Carriage Square Rehab and Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services that met professional standards of quality when the facility staff failed to follow physician orders to be notified of high blood glucose levels (Resident #5), when the facility staff failed to prime the needle of an insulin pen prior to administration (Resident #6) and additionally when the facility staff failed to ensure they had all required supplies for central line (a long, flexible tube inserted in a vein and into the heart) dressing change prior to initiation of dressing change (Resident #4). This affected three residents. The facility census was 85. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment when the facility staff failed to change gloves and perform hand hygiene between dirty and clean tasks when staff did not wipe all areas affected by urine while staff performed perineal hygiene incorrectly for one resident (Resident #1); when the facility failed to provide a barrier between the residents' catheter drainage bag (a tube inserted into the bladder to drain the urine to an external collection device) and the floor for one resident (Resident #2); [...]

Inspectors wroteBased on interview and record review the facility failed to provide timely access to resident electronic medical records (EMR), staff list, and resident matrix (a document listing all resident's and their clinical characteristics) from 1/27/2026 at 9:50 A.M. through 1/27/2026 at 12:00 P.M. This resulted in the surveyors being unable to timely review necessary records to conduct the survey and review of care provided to residents. The facility census was 98. No policy regarding providing access to medical records in a timely manner was provided by the facility. During an Interview on 1/27/26 at 9:50 A.M. the Administrator and Director of Nursing (DON) were provided with a list of items needed that included a resident matrix (a comprehensive, mandated document used by nursing homes to list all current residents and track key clinical care categories including resident room numbers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two resident's (Resident # 1 and #3) who had urinary catheter (a tube inserted into the bladder to drain urine from the body), received appropriate treatment and services to prevent urinary tract infections when the facility failed to provide proper catheter care management. This deficient practice affected two of the four sampled resident's. The facility census was 89. Review of the facility polity titled, Catheter-Care, dated 10/24/22, showed: -Purpose: to prevent catheter associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary; -Cleanse the outside of the catheter wiping away from the meatus; -Take care to ensure the collection bag does not touch the floor at any time. 1. Review of Resident #1's care plan, revised 9/19/25,showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure enhanced barrier precautions (EBP) and infection control measures were used during high-contact care for residents with wounds ( Resident #3 and 4) and indwelling devices Resident #1 and 3), were being utilized for three (Resident's #1, 3, and 4) of four sampled residents. The facility census was 89. Review of the facility policy titled, Standard and Enhanced Precautions, dated 7/1/23, showed: [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy for medical record requests when staff reported they printed and gave copies of electronic medical records without a formal written record request. The facility also failed to provide requested medical records in a timely manner for one previous resident (Resident #1). The facility census was 130. Review of the facility provided policy titled,Resident Access to PHI or Financial Records, dated October 24,2022 showed:-The facility recognizes the resident's right to have access to his/her Protected Health Information (PHI); -All requests for access must be in writing; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that resident's who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible when improper incontinent care was provided to three Residents (Residents #1, #2, and #3) of the three sampled residents. The facility census was 91. Review of the facility's Perineal Care policy, dated 10/24/2022, showed: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need; The purpose of perineal care is to maintain cleanliness of the genital area, reduce odor, and to prevent infection or skin breakdown. Staff are to use clean soapy washcloths when providing perineal care, moving from front to back, using a clean area of the washcloth for each stroke. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the physician timely when a resident had a change of condition, failed to start an antibiotic that was ordered by the resident's physician, and failed to obtain a physician ordered urinalysis (UA) timely for one resident (Resident (R) 63) of 33 sampled residents. These failures resulted in R63's hospitalization due to sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) related to a urinary tract infection (UTI). The facility census was 93. The facility's Administrator and Director of Clinical and Reimbursement Services were informed on 03/13/25 at 3:23 P.M. of an Immediate Jeopardy, which began on 03/08/25. The Immediate Jeopardy was removed on 03/14/25, as confirmed by surveyor onsite verification.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to effectively manage pain for one of one resident (Resident (R) 71) reviewed for pain out of 33 sampled residents. The facility failed to order R71's oxycodone (an opioid pain medication) in a timely manner and the physician ordered pain medication was not administered as ordered. This failure caused R71 to experience terrible pain, was unable to relax enough to sleep, and felt like he was having withdrawals. The facility census was 93.

