Care Pavilion Nursing and Rehabilitation Center

Inspectors wroteBased on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility failed to maintain an environment that was safe, sanitary, and comfortable for residents, staff and the public for three of three resident care areas observed (Main Lobby, Two East, Three East).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined the facility failed to implement interventions to assess and treat a deteriorating sacral pressure ulcer. This failure resulted in actual harm to Resident R1 who developed sepsis requiring hospitalization for one of two residents reviewed (Resident R1).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined the facility failed to identify a full-thickness foot wound with exposed adipose (fat) tissue in a timely manner, for one of three residents reviewed for wounds. This failure resulted in actual harm to Resident R4 who developed an infection of the right big toe. (Resident R4)

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, the facility failed to maintain an effective pest control program for seven of seven nursing units reviewed (1 East unit, 1 [NAME] unit, 2 East unit, 2 [NAME] unit, 3 East unit, 3 [NAME] unit, 4 [NAME] unit).

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to maintain clean, safe and homelike environment on three of seven nursing units reviewed (1 East unit, 2 East unit, 2 [NAME] unit).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to investigate an injury of unknown origin to rule out abuse and neglect for one of three residents reviewed for wounds (Resident R4).

Inspectors wroteBased on review of communication records, facility documentation and interviews with staff, it was determined that the facility failed to provide medical records in a timely manner to the Area Agency on Aging as required by law, for one of one records reviewed (Resident R2).

Inspectors wroteBased on observations, and resident interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for five of nine residents reviewed (Residents R1, R3, R4, R6 and R8).

Inspectors wroteBased on observations, staff interviews, and review of facility policy it was determined that the facility did not ensure professional standards of practices related to access to life-sustaining medical equipment for two of three nursing units reviewed (First Floor east unit and First Floor west unit). Findings Include: Review of facility policy titled, Cardiopulmonary Resuscitation (CPR) Certification Policy with a review date of [DATE] states, Policy- to ensure that a resident has the right to a dignified existence and self-determination including the right to formulate advance directives as well as to receive life sustaining treatment if desired. The Procedure reads, .4. If CPR is warranted, still will immediately initiate CPR. 5. A Code Blue will be announced over the intercom system and the code sheet will be initiated. 6. [...]

Inspectors wroteBased on observations of the physical environment for resident rooms and bathrooms, interviews with residents and staff, reviews of policies and procedures and the pest control operators' reports, it was determined that the facility was not maintaining an effective pest control program for two of four nursing unit (the first and third-floor nursing units).

Inspectors wroteBased on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of resident records, review of facility policy, and staff interviews, the facility failed to monitor residents for changes in nutritional status and failed to implement appropriate interventions in response to identified nutritional changes for three of seven residents reviewed (Residents R38, R183 and R375).

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures during test tray evaluation and for 15 of 35 residents reviewed (Residents R9, R42, R60, R63, R67, R72, R89, R144, R246, R288, R294, r299 R329, r315, and R339).

Inspectors wroteBased on review of facility documents and interview with staff, it was determined that the facility failed to ensure that residents were provided with education related to influenza vaccines prior to administering influenzas vaccines to residents for eight of eight residents reviewed. (Resident R8, R9, R14, R17, R20, R128, R260 and R284)Review of facility policy on Infection Prevention and Control Program revealed that under section Policy Statement: The infection prevention and control program is a facility wide effort involving all disciplines and individuals. Under section Policy Interpretation and Implementation. Coordination and oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist. #8. Immunization: a. Immunization is a form of primary prevention. b. [...]

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public for two of seven nursing units reviewed (3 [NAME] nursing unit, 3 East nursing unit.) and the boiler room.

Inspectors wroteBased on review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to assist residents to access Alcoholics Anonymous (AA)/ Narcotics Anonymous (NA) resources for one of 42 residents reviewed (Resident R63).

Inspectors wroteBased on observation, review of clinical record, review of facility policy and interview with staff and residents, it was determined that the facility failed to ensure that postal mail was delivered in timely manner for one of 42 residents reviewed. (Resident R128)Review of facility's undated policy on Mail and Package Handling revealed that under section Policy Statement: It is the policy of Care Pavilion Rehabilitation & Nursing to ensure that all residents and facility mail and packages are handled in a secure and respectful manner and distributed timely. Section Procedure: #1. Mail Arriving in Envelopes: All incoming mail that arrives in envelopes, including USPS, UPS, FedEx, and other courier deliveries, must be directed to the Business Office immediately upon receipt. #3. Resident Mail Handling: [...]

