every 4 years. The Background Information Disclosure (BID) was not found by the facility. This had the potential to affect a pattern of residents residing at the facility.

Inspectors wroteBased on record review and interview, the facility did not ensure antibiotic protocols were used to prevent the unnecessary administration of antibiotics to 9 (R3, R34, R12, R11, R5, R84, R8, R38, and R13) of 19 residents reviewed for antibiotic usage. *R8, R38, R3, R34, R12, R11, R19, R84, and R13 did not meet the criteria for the use of an antibiotic.

Inspectors wroteBased on interviews, record reviews and facility document reviews, the facility did not implement measures to protect a resident from sexual abuse. This was discovered in 2 facility self reports involving (R23 & R76) of 9 facility self-report investigations. On 2/15/23 R23 touched R76 inappropriately in their genital area. R23 had a documented history of previously engaging in inappropriate activity with residents including kissing other residents. The facility had not assessed residents, including R76, for their ability to understand and consent to sexual activity/relations. The facility self report indicates the social worker sat down with R23 and R76 to clarify their relationship. [...]

Inspectors wroteBased on interviews/ and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 3 Residents (R162, R94 & R462) of 5 residents reviewed who potentially had a crime committed against them. R94 had a resident-to-resident verbal altercation in which R162 expressed being very afraid of R94. The facility did not notify the police of R94's threat to R162. Agency Certified Nursing Assistant (CNA) Z was verbally and physically abusive towards R94 and Agency CNA Z was asked to leave the facility. The facility did not call the police. Additionally, the facility did not investigate threats made to another resident by CNA Z that staff referenced in their statements. [...]

Inspectors wroteBased upon record review and interview, the facility did not ensure investigations of allegations of neglect involving 2 Residents (R61 & R42) of 2 allegations of neglect were reported timely to the state agency. The facility did not ensure investigated allegations of neglects involving R61 and R62 were submitted timely to the state agency as facility administration forgot to submit the investigations to the state agency.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards for 1 (R262) of 22 sampled residents. * R262 had an order on admission to have a shower daily. The order was not transcribed and R262 only received a weekly shower while in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure adequate supervision and assistive devised were used to prevent accidents for 3 (R61, R37, and R463) of 6 residents reviewed for falls. R61 fell out of bed on 1/4/2023 while receiving cares with the assist of one Certified Nursing Assistant (CNA). The facility staff were not following F61's plan of care: R61 required the assist of two CNAs when receiving cares per the Care Plan. R37 had three falls out of bed, 11/5/2022, 11/23/2022, and 12/15/2022, without having a body pillow in place. R37 was to have a body pillow in place per plan of care. Multiple observations were made during the survey of no body pillow in place when R37 was in bed. R463 fell on [DATE] when being transferred with no gait belt in place. R463 was to have a gait belt used when transferring per plan of care.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R17 and R262) of 7 residents reviewed for weight loss had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. * A review of R17's admission weight on 8/10/22 was documented at 198 pounds in the medical record and the admission nutritional assessment documented an admission weight of 220 pounds. The Dietician disputed the admission weight value with no further follow up or reweigh. R17's documented weight on 8/30/22 was 177.6 pounds which was a 10.30% weight loss from 198 pounds. The facility did not implement an intervention until 10/25/22. * R262 was not assessed for fluid needs on admission. R262 was not screened for beverage preferences and there was no care plan for dehydration.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R85) of 5 residents reviewed receiving psychotropic medication were free from unnecessary drugs. *R85 had orders for a psychotropic medications and did not have specific documented targeted behavior monitoring and/or specific reasons for use of the medication in their medical records. R85 did not have specific targeted behaviors for administration of psychotropic medication addressed in her plan of care.

Inspectors wroteBased on interview, and record review the facility did not ensure that medical records contained documentation related to Influenza and/or Pneumococcal immunizations for 3 (R20, R105, R85) of 5 residents reviewed for immunizations. R20's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine. R103's medical record did not contain documentation indicating the facility offered or administered the Pneumococcal vaccine. R85's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine.