Carmel Hills Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one sampled resident (Resident #3), out of three sampled residents, when on 3/19/26 Floor Tech (FT) A did not secure the door to the secured unit resulting in the resident exiting the facility and later being found in the community and sent to the Emergency Room. The facility census was 154 residents. On 3/31/26 the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 3/19/26. All staff received education prior to working their next shift. The deficiency was corrected on 3/20/26. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the sprinkler heads above the food preparation and food serving areas, free from dust and grease; maintain the oven mittens in good repair; maintain the drainage pipes, metal fixtures and walls under the dishwasher area, free of a buildup of grime and discarded dishes; ensure items (lemon juice and beef base), were refrigerated; maintain the handwashing sink free of obstructions; maintain hot foods ( pureed French Toast and regular French Toast) at or close to 135 ºF ( degrees Fahrenheit) at the steam table; to ensure that fresh fruits ( grapes) were washed prior to mixing them with the fruit salad for breakfast and to ensure Dietary Aide (DA) B use tongs or gloves while he/she handled French Toast from the steam table. This practice potentially affected 143 residents who received food from the kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot foods (vegetables on 5/14/25) and (French Toast on 5/16/25) were at or close to 120 ºF (degrees Fahrenheit) for two different meals. This practice potentially affected at least four residents (Residents #11, #3, #2 and #13) out of 19 sampled residents. The facility census was 143 residents. Review of the facility's policy entitled Food Temperatures and revised on 12/20, showed: - Purpose: To provide the nutrition services department with guidelines for food preparation and service temperatures. - Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. - Procedure: Measuring Food Temperature It is recommended to use a thermometer with a practical range of 0 ºF to 220 ºF. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the legal guardian of one discharged resident (Resident #6), in a timely manner (usually within 24 hours) after the resident passed away. The facility also failed to notify the facility's Business Office Manager (BOM) in a timely manner, which caused the business office to cash a check sent by the legal guardian's office to the facility, 14 days after the resident passed away out of 19 sampled residents. The facility census was 143 residents. On 5/21/25 the Administrator were notified of the past noncompliance that occurred on 3/26/25. All staff were educated on the notification policy. The deficiency was corrected on 4/22/25. Review of the Facility's policy entitled Change of Condition Notification revised 6/20, showed: -Purpose: [...]

Inspectors wrote2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, heart disease, stroke, high blood pressure and asthma. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert with significant confusion. -Needed substantial assistance with transfers, mobility, bathing and dressing. Review of the resident's Care Plan updated 2/13/25, showed the resident had impaired cognitive functioning, vision loss, was at risk for falls, was incontinent and had a self care deficit. Interventions showed the resident was dependent on staff for bathing and staff was to provide maximum assistance to the resident. Review of the resident's bathing sheets from 3/24/25 to 5/8/25, showed the resident received bathing on the following dates: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #17) was supervised during smoking times. On 5/15/25 the resident was outside on the smoking patio when the wind came up and the resident's hair caught fire. Hospitality Aide B failed to report the smoking incident which resulted in a delayed burn treatment for the resident. The facility further failed to ensure resident electronic smoking materials were stored safely and not used in the facility for one sampled resident (Resident #9) who had a Electronic-cigarettes (also known as e-cigarettes/vape pen are battery-operated devices that heat a liquid and produce an aerosol) found in the resident bed, and also observed on bedside table, out of 19 sampled residents. The facility census was 143 residents. Review of the Facility's Smoking by Resident Policy revised on 6/2020 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer substitutes and honor preferences for one sampled resident (Resident #2) out of 19 sampled residents. The facility census was 143 residents. Review of the facility's policy, Resident Preference Interview, revised December 2020 showed: -Resident preferences will be reflected on the tray card and updated in a timely manner. --If a preferred item is not available, a suitable substitute should be provided. 1. Review of Resident #2's admission record showed he/she was admitted [DATE] with diagnoses to include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure snacks were being offered on the long term care unit consistently between meal times during the day and evening for two sampled residents (Resident #11 and #13) out of 19 sampled residents. The facility census was 143 residents. Record review of the facility snack schedule showed facility snacks were supposed to be at 10:00 A.M., 2:00 P.M., and 7:00 P.M. daily. 1. Review of Resident #11's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, high cholesterol, high blood pressure and cancer. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/11/25, showed the resident: -Was alert and oriented with no confusion. [...]

Inspectors wroteRefer to F550 Event ID ZSB9 Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents.

Inspectors wroteSee F 804 Event ID ZSB9 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiency dated 11/25/24. Based on observation, interview and record review, the facility failed to ensure hot foods on room trays were served at or close to 120 ºF (degrees Fahrenheit), on 1/15/25 during lunch and on 1/16/25 during breakfast. This practice potentially affected at least 60 residents who resided on the 100, 200, 300 and 400 Halls. The facility census was 158 residents.

Inspectors wrote5. Review of the undated policy Understanding Enhanced Barrier Precautions showed: -When using PPE staff members wear a clean gown and gloves while performing high contact resident care activities with residents who are at increased risk of carrying a resistant organism. This includes all residents with any of the following: --Known infection or colonization with a resistant organism when Contact Precautions do not otherwise apply. --Wounds or indwelling medical devices like central line, urinary catheters, feeding tube, tracheostomy, or ventilator. -High contact resident care activities were typically bundled care activities that were provided either during the morning or evening care to include: --Dressing. --Bathing/showering. --Changing linens. --Changing briefs or assisting with toileting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure suction and oxygen equipment were kept covered to prevent cross contamination for one sampled resident (Resident #95) who had a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea. This hole allows air to pass into your windpipe); failed to ensure oxygen face masks and nasal cannulas (a medical device that provides supplemental oxygen to patients through two prongs that sit inside the nostrils) were covered for two sampled resident (Resident #126 and Resident #19) who had respiratory concerns; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate storage and labeling of medications throughout the facility's medication carts and medication storage rooms. This deficient practice had the potential to affect all residents within the facility. The facility census was 151 residents. Review of the facility's policy titled Storage of Medications dated August 2020 showed: -Nurses were not to transfer medications from one container to another or return partially used medication to the original container. -All medications dispensed by the pharmacy were to be stored in the pharmacy container with the pharmacy label. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents (Residents #109, #91 and #139) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Food Temperature policy, dated December 2020, showed: -The purpose of the policy was to prove the nutrition services department with guidelines for food preparation and service temperatures. -Food prepared and served in the facility would be served at proper temperatures to ensure food safety. -Acceptable serving temperatures were: Above or equal to 135-degree Fahrenheit (F) for; eggs, vegetables, potatoes, pasta, meats, casseroles, and entrees. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The facility promoted resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. -The staff assisted with the residents in maintaining self-esteem and self-worth. -Staff were to treat residents with respect including respecting their social status, speaking respectfully, and listening carefully. -Staff were to focus on residents as individuals when they speak to them and address residents as individuals when providing care and services. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sampled (Resident #96) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's policy titled Self-Administration of Medication dated August 2020 showed: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. -The results of the interdisciplinary team assessment of the resident skills and of the determination regarding bedside storage were recorded in the resident's medical record on the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing for two sampled residents (Residents #137 and #109) out of 35 sampled residents. The facility census was 151 residents. Review of the Facility's Transfer and Discharge Policy revised 06/2020 showed: -The purpose of the policy was to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. -The facility may use Notice of Transfer/Discharge or another comparable form to provide the resident or his/her personal representative with advanced notice of transfer or discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notification to a resident and/or the resident's representative upon transfer or discharge for two sampled residents (Resident #137 and #109) out of 30 sampled residents. The facility census was 151 residents. Review of the facility's Bed Hold Policy dated 6/2020 showed: -The purpose of the policy was to ensure that the resident and/or their representative was aware of the facility's bed hold policy, and that such policy complies with state and federal law and regulations. -When a resident was admitted to the facility, the facility informed the resident or his/her personal representative in writing that the facility had a bed hold policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for two sampled residents (Residents #14, #98) out of 35 sampled residents. The facility census was 151 residents. A policy was requested and not received from the facility. 1. Review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] with the diagnosis of Need for Assistance with Personal Care. Review of the resident's nursing Admission/readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious teeth. Review of the resident's Nutrition Assessment-Registered Dietician Evaluation dated 1/20/23 showed the resident has his/her own teeth in fair condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the residents' functional and health status, strengths and needs as related to dental services for two sampled residents, (Resident #14 and #98), failed to assess and care plan the usage of a Bilevel Positive Airway Pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) for one sampled resident, (Resident #98), and failed to assess and care plan two falls for one sampled resident (Resident #109) out of 35 sampled residents. The facility census was 151 residents. Review of the facility policy Care Planning revised June 2020 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to update the care plan for an anticoagulant medication (a blood thinning medication) for one sampled resident (Resident #110) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Comprehensive Care Plans and Revisions policy dated 6/2020 showed: -The care plan was to be prepared by an Interdisciplinary Team (IDT) and Nursing Staff. -The Facility's IDT will develop a comprehensive care plan for each resident in accordance with OBRA and MDS guidelines. -A comprehensive person-centered Care Plan must be completed within 7 days after the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to document discharge planning prior to the resident's discharge from the facility and failed to complete a discharge summary for one discharged resident (Resident #201) who was discharged to home out of four discharged records. The resident sample was 35. The facility census was 151 residents. Review of the facility's Discharge Planning policy and procedure dated 8/2020, showed: -Discharge Planning will start on the day the resident was admitted to the facility. -If the Interdisciplinary team and the attending physician determine that the resident may soon be discharged , Social Service staff will coordinate the discussion of discharge with the Interdisciplinary team, the resident, and the resident's representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain treatment and monitoring orders for a head laceration with staples for one sampled resident (Resident #45) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Physician Orders policy revised on 6/2020 showed: -The facility will ensure physician orders are complete and accurate. -Medical records department will verify that physician order are complete, accurate and clarified as necessary. -Physician order will include a description complete enough to ensure clarity of the physician plan of care. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise, assess, and investigate a burn related to smoking for one sampled resident (Resident #104) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Incident Investigation policy revised in August 2020 showed: -The purpose was to ensure the facility tracked incidents that take place at the facility to increase the quality of care provided to residents. -The facility would have a licensed nurse fill out the Incident/Accident report as soon as possible. -An incident included but was not limited to the following: --Burns. -In the event of an incident a licensed nurse or the individual who first encountered or witnessed an incident would complete the Incident/Accident report. -As appropriate, interviews with staff members and other witnesses would be documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to obtain comprehensive physician order for a Suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) include type, size and care required and failed to ensure plan of care updated with the new Suprapubic catheter care and care of the stoma site for one sampled resident (Resident #15) out of 35 sampled resident. The facility census of 151 resident. Review of the facility policy Physician Orders dated 6/2020, showed: -The purpose of the policy was to ensure that all physician orders are completed and accurate. -Documentation pertaining to physician's orders will be maintained in the resident's medical record. -The licensed nurse receiving the physicians order will be responsible for documenting and implementing the order. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via a Gastrostomy Tube also known as a feeding tube-surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube for one sampled resident (Resident #116) out of 35 sampled residents. The facility census was 151 residents. Review of the facility policy Physician Orders dated 6/2020, showed: -The purpose of the policy was to ensure that all physician orders are completed and accurate. -Documentation pertaining to physician's orders will be maintained in the resident's medical record. -The licensed nurse receiving the physicians order will be responsible for documenting and implementing the order. A policy for enteral tube feeding was requested but not provided by the facility. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for assessing the resident's Dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) shunt (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for Dialysis) consistently, and failed to ensure Dialysis communication was received and documented after each Dialysis treatment for continuum of care, for two sampled residents (Resident #7 and #97) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Dialysis Care policy dated June 2020, showed: -The policy is to provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's physician responded with a rationale to the pharmacist's recommendation for a Gradual Dose Reduction (GDR) of the resident's psychotropic medications (drugs which affect psychic function, behavior, or experience) on the Drug Regimen Review (DRR) for one sampled resident (Resident #137) out of 35 sampled residents. The facility census was 151 residents. Review of the facilities Medication Management policy dated August 2020, showed: -In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility, the attending physician/prescriber, and the consultant pharmacist perform on going monitoring for appropriate, effective, and safe medication use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent for one sampled resident (Resident #96). The medication error rate was eight percent. The facility census was 151 residents. 1. Review of Resident #96's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation). -Pulmonary Fibrosis (a diseases in which the lungs become scarred over time). Review of the resident's admission Minimum Data Set (MDS- federally mandated assessment instrument completed by facility staff for care planning) dated 10/16/24 showed the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff administered the incorrect insulin (a synthetic hormone used to lower blood glucose levels) for one sampled resident (Resident #120) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Insulin Administration policy dated September 2014 showed: -The type of insulin should have been verified prior to administration to ensure it corresponded with the physician's order. -The nurse was to notify the Director of Nursing (DON) or physician of any discrepancies. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine and emergency dental services to meet the needs of residents were offered to two sampled residents, (Residents #14 and #98) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's undated Dental Services policy showed: -Refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the residents, if needed or requested and arrange transportation to and from the dentist's office. --Routine services include but are not limited to: ---Annual inspections. ---Dental cleaning, fillings, and x-ray as needed. ---Minor dental plate adjustments. ---Smoothing of broken teeth. --Emergency dental services include but are not limited to: ---Acute or intolerable pain in teeth, gums, palate. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal pneumonia vaccines (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) were offered, administered, or documented for one sampled resident (Resident #95) and failed to ensure an influenza vaccine (an annual vaccine to protect against the influenza virus) was offered, administered, or documented for one sampled resident (Resident #48) out of five residents sampled for vaccination provision. The facility census was 151 residents. Review of a facility policy titled Pneumococcal Disease Prevention, dated June 2020 showed: -Residents that reside in nursing homes are recommended to have the pneumococcal vaccine. -Residents would be assessed for and offered pneumococcal vaccinations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the Coronavirus Disease 2019 (COVID-19), and failed to administer recommended vaccines for three sampled residents (Residents #71, #93 and #95) out of five sampled residents. The facility census was 139 residents. Review of the Centers for Disease Control (CDC) Clinical Considerations for COVID-19 Vaccines, dated 10/31/24, showed: -Unvaccinated residents (residents who did not receive a multidose vaccine series) should receive a two dose vaccine series. -The Moderna COVID-19 vaccine is a two-dose initial vaccine series with recommended boosters thereafter. 1. Review of Resident #71's medical record showed: -An admission date of 2/12/24. -A single dose of Moderna COVID-19 vaccine administered 10/27/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #1) narcotics were secure when 47 pills of Oxycodone (a narcotic pain medication) were noted as missing on 9/11/24 out of three sampled residents. The facility census was 159 residents. On 10/16/24 the administrator was notified of the past noncompliance which occurred on 9/11/24. On 9/11/24 the Administrator was notified of missing Oxycodone from the licensed nursing cart. The staff was educated on narcotic count and handling, and changed the policy for removing empty cards from all narcotic lock boxes on 9/11/24. The deficiency was found to be corrected on 9/11/24. Review of the facility's Storage of Controlled Substances Policy dated 8/2020 showed: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide an appropriate immediate discharge letter for one sampled resident (Resident #5) out of nine sampled residents. The facility census was 160 residents. Record review of the facility's policy for Transfer and Discharge revised 10/24/22 showed: -The purpose of the policy was to ensure that residents were transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accidents for two sampled residents (Resident #1 and #3) out of six sampled residents. On 1/5/24 about 10:15 P.M., Certified Nurse Assistant (CNA) A transferred Resident #1 without using the Hoyer lift (a mechanical means to transfer a resident) from the wheelchair to the bed. During the transfer CNA A realized it was not safe to continue and lowered the resident to the floor. CNA A and CNA B then transferred the resident from the floor to bed by placing their arms under the resident's arms, one on each side and lifting the resident up. They did not use a gait belt or mechanical lift to transfer the resident back to his/her bed. Facility staff did not report the fall or assess the resident after the fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident #1) received timely assistance in obtaining a hearing device for communication. The facility census was 154 residents. Review of Resident #1's admission Record showed: -Was admitted to the facility on [DATE] with the following diagnosis; -Cognitive Communication Deficit (having trouble reasoning and making decisions while communicating, remembering their conversations and experiences and trouble responding in an appropriate or socially acceptable manner). Review of the resident's Care Plan, revised on 3/24/23, showed: -Focus: --Had a communication problem related to hearing deficit. -Goal: --Will be able to make basic needs known on a daily basis through the review date of 12/6/23. -Interventions: --Anticipate and meet needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate discharge notice for one sampled resident (Resident #2) out of four sampled residents. The facility census was 148 residents. Review of the facility policy titled, Transfer and Discharge, dated 6/2020, showed: -To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. -Prior to transfer/discharge, social services staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged . -Social Service staff or designee will provide the resident or responsible party with Notice of Proposed Discharge letter. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident #2) out of four sampled residents, to return to the facility after a hospitalization. The facility census was 148 residents. Review of the facility policy titled, Transfer and Discharge, dated 6/2020, showed: -To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. -Prior to transfer/discharge, social services staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged . [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the memory care unit doors to properly close allowing unauthorized exit by residents. On 8/7/23, one sampled resident (Resident #2), wandered from the secured unit and was found .3 mile from the facility after the magnetic door lock failed to securely lock out of three sampled residents. The facility census was 148 residents. On 8/11/23, the Administrator was notified of the past noncompliance which occurred on 8/7/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on the facility Wandering and Elopement policy, resident interventions and behaviors before the start of the next shift. Resident care plans were updated. The magnetic locks were fixed and self closing hinges for the door were installed. [...]

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staffing on a 24-hour basis to care for resident's needs and to ensure resident safety by not having adequate staff in the building for all shifts. This practice had the potential to effect all residents. The facility census was 148 residents. Record review of the facility's Nursing Department - Staffing, Scheduling and Postings policy, dated June 2020, showed: -The purpose was to ensure an adequate number of nursing personnel were available to meet resident needs. -The facility employed sufficient nursing staff on a 24 hour basis. -Schedule was done as needed to meet resident needs and accounted for the number, acuity and diagnoses the of the facility's resident populations. -The facility utilized the Facility Assessment to identify competency needs of the nursing staff. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the fan vent covers and the light fixture of the walk-in refrigerator free of a heavy dust buildup; maintain the ceiling and the light fixtures in the kitchen free of a heavy dust buildup; maintain the ice machine free of brown colored grime; maintain the floor of the dry goods storage room free of food crumbs; maintain the nozzles of the automated dish washer spray wands free of debris inside the nozzles and free from a layer of grime on the upper part of the dishwasher; ensure the handle of the spatula was easily cleanable; ensure the mittens were free from rips and loose fibers that could potentially get into foods; and maintain the snack food refrigerator on the Sunset Unit in a clean manner and without expired containers of condiments. This practice potentially affected 144 residents who ate food from the kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding one resident (Resident #60) out of 30 sampled residents not receiving showers on a regular basis; and to implement a QAPI program to ensure safe smoking practices by staff and residents. The facility census was 148 residents. 