Inspectors wroteBased on review of facility policies, personnel files and interviews with staff, it was determined that the facility failed to obtain criminal background checks as required for one of five personnel files reviewed for newly hired staff (Employee E19).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges as required for three of three months reviewed (August, September and October 2025).

Inspectors wroteBased on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the resident's diagnoses and medical conditions for two of 42 residents reviewed (Residents R81 and R296).

Inspectors wroteBased on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for three of four residents reviewed (Residents R13, R19 and R10).

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission to the facility that included the minimum healthcare information necessary to properly care for a resident for one of 42 residents reviewed (Resident R375).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to update resident care plans related to hospice care, life code status, vascular wounds and tube feedings for two of 42 residents reviewed (Residents R81 and R336).

Inspectors wroteBased on observation, review of clinical record, interview with staff it was determined that the facility failed to ensure that residents are provided with services to maintain and prevent further deterioration of range of motion for two of 42 residents reviewed. (Resident R260 and Resident R16) Review of Resident 260's clinical record revealed that Resident R260 was admitted to the facility on [DATE], with diagnoses of hemiplegia/hemiparesis following unspecifies cerebrovascular accident. Review of Resident R260's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated September 26, 2025, revealed a BIMS (Brief Interview of Mental Status) score of 15 suggesting that Resident R260 was cognitively intact. [...]

Inspectors wroteBased on clinical record reviews, review of facility documentation, and interviews with residents and staff, it was determined the facility failed to provide adequate supervision to Resident R284 with a diagnosis of alcohol dependency upon return from a leave of absence (Resident R284). The facility failed to ensure that a resident was properly secured during transportation to an outside appointment which resulted in the resident sliding out of the transportation van. (Resident R12)

Inspectors wroteBased on observations, clinical record review, a review of facility policies and staff interviews, it was determined that the facility failed to provide adequate nutritional care related to enteral nutrition for two out of 35 sampled residents reviewed (Resident R336 and R86).

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of midline catheter line in accordance with professional standards of practice for one of one residents reviewed for intravenous care (Resident R375).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure the proper functioning of an oxygen concentrator for one of one resident review receiving respiratory therapy. (Resident R357)

Inspectors wroteBased on review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets necessary to care for residents' needs for three of three newly hired nursing staff reviewed (Employees E19, E27 and E28).

Inspectors wroteBased on review of clinical records, observations and interviews with staff, it was determined that the facility failed to ensure an adequate supply of medications for one of 42 residents reviewed. (Resident R31)

Inspectors wroteBased on observation, review of clinical records, staff and resident interviewed, it was determined that the facility failed to ensure that residents receive routine and emergency dental services for one of 42 residents reviewed. (Resident R128) Review of Resident R128's clinical record revealed that Resident R128 was admitted to the facility on [DATE], with diagnoses of but not limited to Schizoaffective Disorder, Type 2 Diabetes Miletus, Further, Resident R128's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated May 1, 2025 section C0500 BIMS (brief interview for mental status) score revealed that Resident R128's BIMS score was 14 suggesting that Resident R128 was cognitively intact. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area.

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to ensure a resident's hospice services were accurately reflected in the clinical record for one of two residents reviewed for hospice (Resident R81).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure proper infection control practices were followed during wound care for 1 of 2 residents observed for wound care (Resident R88). Review of facility policy titled Blood or Body Fluid Exposure dated July 2016 revealed that the policy requires that all blood and body fluids be treated as potentially infectious, and that staff wear appropriate protective equipment (gloves, gowns, masks, occlusive bandages) when performing tasks with potential exposure. Any employee exposure must be reported immediately to the Infection Preventionist (or designee), and appropriate cleaning, reporting, and counseling procedures must be followed. [...]

Inspectors wroteBased on observation and interview with staff, it was determined that the facility did not ensure that essential equipment was in a safe and functioning manner related to the dish machine sanitizer pump not operating and keeping the machine out of service for two days causing the facility to serve meals on disposable paperware.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that handrails were safe and properly secured for one of seven nursing units reviewed (3 [NAME] nursing unit).

Inspectors wroteBased on review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program for five of five newly hired staff (Employees E19, E27, E28, E29 and E30).

Inspectors wroteBased upon observation, interviews with residents and staff, review of resident records, facility documentation and policies, and in accordance with accepted professional standards and practices, it was determined the facility failed to maintain medical records on each resident that were complete and accurately documented for one of 13 resident records reviewed (Resident R6).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure proper supervision of residents during smoking hours which resulted in actual harm to Resident R1 who sustained first and second degree burn on face when nasal cannula ignited while smoking with oxygen in use for one of 38 residents reviewed (Resident R1). This deficiency was cited as past non compliance.