Inspectors wroteBased on interview, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RR) during admission included a clause that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. This failure affected all residents who had signed the Arbitration Agreement and any future residents who might sign the agreement. The facility census was 93.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to ensure there was a designated Infection Preventionist (IP) that had completed specialized training in infection prevention and control that had sufficient time to assess, develop, implement, monitor, and manage the facility's Infection Prevention and Control Program (IPCP). The failure placed all residents in the facility at risk for acquiring diseases and infections. The facility census was 93.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff consistent with their expected roles annually per the facility assessment. The facility failed to provide training related to cultural competency as identified by the facility assessment as a need. Additionally, the facility provided training related to abuse and neglect, infection control, and behavioral health, however, they failed to develop, implement, and maintain an effective system to monitor what training staff had or had not completed. This failure potentially allowed staff to work without the skill sets necessary to care for the resident population and placed all residents at risk for negative healthcare outcomes. The facility census was 93.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on communication. This failure potentially allowed staff to continue to work without the skills sets necessary to care for the residents. The facility census was 93.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on the elements and goals of the facility's Quality assurance and performance improvement (QAPI) program. This failure resulted in all staff not receiving the required training. The facility census was 93.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on compliance and ethics program annually. This failure resulted in staff not receiving the required training on the compliance and ethics program standards, policies, and procedures. The facility census was 93.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to have an effective continuing education program for the Certified Nurse Aides (CNAs) to receive the required 12-hour in-service training yearly. This failure potentially allowed CNAs to work without receiving the number of hours required for continuing education and skill sets necessary to care for the resident population. The facility census was 93.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory care equipment was properly maintained; and failed to ensure respiratory care was provided per physician orders for three of four residents review for respiratory care (Resident (R) 15, R53, and R41) out of 33 sampled residents. These failures placed the residents at risk for increased risk of respiratory infections and oxygen saturations not being maintained. The facility census was 93.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. The facility also failed to ensure dishes were properly dried after being washed. Additionally, the facility failed to ensure all items in the kitchen's refrigerator, freezer, and dry food storage were sealed, labeled, and dated. These failures placed all residents of the facility at risk for food borne illnesses. The facility census was 93.

Inspectors wroteBased on interview, record review, facility policy review, the facility failed to maintain an effective infection prevention and control program (IPCP) as follows: 1. The facility staff were not recording incidents of infections identified through surveillance, tracking and trending, and the corrective actions taken by the facility. 2. The Maintenance Director did not have measures in place to prevent the growth of water-borne pathogens in the water fountain as identified in the assessment. 3. The facility staff failed to clean and disinfect the multi-use glucometer when performing fingerstick blood glucose testing between residents per the manufacturer's instructions. The facility census was 93.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop comprehensive care plans which reflected residents' current status for two of 33 sampled residents (Resident (R) 74 and R10). R74 was receiving hospice services; however, there was no care plan developed to reflect hospice services. Additionally, R10 had the diagnosis of and receiving treatment for diabetes mellitus; however, the resident's care plan did not reflect the diabetes mellitus treatment. These failures placed the residents at risk of having unmet care needs. The facility census was 93.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents were free from significant medication errors for one of 33 sampled residents (Resident (R) 89). R89 received metoprolol tartrate (a medication used to treat high blood pressure, chest pain, and heart failure) and metformin (a medication used to treat high blood sugar levels caused by type II diabetes) which was not ordered by the physician. This failure increased R89's risk of decreased blood pressure, heart rate, and drowsiness. The facility census was 93. On 3/14/25, the administrator was notified of the past noncompliance which occurred on 03/01/25. Immediate resident assessment completed, SBAR completed on 03/01/25, 1:1 (one to one) education provided to CMT1 on medication administration rights. [...]