1. Record review of the QAPI meeting minutes dated 1/3/23, showed the absence of any discussion of any matters related to enhancing the shower experience for residents or the promotion of safe smoking practices for facility staff and residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to repair two convection ovens (an oven that has fans to circulate air around food to create an evenly heated environment which causes a fan-assisted oven to cook food faster) and one regular oven for an unknown period of time. The facility census was 148 residents. 1. During an interview on 3/20/23 at 9:51 A.M. Dietary [NAME] (DC) A said Convection Oven #1 (the upper oven) convection ovens did not work at all and the Convection Oven #2 (the lower oven) only cooked at one temperature, and one of the regular ovens did not turn on at all. Observation on 3/20/23 at 10:10 A.M., showed DC A placed two trays of pork cutlets into Convection Oven #2. During an interview on 3/20/23 at 2:03 P.M., the Dietary Manager said: - The top convection oven has not been working for about six months to a year. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oversight for three sampled residents, who did not have orders for self-administration of medications (Resident #23, Resident #24 and Resident #96), when staff left the residents medications at the bedside, left the room, and did not watch to ensure the residents took their medications out of 30 sampled residents. The facility census was 148 residents. Record review of the facility's undated policy Medication Administration, showed: -Medication would be administer by a licensed nurse per the order of an attending physician or licensed practitioner. -Medications would not be left at bedside. -The licensed nurse would remain with the resident until the medication was actually swallowed. -When an as needed medication was given, it would be documented on the Medication Administration Record (MAR). 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain oscillating fans in resident use areas (the Sunset nurse's station the 300 Hall shower room) free from a buildup of dust, and to maintain the sprinkler heads and the ceiling vent in the Main Dining room (MDR) free from a buildup of dust. This practice potentially affected at least 50 residents who used or resided in those areas of the facility. The facility census was 148 residents. 1. Observations with the Maintenance Director on 3/22/23 at 10:02 P.M., showed a heavy buildup of dust on the fan at the Sunset Nurse's Station. 2. Observations with the Maintenance Director on 3/24/23, showed: - At 12:34 P.M., a buildup of dust on the sprinkler heads in the MDR. - At 12:36 P.M., a buildup of dust on a ceiling vent in the MDR. [...]

Inspectors wroteBased on interview and record review, the facility failed to reassess the effectiveness of individualized resident care and interventions by not reviewing and revising resident care plans (a document that specified health care and support needs and outlined how the facility met resident requirements) for six sampled residents (Resident #58, #105, #31, #126, #95 and #88) out of 30 sampled residents. This practice had the potential to effect reach resident's physical and mental well-being. The facility census was 148 residents. Record review of the facility's Care Planning policy, dated 10/24/2022, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. -A Licensed Practical Nurse (LPN) initiated and finalized the Care Plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician when the resident's blood sugar was outside prescribed parameters for two sampled residents (Resident #23 and Resident #119) out of 30 sampled residents; and to ensure proper hand hygiene was completed during medication passes for one sampled resident (Resident #104) and for one supplemental resident (Resident #86) out of 30 sampled residents and eight supplemental residents. The facility census was 148 residents. A policy for physician notification was requested and not received at the time of exit. Record review of the facility's undated policy, Medication - Administration showed: -When administration of the drug is dependent upon vital signs or testing, the vital signs/testing would be completed prior to administration of the medication and recorded in the medical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for restorative assist care (RA) were initiated timely and followed for three sampled residents (Resident #36, #23, and #88) out of 30 sampled residents. The facility census was 148 residents. Record review of the facility Restorative Nursing Program Guidelines, revised June 2020, showed: -The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to live as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. -A resident may be started on a Restorative Nursing Program: --Upon admission to the facility with restorative needs but is not a candidate for formalized rehabilitive therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing/showers were completed at least once weekly and at the resident's preference for five sampled residents (Resident #60, #153, #8, #67 and #96) out of 30 sampled residents. The facility census was 148 residents. Record review of the facility's undated policy titled Showering A Resident showed a shower bath is given to residents to provide cleanliness, comfort and to prevent body odors. Residents are offered a shower or bath at at a minimum of once weekly and given per resident request. 1. Record review of Resident #60's admission Sheet showed he/she had diagnoses of muscle weakness, unsteadiness on feet and pain. Record review of the resident's care plan dated 8/9/22 showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from harm while outside smoking resulting in one sampled resident (Resident #63) who was visually impaired, while lighting his/her cigarette pulling his/her hand away and shaking it suddenly and saying ah when his/her finger was burned by the flame; the facility failed to maintain hot water temperatures on the Renew Unit below 120 ºF (degrees Fahrenheit) from 2/24/23 through 3/29/23, potentially affecting 19 residents who resided in resident rooms 520, 519, 518, 517, 516, 515, 514, 513, 512, 511, 509, 503, and 501; failed to ensure the hot water situation was addressed until 3/29/23, resulting in one cognitively impaired supplemental resident (Resident ##115) indicating the water was too hot for him/her when he/she washed his/her hands. [...]