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 7 Residents reviewed (R2).

Inspectors wroteBased on review of facility documentation, observations and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on observations, interview with staff and resident it was determined that facility did not ensure to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident R1)

Inspectors wroteBased on review of clinical record and interview with staff, it was determined that facility did not ensure that residents received treatment and care in accordance with professional standards practice related to physician orders for blood sugar levels for one of three residents reviewed (Resident R3)

Inspectors wroteBased on reviews of clinical records, interviews with staff, reviews of the facility assessment and policies and procedures reviews, it was determined that the facility failed to established criteria or a screening process for the safe escort to ensure the safety of residents for an approved leave of absence for one of nine residents reviewed. (Resident R8)

Inspectors wroteBased on review of clinical records, interview with residents and staff, it was determined facility did not implement infection prevention and control program for one of three residents reviewed (Resident R1)

Inspectors wroteBased upon interviews with resident, resident's family, and staff, review of resident records and facility policy it was determined that the facility neglected to give timely incontinence care to one of four residents reviewed (Resident R1).

Inspectors wroteBased on interviews with staff review of resident records and facility policy and procedure, it was determined that the facility failed to notify state agencies as required for two of four resident records reviewed (Residenr R1 and R2).

Inspectors wroteBased on observations, interviews with staff and resident family and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for one of four residents reviewed (Resident R1 ).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one out of the five residents reviewed. (Resident R1)

Inspectors wroteBased on observations, resident and staff interview and review of facility policy, it was determined facility failed to maintain standards of an infection control practices by reusing resident's bedpan for three out of five residents reviewed. (R1, R2, R3).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for one of four nursing units (4th floor nursing units).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of four nursing units. (third floor) Findings Include: Observation of Resident R3 on April 1, 2025, at 11:30 AM revealed that there were two urinals filled with urine sitting on resident's bedside table and dresser. Interview with Resident R3 on April 1, 2025, at 11:30 AM stated one urinal was filled last night before he went to sleep but staff did not empty it on 3-11 p.m. shift or overnight shift. Resident also stated the morning staff did not empty the urinal even though the staff was inside the room multiple times. Interview with Employee E5 on April 1, 2025, at 12 noon stated staff should have emptied Resident R3's urinal. [...]

Inspectors wroteBased on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined the facility failed to protect Resident R271 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R137 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident 208 on January 31, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R137 was found pinning down and performing oral sex on Resident R271. (Resident R137 and Resident R271) Findings Include: Review of facility policy titled Abuse reviewed December 13, 2024, revealed sexual abuse is defined as non-consensual sexual contact of any type with a resident. It is the policy of the facility that residents will be protected from abuse while they are residing at the facility. [...]

Inspectors wroteBased on observations of the food and nutrition services department, reviews of the pest control operator's reports, interviews with staff, reviews of policies and procedures and reviews of the city department of health inspection report, it was determined that the dietary services was not maintained in accordance with standards for food service safety .

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to implement pressure ulcer prevention interventions for three of six residents reviewed for pressure ulcers (Resident R122, Resident R231 and R153). Findings Include: Review of the facility's policy titled, Prevention of Pressure Ulcers states to identify residents at risk for pressure ulcers, common sites of pressure ulcers include back of head, around ears, and heels of feet. Reduce or remove underlying risk factors and monitor the impact of the interventions and to modify the interventions as appropriate. Review of Resident R122's clinical record revealed a physician order dated September 17, 2022, to put on heel protectors to bilateral heels while Resident R122 was in bed for the prevention of skin breakdown. [...]

Inspectors wroteBased on staff interviews and review of resident's records and facility policy, it was determined that the facility did not ensure that a resident had reasonable access to their personal funds for one of 36 resident records reviewed (Resident 91).

Inspectors wroteBased on review of clinical records and interviews with staff and facility policy, it was determined the facility did not ensure a resident's code status was updated to reflect the residents wishes for one of 36 resident records reviewed (Resident R101).