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to ensure an effective antibiotic stewardship program when the Minimum Data Set Coordinator (MDSC) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) in order to reduce the development of antibiotic-resistance organisms for one of four residents (Resident (R) 1) reviewed for UTIs out of 33 sampled residents. In addition, the Antibiotic Stewardship Program lacked documentation of the tracking or trending of antibiotic usage or where infections occurred in the facility. The facility census was 93.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse and neglect policy when they did not provide education to their staff after an alleged sexual assault by a staff member to a resident (Resident #1) on [DATE] and following an allegation regarding inappropriate touching by staff to a resident (Resident #2) on [DATE]. The facility census was 87. Review of facility policy, abuse prevention and prohibition program, revised [DATE], showed: -To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that an allegation of sexual assault was reported to law enforcement (LE) for one resident (Resident #1) when Physical Therapist Assistant (PTA) A was observed with his/her hand inside Resident #1's brief by Certified Nurse Aide (CNA) A on [DATE] and failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two hour time frame when Resident #2 reported PTA B inappropriately touched him/her on the leg on [DATE]. The facility census was 87. Review of facility policy, Abuse Prevention and Prohibition Program, revised [DATE], showed: -Reported suspected incidents of criminal sexual abuse has been committed against a resident must immediately report this information to Administrator and Director of Nursing Services. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation when on [DATE] Certified Nurse Aide (CNA) A reported an observation of Physical Therapy Assistant (PTA) A with his/her hand inside Resident #1's brief. The facility failed to notify the physician of the alleged sexual assault, contact law enforcement, and have the resident assessed for a medical exam. The facility also failed to have evidence the alleged violations were thoroughly investigated when Resident #2 alleged PTA B touched him/her inappropriately on [DATE] when they failed to notify the physician. The facility census was 87. Review of facility policy, abuse prevention and prohibition program, revised [DATE], showed: -Each resident has right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. [...]

Inspectors wroteBased on record review and interview, the facility failed to screen new employees by completing the 2-step TB test, failed to monitor the transmission of communicable diseases, and failed to track and document all staff tuberculosis (TB) testing. In addition, failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) when they failed to develop and implement a water management plan. This had the potential to affect every resident in the facility. The facility census was 80. 1. Review of the facilities undated standard operating procedure for 2-step TB testing showed: - Every new employee is required to be tested for TB; - Results need to be checked prior to the employee starting to work; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional and comfortable environment for resident, staff and the public when they failed to ensure their building was maintained in good condtion. This had the potential to affect all residents, staff, and visitors. The facility census was 80. 1. Observation on 7/14/23 beginning at 9:00 A.M. showed the following: - Outside the building at the end of 300 hall there was soffit sagging causing a large gap exposing the attic space above; - Soffit was sagging outside the exit across from the staff break room. During an interview on 7/14/23 beginning at 4:00 P.M. the Maintenance Director said: - He had worked in the facility for about two weeks; -- The facility should be maintained in good condition. Work orders were submitted by staff electronically . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when they allowed Resident #55 to sit in their wheelchair in the hallway with clothing pulled up exposing stomach, and failed to ensure privacy of Resident #70 who was visible from the hallway laying in bed wearing nothing but an incontinent brief. Staff failed to administer medication in a private setting for Resident #49 and #57. Additionally,the facility failed to ensure that Resident #47's room was free of pests and free from the smell of urine. The facility census was 80. Review of the facility's Privacy and Dignity policy, dated 10/24/22, showed: -The facility promotes resident care in a manner and in an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to consider and accommodate the residents' preferences for evening snacks, which affected three of 18 sampled residents, (Resident # 22, #50 and #74) as well as other residents who attended the resident group interview who stated the facility failed to provide them a shower two times a week for one Resident, #43, which hindered the resident's self determination. This effected five of 18 sampled residents (Resident #22, #50, #57, #43, and #74) . The facility's census was 80. Review of the