Inspectors wrote2. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). Record review of the resident's admission MDS dated [DATE], showed the resident: -Was alert oriented and cognitively intact. -Had no behaviors and was not resistive to cares. -Needed extensive assistance of one person with bed mobility, transfers, bathing, dressing, toileting and did not walk. -Had not had any falls prior to admission or since admission. -Had shortness of breath and received oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility to ensure pain medication was ordered, obtained and provided in a timely manner for one sampled resident with chronic pain (Resident # 36); and did not provide adequate pain relief for three sampled residents (Resident #24, Resident #37, and Resident #119) out of 30 sampled residents. The facility census was 148 residents. Record review of the facility's policy, Pain Management, dated 6/2020 showed: -The Licensed Nurse would administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). -The Licensed Nurse would assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. -The shift pain score would indicate the highest pain level that occurred on that shift. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper documentation was completed for the shift change narcotic count books and the individual narcotic count sheets for two sampled residents (Resident #51 and Resident #119) and one supplemental resident (Resident #11) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents. Record review of the facility's policy titled Controlled Substance Administration and Accountability dated October 2022 showed: -All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. -Written documentation must be clearly legible with all applicable information provided. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's medication that had been prescribed by a physician were dated when they were opened and to ensure staff's personal items were not in the same drawer with resident's medications, out of 30 sampled residents. The facility census was 56 residents. Record review of the facility's policy, Storage of Medications, dated 9/2018 showed: -Medications and biologicals were stored safely, securely, and properly. -Outdated, medications were immediately removed from inventory. -Medication storage areas were kept clean, and free of clutter. 1. Observation on 3/24/23 at 7:30 A.M. of the medication cart on 100 hallway with Certified Medication Technician (CMT) B showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menus by cooking meals according to the menu; to ensure recipes were available for breakfast meals, and to document meal substitutions in the substitution log book for the Registered Dietitian (RD) to sign off on when the RD's came to the facility for their consults. This practice potentially affected 145 residents who ate food from the kitchen. The facility census was 148 residents. 1. Record review of the menu for the breakfast meal on 3/24/23, showed the residents were supposed to receive the following: Vitamin C juice, choice of cold or hot cereal, assorted fresh fruit, western egg bake, blueberry muffin and whole milk. Observation on 3/24/23 at 7:05 A.M., showed the absence of western egg bake form the steam table. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to assess the dietary preferences of four sampled residents (Residents #24, #96, #73, and #88) out of 30 sampled residents and one supplemental Resident (Resident #78), by not doing a dietary profile and to ensure food substitutes which were consistent with ordinary food items which were provided by the facility, were available for residents who did not prefer to eat the items which were offered. This practice potentially affected 144 residents who ate food from the kitchen. The facility census was 148 residents. 1. Record review of the resident council minutes dated 12/16/22, showed the residents stated that alternates were not available on weekend meals. Record review of the Resident Council Concern Response form dated 1/1/23 showed the following statement has active response and did not give back. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to re-train Certified Nursing Assistants (CNA) by not providing a competency evaluation program for five out of five CNA's. This had the potential to affect all residents. The facility census was 148 residents. Record review of the facility's Care Standards Policy, dated June 2020, showed: -The purpose of this policy was to ensure all residents receive necessary care and services that are evident-based and in accordance with accepted professional clinical standards of practice. -The Director of Nursing (DON) ensured care and services were delivered according to accepted standards of clinical practice -The DON or designee evaluated staff competency in skills and techniques necessary to care for resident's assessed needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the eating and ambulation (walking) needs for one visually impaired sampled resident (Resident #104) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents. A policy regarding Care for the Visually Impaired was requested and not received at the time of exit. 1. Record review of Resident #104's undated face sheet showed he/she admitted to the facility with legal blindness. Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/29/23 showed: -The resident was cognitively intact. -The resident's vision was severely impaired meaning the resident had no vision or saw only light, colors, or shapes and his/her eyes did not appear to track. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that hold drained urine) during before and after care for one sampled resident (Resident #153) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 30 sampled residents. The facility census was 148 residents. Record review of the Facility Catheter Care policy revised on 6/2020 showed: -Position the catheter drainage system and bag utilizing gravity to facilitate drainage of the urine. The collection bag (drainage bag) will be kept below the level of the bladder, including during transport and avoiding contact with the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate care was completed during enteral feeding (tube feeding- the delivery of nutrients through a feeding tube directly into the stomach, duodenum (first part of small intestine), or jejunum (middle part of the small intestine)) for one sampled resident (Resident #97) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents. A policy for tube feeding was requested and not received at the time of exit. 1. Record review of Resident #97's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Cerebral Infarction (stroke- a disruption of blood flow to the brain). -Unspecified Protein-Calorie Malnutrition (lack of proper nutrition). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for obtaining and recording weights and monitoring the fistula (a procedure that connects an artery to a vein that allows blood to pass freely) for one sampled resident (Resident #114) who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments out of 30 sampled residents. The facility census was 148 residents. 