Inspectors wroteBased on observations and resident interviews, it was determined that the facility failed to maintain the facility in clean and homelike environment for two of six nursing units toured (3 west and 3 east). Findings Include: Interview on February 11, 2025, at 1:15 p.m. with Resident R502 revealed about two weeks ago there was allegedly a leak from the unit above and water was pouring from the ceiling. Observations on February 11, 2025, at 1:15 p.m. in room [ROOM NUMBER] confirmed the ceiling tiles above the sink in the room and in bathroom had water damage and had a brown/yellow discoloration. Observations on February 12, 2025, at 11:55 a.m. on the 3 east nursing unit revealed in the soiled linen closet there was multiple bags of soiled linen and trash on the floor of the closet. Observations on February 12, 2025, at 12:00 p.m. [...]

Inspectors wroteBased on review of clinical records, and interviews with staff and facility policy, it was determined that the facility failed to provide vision and audiology services in a timely manner for one out of 36 residents reviewed (Resident R91).

Inspectors wrote] Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of one resident reviewed with limited range of motion (Resident R231). Findings Include: Review of Resident R231's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 23, 2024, revealed the resident had severe cognitive impairment and had diagnoses of hemiplegia (one sided paralysis or weakness of the face, arm, or leg) affecting left nondominant side, muscle wasting, and other muscle spasm. [...]

Inspectors wroteBased on review of clinical records, interviews with staff and review of facility documentation and policy, it was determined the facility failed to ensure residents received adequate supervision to maintain residents' safety for 3 of 36 resident records reviewed (Residents R93, 253, and 224 )

Inspectors wroteBased on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for two of five residents reviewed with incontinence (Resident R80, and R256).

Inspectors wroteBased on review of facility policy, observations, review of clinical record, and resident interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of four residents reviewed for nutrition (Resident R251 and R214). Findings Include: Review of facility policy Weight Assessment and Intervention dated February 15, 2022, revealed the nursing staff and Registered Dietitian will work to prevent, monitor, and intervene for undesirable weight loss of the residents. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. Significant Weight Changes are defined as: a. more or less than 5% within 30 days; and b. more or less than 10% within 6 months. [...]

Inspectors wroteBased on review of clinical record and interviews with staff, it was determined that the facility failed to follow physician orders regarding tube feeding for one resident out of six residents' with tube feedings reviewed. (Resident R96).

Inspectors wroteBased on observation, interview review of clinical records it was determined that the facility failed to provide oxygen therapy consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of 36 resident records reviewed (Resident R153)

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of four dialysis residents reviewed (Resident R64).

Inspectors wroteBased on review of facility policy, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one 36 residents reviewed (Resident R502). Findings Include: Review of facility policy Administering Medications revised April 17, 2024, revealed medications should be administered in a safe and timely manner, and as prescribed. Continued review of facility policy revealed that if a medication is not available the nurse will identify reason for the unavailable medication and subsequently reach out to the pharmacy as applicable, to determine when medication will be available. If the mediation is not available in the emergency supply the nurse should contact the physician for further instructions. [...]

Inspectors wroteBased on observations of the food service, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility did not ensure food was palatable, attractive and prepared and served in portion sizes to meet each residents' needs. (Residents: R 278, R 267, R50, R 241, R10, R175, R 299, R 279, R5, R16, and R11).

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation with a resident who had a history of sexually inappropriate behaviors engaging in unwanted/non-consensual sexual contact with a resident who had severe cognitive impairment. Findings Include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the employee assumes full-time administrative authority, responsibility and accountability for the operations of the nursing facility. The employee manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. [...]

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for one of two residents reviewed (Residentb R96).

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of ten residents reviewed (Residents R2, R8, R9, R10 and R11).

Inspectors wroteBased on observations, interviews, and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program for six of ten residents interviewed (Residents R2, R3, R4, R5, R8 and R10).

Inspectors wroteBased on a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of verbal and physical abuse for one of two residents (Resident R1).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that a resident received appropriate care to a surgical wound, for one of seven residents reviewed (Resident R2).

Inspectors wroteBased on reviews of policies and procedures, observation of mechanical and electrical equipment and interviews with staff, it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system directly to a centralized staff work area on one of four nursing units. (Four [NAME] nursing unit)

Inspectors wroteBased on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to develop and implement a comprehensive person center care plan for respiratory care for one of ten residents reviewed. (Resident R1)

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on three of five nursing units (A, B, E Nursing Units).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of three residents reviewed (Resident R4).

Inspectors wroteBased on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to maintain appropriate nutritional parameters for one of four residents reviewed. (Resident R4).

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 4 residents with weight loss reviewed (Resident R4).