facilities nourishment and snacks policy, dated 10/24/22 showed: - It is the purpose of the policy to ensure the facility provides nourishment and snacks in accordance with the prescribed diet and per the menu rotation; - Individual or bulk snacks are available at the nurse's station for consumption; for residents; [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when the staff failed to properly clean residents bedroom floors, prevent strong urine odor in resident rooms, remove pests in resident bathrooms, and failed to clean fecal matter on the exterior of a resident toilet. This effected two out of 18 sampled residents. The facility census was 80. Review of the facility resident rooms housekeeping policy, dated 10/24/22 showed: - It is the purpose of the policy to provide clean and sanitary living spaces; - The housekeeping department it to coordinate daily cleaning of all resident rooms; - The floor is damp mopped with a disinfectant solution. 1. Review of Resident #47's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/4/23 showed: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff provided a bed hold policy to residents or their responsible party when staff transferred three of 18 sampled residents, (Resident #22, #24 and #50) to the hospital. The facility census was 80. Review of the facility's policy for bed hold, revised 10/24/22 showed, in part: - The purpose is to ensure that the resident and/or their representative is aware of the facility's bed hold policy, and that such policy complies with state and federal law and regulations; - If the resident is transferred to a general acute care hospital, as long as the resident or their representative notifies the facility within 24 hours of the transfer that they wish to have the facility hold the resident's bed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered trauma informed plan of care which included measurable objectives and timeframes for one of the18 sampled residents (Resident #70) and failed to develop and implement a comprehensive care plan that included the code status for two of 18 sampled residents (Resident #24 and Resident #46). The facility census was 80. Review of the facility's Comprehensive Care Plan Policy, dated, [DATE], showed: -The facility will develop a comprehensive, person centered care plan for each resident that will include the following: o Goals based on admission orders; o Physician's orders; o Therapy orders; o Service or treatments to be administered; o Services that are to be furnished to obtain or maintain the resident's highest practible physical, mental and psychosocial well being. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of four sampled residents, (Resident #69, #22 and #24) and when the facilty failed to provide a shower twice a week for Resident #43 as well as failed to provide oral care, comb the hair and wash the face for Resident #24. The facility census was 80. Review of the facility's Perineal Care policy dated, 10/24/22, showed: - Perineal care is provided daily and as needed as part of the resident's hygienic program; - Perform hand hygiene and put on gloves; [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the call light button was within reach of two residents (Resident #15 and Resident #11) which could cause an increase risk of falls or delayed response in the event the resident needed assistance. Additionally, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two sampled residents (Resident #24 and #55) during the use of a mechanical lift. The facility census was 80. A review of the manufacture's instructions for the Invacare Reliant 600 mechanical lift., dated 2018, showed: - Open the legs of the lift to the maximum width; - Place the straps of the sling over hooks of the hanger bar; - Do no lock the rear casters of the patient lift when lifting an individual; - Locking the rear casters could cause the patient lift to tip. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide Trauma Informed Care for residents with a history of trauma when the facility failed to train staff to adequately care for three of 18 sampled residents (Resident #11, #68 and #70) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event), and when the facility failed to ensure one resident ( Resident #70) did not receive appropriate mental health services. The facility census was 80. Review of the facility's Social Service Assessment policy, dated, 10/24/22, showed: -Trauma Informed Care - The facility will: o Identify, address and support residents' feelings of self worth; o Use a mulitpronged approach to identify resident with a history of trauma; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 80. The facility did not provide a policy regarding RN staffing. Review of the staffing sheets for May 2023 showed: - No RN scheduled for eight consecutive hours on 5/20/23, 5/21/23, 5/27/23 and 5/28/23. Review of the staffing sheets for June 2023 showed; - No RN scheduled for eight consecutive hours on 6/3/23, 6/4/23, 6/17/23, and 6/18/23. Review of the staffing sheets for July 2023 showed: - No RN scheduled for eight consecutive hours on 7/1/23 and 7/2/23. During an interview on 7/14/23 at 5:22 P.M., the Director of Nursing (DON) said: - She had been in her current