1. Record review of Resident #114's Face Sheet showed he/she was admitted on [DATE] with diagnoses including heart failure, diabetes, hepatitis (a disease that attacks the liver), human immunodeficiency virus (a virus that attacks the body's immune system) and end stage renal disease (ESRD- permanent kidney failure that requires a kidney transplant or scheduled dialysis). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmacy medication regimen review (MRR) for 11 out of 12 months for one sampled resident (Resident #58) out of 30 sampled residents. This practice had the potential to effect each resident's physical and mental well-being. The facility census was 148 residents. Record review of the facility's Documentation and Communication of Consultant Pharmacist Recommendations, dated August 2020, showed: -The consultant pharmacist worked with the facility to establish a system where the consultant pharmacist observed and recommended medication therapies for residents. -Those recommendations were communicated to facility authority and responded to in a timely manner. -Records of the consultant pharmacist's observations and recommendations were made available to nurses, prescribers and the care planning team, which included: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed provide dental services and complete comprehensive dental assessment for one sample resident (Resident #154) who had poor dental health and complaint of dental pain out of 30 sampled residents. The facility resident census was 148 residents. A policy related to dental/oral care was requested but not received at the time of exit. 1. Record review of Resident #154's admission Face sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Abnormal weight loss -Severe protein-calorie malnutrition (is a deficiency of protein and overall energy intake) -He/she had Medicare and Medicaid for health insurance. Record review of resident's All-Inclusive admission with Baseline Care Plans dated 2/27/23 at 10:00 P.M. showed: -His/her teeth were not assessed. -He/she did not have dentures. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain hot foods on the room trays in the sunset location and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) on different days of the survey and failed to have a system of monitoring the temperatures of room trays in place. This practice potentially affected an unknown number of residents who received their meals towards the end of the delivery for those respective locations within the facility. The facility census was 148 residents. 1. Record review of the resident council minutes dated 2/17/23 showed: -Weekend service for meals is terrible. -Corporate needs to be at the resident council meeting because food carts were sitting on the halls for so long that food was cold. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all food items in the resident food refrigerator located on the Renew Unit, were labeled and dated. This practice potentially affected an unknown number of residents for whom food was stored in the refrigerator. The facility census was 148 residents. Record review of The Visitor's Food Policy revised 2/2021, showed: - Purpose: To provide residents with the option of having food prepared by the resident's family brought into the facility. - Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends if the food is compatible with the Attending Physician's diet order. - Procedure: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure one trash container was inside the kitchen was kept closed while it was not in use and failed to ensure the outdoor dumpster was covered for several hours on 3/20/23, and to ensure that all facility staff were able to close the dumpster lid after dumping a bag of trash inside the outdoor dumpster. This practice affected the kitchen and one outdoor area. The facility census was 148 residents. 1. Observations on 3/20/23 at 8:42 A.M., 9:23 A.M. and 10:52 A.M., showed one trash container inside the kitchen, was left open throughout the lunch meal preparation and was not being used. 2. Observation on 3/20/23 at 9:39 A.M., 10:02 A.M., 11:16 A.M., and 2:13 P.M., showed the lids of the outdoor dumpster's were left open. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #84) out of 30 sampled residents did not smoke cigarettes in his/her room. This practice potentially affected at least six residents who reside in adjoining rooms or rooms across the hall in the same area of the hall as that resident. The facility census was 148 residents. Record review of the facility's smoking policy revised in 3/2022, showed: - Smoking was not allowed anywhere inside the facility. - The facility discouraged smoking by residents and ensured that those residents who choose to smoke did so safely. - All smoking materials would be stored in a secure area to ensure they are kept safe. - Cigarette butts were disposed of only in provided receptacles. 1. Record review of Resident #84's Face sheet showed he/she was admitted on [DATE], with diagnoses which include: [...]

Inspectors wroteBased on interview and record review, the facility failed to identify a change in condition in a resident including a decrease of alertness, decreased blood pressure, and decreased oxygen saturation; to notify the resident's physician of the resident's change in condition in a timely manner; to transfer a resident to a hospital when requested by the resident's family in a timely manner, resulting in the resident requiring transportation to the hospital by Emergency Medical Services (EMS) and admission to the Intensive Care Unit (ICU) due to critically low blood pressure for one sampled resident (Resident #316) out of 32 sampled residents. The facility census was 164 residents. Record review of the facility Change of Condition Notification policy dated February 2019 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to have grievance forms accessible for all residents, and educate residents and review the grievance policy and procedures on how to file a grievance, for 15 sampled residents (residents attending the Resident Council Group Interview Meeting, conducted as a part of the survey process). The facility census was 164 residents. 1. During Resident Council Interview on 3/3/20, beginning at 2:00 P.M., the group responses included: -Residents could not anonymously get a grievance form. -Residents were concerned about staff members knowing they were getting a grievance form. -Grievance forms were at the nurses' station and they are too high up for the residents to reach. -Residents did not know how to file a grievance. -Residents did not know if there was a grievance official. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot foods on a room tray for one sampled resident (Resident #4) was maintained at or around 120 degrees Fahrenheit (ºF) at the time the food was delivered to his/her room and, failed to maintain food temperatures on the steam table at or close to 135 ºF during the entirety of the breakfast and noontime meals and. This practice of holding cooked food on a steam table with temperatures over 135 ºF overcooks the food items and lowers the nutrient levels, values and benefits of those food items, affecting all of the residents who receive hot meals from the facility's kitchen. These practices potentially affects all of the residents who receive their meals from the facility's kitchen. The facility census was 164 residents. 