Inspectors wroteBased on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe and functional environment for one of four floors (Third floor). Finding Include: Observation of facility Third floor west nursing unit on August 21, 2024, at 12:00 p.m. revealed that next to room [ROOM NUMBER] there were two large trash containers without lids on the hallway. There was water in both containers. There were also sheets on the floor. However, the floor appeared dry during the observation. There was no rain at the time of the observation. Interview with Nurse Aide, Employee E8, stated there was leak from the ceiling and the containers and sheets were placed there to collect the water. Employee E8 stated the leak was going on for months. Interview with Resident R3 on August 21, 2024, at 12:30 p.m. [...]

Inspectors wroteBased on observation, facility policy review, clinical record review and interviews with staff, it was determined that the facility did not ensure that the resident environment remained as free of accident hazards related to access to smoking materials for two of 35 residents reviewed (Residents R12, and R222), and during three out of three smoking breaks observed.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, review of facility's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for three of 35 residents reviewed (Residents R27, R125, R129)

Inspectors wroteBased on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for two of 35 residents reviewed (Residents R202 and R286).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 35 residents reviewed (Resident R242).

Inspectors wroteBased on observation of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand at the facility in the event that there was a loss of normal water supply.

Inspectors wroteBased on observations, review of facility policy, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide an environment that was free of accidents hazards to three of eleven residents observed. (Residents R3, R8, R9). Findings Include: Interview with Director of Maintenance Employee E9 on March 26, 2024 at 10:30 a.m. revealed they did recently have an issue with one window fully opening. The Director of Maintenance Employee E9 stated that it was brought to his attention by a staff member that room [ROOM NUMBER] had a window that was opening all the way. The Director of Maintenance Employee E9 stated that they immediately did a whole house audit and found that one window in room [ROOM NUMBER] did fully open. The Director of Maintenance Employee E9 stated that it was fixed. On March 26, 2024 at 1:00 p.m. [...]

Inspectors wroteBased on observations, review of facility documentation, interviews with residents and staff, it was determined that the facility has failed to maintain an effective pest control program in the kitchen and two of three nursing units (2nd and 3rd floor). Findings Include: Tour of the main kitchen on March 26, 2024 at 9:02 a.m. was conducted with Regional Director of Dining, Employee E4 and Assistant Director of Dining Employee E5. A tour was taken of the entire kitchen included the loading dock area. Regional Director of Dining stated that there was a crack in the old trash compactor, and they just received a new one. Around the trash compactor was several small pieces of paper trash. The surveyor asked The Regional Director of Dining Employee E4 if he has had any trouble with mice recently and he stated yes. Employee E4 confirmed on March 26, 2024 at 9:20 a.m. [...]

Inspectors wroteBased on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged verbal abuse to the Department of Health as required for one of five resident reviewed (Resident R2).

Inspectors wroteBased on review of facility policies, facility documentation, review of clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from verbal abuse for one of 36 residents reviewed which resulted in an Immediate Jeopardy Situation (Resident R464).

Inspectors wroteBased on observations, staff interviews, review of clinical records, and review of facility documentation, it was determined that the facility failed to provide assistive devices necessary to prevent falls for one of 36 residents reviewed for accidents. (Resident R286).

Inspectors wroteBased on record review and interview with staff. It was determined that the facility did not ensure that a physician's order for a STAT (immediately or without delay) CT (Computed Tomography scan is a diagnostic imaging procedure that uses a combination X-rays and computer technology to produce images of the inside of the body) for one of one resident reviewed.

Inspectors wroteBased on policy and procedure review, interviews with staff and review of the reportable event submitted to the State survey agency, it was determined that the facility failed to report immediately, an allegation of sexual abuse, in response to an allegation made by a resident and failed to report the results of the investigation in accordance with State laws within five working days of the incident for one of 18 residents reviewed.

Inspectors wroteBased on observations, reviews of clinical records, review of policies and procedures, review of facility documentation and interviews with staff and residents, it was determined that the facility failed to conduct a completed and thorough investigation into an allegation of possible sexual abuse for one of 18 residents reviewed. (Resident R1)

Inspectors wroteBased on observations, review of clinical records, review of facility policies, review of documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise a resident who was assessed to be at risk for elopement for one of eight residents reviewed, resulting in Resident R1 exiting the secure dementia unit, eloping from the facility, and missing for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy. (Resident R1)

Inspectors wroteBased on review of facility polices, clinical record reviews and interviews with staff, it was determined that the facility failed to provide a resident's representative with the right to participate in the care planning process for one of 19 residents reviewed (Resident R13).

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to a resident eloping from the facility for one of eight clinical records reviewed (Resident R1). This failure placed Resident R1 at high risk for injury and was identified as an Immediate Jeopardy situation.