position for about two weeks; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made 13 medication errors out of 26 opportunities for error, a medication error rate of 50%, which affected nine of 18 sampled residents, (Resident #12, #17, #20, #32, #36, #49, #54, #57, and #72). The facility census was 80. Review of the facility's policy for medication administration, dated 2007, showed, in part: - Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Review of the facility's policy for eye medication administration, revised 10/24/22 showed, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hot food at a safe and appetizing temperature when they failed to maintain hot foods at or close to 120 degrees Fahrenheit ( degrees F) at the time the food was served. This affected two out of the 18 sampled residents (Residents #22 and #74). The facility census was 80. Review of the undated facility policy titled Food Temperatures, included the following: - Purpose- to provide the dietary 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; - Acceptable Serving Temperatures (included): Cereal, gravy, casseroles, meat, entrees, potatoes, pasta, soup, pureed foods, vegetables, eggs at a minimum of 135 degrees F. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to store dishware in a sanitary manner and failed to maintain their ice machine in a sanitary manager, which has the potential to cause sickness to all residents. The facility census was 80. Review of the facility ' s undated kitchen cleaning checklist showed the following: - The Dietary Manager cleaned the ice machine on Tuesday and Friday; - The checklist did not include cleaning containers used to store dishware. Review of the facility ' s polity titled Ice Machine- Operation and Cleaning, dated October 24,2022, included the following: - Purpose- To establish guidelines for the use and cleaning of the ice machine; - The dietary staff will operate the ice machine according to the manufacturer ' s guidelines. The ice machine will be cleaned routinely; - Sanitation of Equipment (including): [...]

Inspectors wroteBased on interviews and record review, the facility failed to prevent the misappropriation of property for one of 18 sampled residents, (Resident #37) when CNA F used the resident's debit card numbers, without authorization of the resident to make transactions. The facility census was 80. Review of the facility's policy for abuse prevention and prohibition program, revised 10/24/22, showed in part: - The purpose is to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided complete catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent infection or the possibility of infection which affected one of 18 sampled residents, (Resident #50). The facility census was 80. Review of the facility's policy for care of catheter, revised 10/24/22, showed in part: - The purpose is to prevent catheter associated urinary tract infections (UTIs, an infection in any part of the urinary system), while ensuring that residents are not given indwelling catheters unless medically indicated; - Cleanse the perineum and urinary meatus (natural body opening) as part of the A.M. and P.M. care and after each bowel movement or incontinence episode; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff provided proper respiratory care for one of 18 sampled residents (Resident #77) when staff failed to properly date oxygen tubing and failed to ensure the oxygen concentrator filter was in place, placing the resident at risk for poor quality outcomes related to improper management of oxygen equipment. The facility census was 80. Review of the facility's undated policy titled Oxygen Administrator, included the following: - Purpose- to prevent or reverse hypoxemia (lower than normal oxygen level) and provide oxygen to the tissues; - All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled, or as indicated by state regulation. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account and did not allow the residents/guardian the right to manage his/her financial affairs. The facility also did not provide residents access to their funds as soon as possible for 14 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14). The facility census was 76. 1. Record review of the facility's maintained Aged Accounts Receivable Report for the period 07/01/20 through 06/30/21, dated 07/28/21, showed the following residents with personal funds held in the facility operating account: [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff did not maintain the floors in resident rooms and hallways in clean condition which included the baseboard peeling off around a door. Additionally, the facility failed to properly monitor and maintain a low air loss (LAL) matress for one of 18 sampled residents (Resident #32). The facility census was 76. 1. Observation on 7/26/21 beginning at 10:58 A.M. showed the following: - room [ROOM NUMBER]- The floor behind the entrance door was brown and discolored that could be removed with wet paper towel; - Room#604- The floor around the entrance door frame was discolored brown; - room [ROOM NUMBER]- The floor around the entrance door frame was discolored brown. Dirt and debris was on the floor in the back corner on the other side of the bed; [...]