1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ample amounts of food on the regular menu was prepared to serve all residents, including sampled residents (Resident's #80 and #369), and to ensure regular food preference items were available at meal time for two sampled residents (Resident's #52 and #146) out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Dietary: Resident Preference Interview policy, revised February 2019, showed: -Staff would complete the dietary questionnaire upon admission, readmission and no less than annually to capture the resident's dietary preferences. -The tray card would reflect resident preferences. 1. Record review of Resident #80's face sheet showed he/she was admitted to the facility 10/25/19. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary procedures before food preparation tasks. These practices potentially affects an unknown number of residents who received their meals from the facility's kitchen. The facility census was 164 residents. 1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. in the kitchen showed the following: -At 5:05 A.M. in the kitchen, tomatoes and pickles stored on a shelf out their original containers in the refrigerated walk-in unit, were not dated as to when they were opened or how long they had been opened. -The floors near the food preparation table, the electrical floor outlet near the steam table and floors surrounding the steam table were greasy, visibly and to the touch. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the facility's kitchen range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease) exhaust fan was in operational and functional condition. By having a faulty exhaust system the facility is placing in jeopardy the entire kitchen staff of smoke inhalation and the risk of grease building up in the hood creating a fire thus, affecting and the facility residents. The facility census was 164 residents. 1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. in the kitchen, showed the kitchen range hood's exhaust system non-functional and non-operational. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #121) was free from restraints out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Restraints policy revised 2/2019 showed: -Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. -There must be a physician's order for the use of a restraint, including the medical symptom, frequency, type of restraint, release protocols and a plan for reduction. -Before any restraint is used, the licensed nurse would verify that informed consent has been obtained from the resident/responsible party, and education was provided including the risks and benefits of the restraint. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) assessments for two sampled residents (Residents #25 and #367) out of 32 sampled residents. The facility census was 164 residents. 1. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Telephone Order Sheet (TOS) dated 12/3/19, showed an order for the resident to be evaluated by hospice (end of life care) services. Record review of the resident's hospice agreement showed: -He/she was admitted to hospice 12/4/19. -His/her admitting diagnosis was heart failure. Record review of the resident's Nurses' Progress Note dated 12/5/19, showed he/she was admitted to hospice. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents and their representative with a summary of the baseline care plan for two sampled residents (Resident #50 and #126) out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Care Planning Policy dated February 2019, showed: -The facility will develop a person-centered baseline care plan for each resident within 48 hours of admission. -Once the baseline care plan is completed, the facility must provide the resident and/or the resident's representative with a written summary of the baseline care plan. -The baseline care plan summary must be provided to the resident and/or the resident's representative by the time the Comprehensive Care Plan is completed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for one sampled resident (Resident #126), out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Care Planning policy, revised February 2019, showed: -A comprehensive person-centered Care Plan would be developed for each resident. -Each resident's Comprehensive Care Plan would describe: --Services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. --Any services that would be required, but were not provided due to the resident's exercise of rights, which includes the right to refuse treatment. -The Care Plan would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) remained clean, free of stool, and coved with a dressing per physician's orders; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #143) was provided adequate incontinence care when he/she was visibly wet, had puddles under his/her wheelchair, and there was a strong urine odor in his/her room out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's policy titled Perineal Care (washing the genitals and anal area) dated February 2019 showed: -The purpose was to maintain cleanliness of the genital area, to reduce odor, and to prevent infection of skin breakdown. -Perineal care was provided as part of a resident's hygienic program, a minimum of once daily and per resident need. 1. Record review of Resident #143's face sheet showed he/she admitted tot he facility on 2/9/20 with diagnoses including: -End stage renal disease (the last stage of chronic kidney disease). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the behavioral needs for one sampled resident (Resident #85) who had an increase in his/her depression indicators out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Social Services Program policy updated 2/2019 showed: -The facility needed to provide medically related social services. -The director of social services and/or designee would meet with the resident to evaluate the psychosocial needs of the resident. -The resident needed to be assessed for negative impact on psychosocial development including anxiety, coping ability, depression, and anger. 1. Record review of Resident #85's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess one sampled resident (Resident #154) for ongoing appropriate interventions related to the resident's behaviors; to complete a thorough investigation of an incident and provide appropriate monitoring at the time of the incident that occurred on 2/26/20; to notify the physician of one closed record resident's (Resident #85) mental status changes with increasing behaviors and failed to adequately monitor the resident as the behaviors increased out of 32 sampled residents. The facility census was 164 residents. Record review of the facility's Behavior-Management policy revised 2/2019 showed: -The key components were: --Identifying residents whose behaviors may pose a risk to self or others. --Develop practical care strategies based on assessed needs. --Implementing a behavioral management program. [...]