Inspectors wroteBased on record review and interviews, the facility failed to run criminal background checks (CBC) and check the Nurse Aide (NA) Registry prior to hire. This affected six of 10 sampled staff. The facility census was 76. Review of the facility policy titled Employment Screening, dated 7/1/14, included the following: - In accordance with State and Federal regulations this facility will not knowingly hire, contract or retain any individual that is ineligible to work in a health care facility, that has been excluded from participation in the Medicare or Medicaid programs, or has not met required licensure or certification requirements for the position being considered; - New employees: Unless otherwise stipulated by this policy a new employee may not start working until all of the following is completed or initiated: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they provided residents with a written letter of the reason for discharge/transfer before transferring or as soon as practicable to four of 18 sampled residents (Resident #58, #81, #52, #28). Facility census was 76. Facility did not have a policy for transfer/discharge letters. 1. Review of Resident #58's electronic medical record on 7/27/21 at 11:09 A.M. showed: -Resident hospitalized on [DATE] due to abnormal lab levels. -No documentation of a transfer/discharge letter given. 2. Review of Resident #81's electronic medical record on 7/28/21 at 10:23 A.M. showed: -Resident sent to the hospital on 5/16 due to change in mental status. -No documentation of a transfer/discharge letter given. 3. Review of Resident #52's electronic medical record on 7/29/21 at 2:00 P.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff issued a notice of their bed-hold policy prior to/upon transferring four of eighteen sampled residents (Resident #58, #81, #52, and #28) to the hospital. Facility census was 76. Facility did not have a bed-hold with transfers policy. 1. Review of Resident #58's electronic medical record on 7/27/21 at 11:09 A.M. showed: -Resident hospitalized on [DATE] due to abnormal lab levels. -No documentation of the bed hold policy provided. 2. Review of Resident #81's electronic medical record on 7/28/21 at 10:23 A.M. showed: -Resident sent to the hospital on 5/16/21 due to change in mental status. -No documentation of the bed hold policy provided. 3. Review of Resident #52's electronic medical record on 7/29/21 at 2:00 P.M. showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed professional standards of practice on four of 18 sampled residents when staff crushed a medication on the do not crush list which affected one resident (Resident #7) and failed to follow physicians orders for splints/cloth rags for contracted hands for Resident #34; failed to follow physician's orders for oxygen and protective boots to prevent and heal pressure ulcers for resident #12 and #52. The facility census was 76. 1. Review of Resident #7's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 7/15/21 showed: -Resident is non-interviewable. -Resident has physical and verbal behavioral symptoms. -Resident requires one or two staff assistance on all activities of daily living (ADLs). -No swallowing disorder. -Diagnoses include: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date oxygen tubing, clean oxygen concentrator filters, document oxygen tubing changes, and provide humidifier bottles with oxygen administration, which affected three of 18 sampled residents (Residents #35, #70, and #77). The facility census was 76. Review of facility policy, Medical Equipment Disinfection, dated 8/24/18, showed: -Dedicated medical equipment will be cleaned at least weekly and/or when they become visibly soiled. -Humidification bottles should be changed monthly, when visibly soiled, or if it malfunctions. -Oxygen tubing should be changed monthly, when visibly soiled, if contamination occurs, or if it malfunctions. 1. Observation and record review on 7/27/21 at 9:18 A.M. showed: -Resident #35's oxygen concentrator filter was fuzzy. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to label seasoning when it was received, and failed to ensure they kept food covered when they were not preparing or serving it. The facility census was 76. Review of the undated facility policy titled Three Compartment Sinks- Manual Dishwashing, included the following: - Fill the first sink with detergent and water; - Fill the second sink with clean water; - Fill the third sink with water and sanitizer to the corrected concentration. Hot water can be used as an alternative; - Wash items in the first sink- use a brush, towel, or nylon scrub pad to loosen dirty. Change the water and detergent when the suds are gone or the water is dirty; - Rinse items in the second sink. [...]

Inspectors wroteBased on interview, record review, and observation the facilty failed to obtain physician orders and assess the residents for safe administartion of medication to be kept at the bedside for two residents (Resident #15 and #329) out of 18 sampled residents. The facility census was 76. The facility did not provide a policy for administration of bedside medications. 1. Review of Resident #15 quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/22/21 showed: - Brief Interview for Mental Status (BIMS), a test to determine the resident's cognitive function, score of 11, the resident is able to make good decisions. - Functional status: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were in reach for eight of eighteen sampled residents (Resident #4, #12, #20, #34, #25 and #73) with limited range of motion and limited mobility. The facility also failed to ensure one additional resident ( Resident #52) had an indwelling catheter anchor when staff failed to following physician's orders for catheter securing device (a device used to stabilize the catheter tubing to decrease tension and facilitate urine flow). The facility census was 76. The facility did not provide a policy on call lights or indwelling catheter anchors. 1. Review of Resident # 34's Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 6/30/21 showed: [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure recent survey results were available to residents. This affected all residents in the facility. The facility census was 76. The facility did not have a policy regarding the survey book results. Observation on 7/26/21 at 12:10 P.M. showed the survey book only had results from 2019. During an interview on 7/27/21 at 5:00 P.M showed and the Administrator said: -The book only had results from 2019. -He/she thought it was updated. -2020 findings had been pulled and not placed back in the book. During an interview on 7/28/21 at 1:57 P.M the Interim Assistant Director of Nursing (ADON) and ADON said: -The survey book should be updated with all surveys, investigations, and infection control surveys.

Inspectors wroteBased on record review and interviews, The facility failed to ensure restorative nursing services were maintained in accordance with therapy recommendations to maintain or improve and to prevent further decline in mobility and/or range of motion. The facility census was 76. Review of the facility policy titled Restorative Nursing, dated 5/22/08, included the following: - Restorative/rehabilitative programs will be used for residents who have been identified through assessment to have activities of daily living (ADL) deficits that have a reasonable likelihood for improvement or maintenance functional levels; - All residents will have a completed restorative nursing assessments completed within 14 days of admission; - Task analysis worksheets will be completed for deficit areas targeted for a restorative program. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to properly assess and receive physician orders for two residents before utilizing bed rails. This affected two of 18 sampled residents (Residents #58, and #70). The facility census was 76. 1. Review of Resident #58's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/16/21, included the following: - Date admitted [DATE]; - Cognitively intact; - Required extensive assistance with bed mobility, dressing, toilet use. Review of the resident's undated care plan did not show that the use of side rails. Review of the resident's medical records on 6/27/21 showed the following: - Bed rail assessment dated [DATE] indicating the interdisciplinary team found it beneficial for the resident to have bed rails; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing was posted daily. Facility census was 76. The facility did not have a policy for Daily Nurse Staffing. Observation on 07/26/21 at 12:10 P.M. showed the daily nurse staffing posted outside the social services door dated 7/20/21. Observation on 07/27/21 at 07:25 A.M. showed daily nurse staffing sheet still said 7/20/21. Observation and interview on 07/27/21 at 5:00 P.M. showed and the Administrator said: -Daily nurse staffing sheet still said 7/20/21. -He/she thought the daily nurse staffing was posted as required. -Nurse staffing should be posted daily. During an interview on 07/28/21 at 1:57 P.M. the Interim Assistant Director of Nursing (ADON) and ADON said: -The Business Office Manager is responsible for posting the nurse staffing every day. During an interview on 07/28/21 at 4:57 P.M. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents knew they had a choice for an alternative meal before the were served the meal on the main menu. This affected two of 18 sampled resident ( Resident's #34 and #48) and two additional residents (Residents #4 and #12). The facility census was 76. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/2/21, included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on 7/28/21 at 12:32 P.M. the resident said: - Menus were posted at end of the hall; - He/she did not have a menu and they did not typically pass them out but if you ask, nurses can tell you what is on the menu; - If you do not like what they serve then you can get an alternate. [...]