Cedargate Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when two residents (Residents #1 and #2) outside of five sampled residents did not receive a minimum of two showers per week. The facility census was 50. Review of the facility's policy titled, Resident Showers, revised 06/26/26, showed:- It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;- Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Review of the facility Resident Shower List showed:- Resident #1 scheduled for showers two times weekly on Wednesdays and Saturdays; - Resident #2 scheduled for showers two times weekly on Wednesdays and Saturdays. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Food Receiving and Storage, revised 07/2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices, food services or other designated staff will maintain clean food storage areas at all times; -When food is delivered to the facility, it will be inspected for safe transport and quality before being accepted; - Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a cover on the trash containers within the kitchen and failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpsters. This failure had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Garbage and Rubbish Disposal, undated, showed: - All garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use; - Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. 1. Observations of the kitchen on 05/19/25 at 9:36 A.M., and 3:31 P.M., 05/20/25 at 8:27 A.M., 9:44 A.M., and 10:45 A.M., and 05/21/25 at 8:54 A.M., showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 55. Review of the facility's policy titled, Antibiotic Stewardship, revised July 2016, showed: - Antibiotics will be prescribed and administered to the residents under the guidance of the facility's Antibiotic Stewardship Program; - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. Review of the facility's Infection Reports, Antibiotics Binder, showed: - No documentation for 01/01/24 - 12/31/24, February 2025, March 2025, and April 2025; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure at least one person with specialized training in infection prevention and control for the Infection Preventionist (IP - a professional who assures healthcare workers and residents are doing everything possible to prevent infection) was responsible for the duties of the position. This had the potential to affect all residents in the facility. The facility census was 55. Review of the facility's policy titled, Antibiotic Stewardship - Staff and Clinician Training and Roles, last revised July 2016, showed: - The IP will audit and the Director of Nursing (DON) will provide feedback to providers on antibiotic prescribing practices; - The IP will monitor over time and report to the Infection Prevention and Control Committee (IPCC); [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for three residents (Residents #4, #16, and #22), failed to provide an appropriate diagnosis for the use of an antipsychotic (medications used to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for one resident (Resident #4), and failed to limit the use of as needed (PRN) psychotropic medication orders for 14 days for two residents (Residents #4 and #12) out of eight sampled residents and one resident (Resident #30) outside the sample. The facility census was 55. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in proper position and not above the bladder, for two residents (Residents #4 and #7) out of two sampled residents. The facility also failed to properly provide incontinent care for three residents (Residents #5, #22 and #29) out of four sampled residents. The facility census was 55. Review of the facility's policy titled, Catheter Care, revised September 2014, showed: - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Review of the facility's policy titled, Urinary Continence and Incontinence - Assessment and Management, revised September 2010, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) center per facility policy for one resident (Resident #27) out of one sampled resident. The facility's census was 55. Review of the facility's policy, Dialysis Services, undated showed: - This facility is committed to ensuring safe, high-quality dialysis care for residents who require dialysis services; - The goal is to promote positive health outcomes, minimize complications, and ensure resident safety and dignity throughout dialysis treatment; - Resident's receiving dialysis will have an individualized care plan in coordination with the dialysis provider; - The care plan will include access site monitoring; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain infection control with hand hygiene and glove changes during incontinent care for four residents (Residents #4, #5, #7, and #105) out of four sampled residents, urinary catheter care for two residents (Residents #4 and #7) out of two sampled residents, and colostomy (an opening for the colon (large intestine) through the abdomen created by a surgery to allow feces to exit the body) care for one resident (Resident #105) out of one sampled resident. The facility also failed to correctly screen two residents (Residents #19 and #27) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility's census was 55. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 55. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated April 2014, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals; - Establishing a QAPI committee/sub-committee that works in tandem with the facility leadership and the QAA Committee; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 49. The facility did not provide a kitchen policy. Review of the facility's policy titled, Food Preparation and Service, revised 07/2014, showed: - Only pasteurized shell eggs will be cooked and served when residents request undercooked, soft-served or sunny side up eggs and preparing foods that will not be thoroughly cooked example (e.g.) hollandaise sauce, French toast, ice cream, et cetera (etc); - Unpasteurized eggs will be cooked until all parts of the egg (yolk and whites) are completely firm. 1. Observation on 05/07/24 at 8:38 A.M., of the walk-in refrigerator showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower, which put residents at an increased risk of injuries from exposure to the hot water. This practice had the potential to affect all the residents at the facility. The facility census was 49. Review of the facility's policy titled, Safety of Water Temperature, revised 12/2009, showed: - Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F; - Maintenance staff will be responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #6) out of nine sampled residents and one resident (Resident #19) outside the sample, exposed during care. The facility census was 49. Review of the facility's policy titled, Dignity, dated August 2009, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #6's medical record showed: - admission date of 08/30/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 49. The facility did not provide a policy regarding the environment. Observations on 05/07/24 at 8:21 A.M., 05/08/24 at 11:18 A.M., and 05/09/24 at 08:32 A.M., showed water dripped on the floor beside a yellow caution cone beneath a heating ventilation and air conditioning (HVAC) ceiling vent near room [ROOM NUMBER] and the west wing nursing station. Observations on 05/09/24 at 9:12 A.M., 9:33 A.M. and 9:47 A.M., showed: -The east wing men's handicap shower room [ROOM NUMBER] with two 6 inch (in.) diameter piles of fecal material about 1/4 in. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Residents #11 and #45) out of five sampled residents transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Emergency Transfer or Discharge, revised August 2018, showed: - Emergency transfers or discharges may be necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Did not address written notification to the resident or resident's representative. 1. Review of Resident #11's medical record showed: - admission date of 09/21/22; - The resident transferred to the hospital for medical evaluation on 01/11/24, and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #11 and #45) out of five sampled residents. The facility census was 49. Review of the facility's policy titled, Bed Holds and Returns, revised 03/2020, showed prior to transfers, written information will be given to the residents and the resident representatives that explain in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non Medicaid residents), or to hold a bed beyond the state bed hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for three residents (Resident #5, #7 and #18) out of 13 sampled residents. The facility census was 49. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2020, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will include an assessment of the resident's strengths and needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #4) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility failed to provide needed care and services in accordance with professional standards of practice for one resident (Resident #23) out two sampled resident who required positioning due to an impairment. The facility census was 49. The facility did not provide a hospice policy. 1. Review of Resident #4's medical record showed: - admitted to hospice on 02/27/24; - No facility staff signatures for the hospice coordinated plan of care, dated 02/09/24; - The facility failed to provide a complete hospice coordinated plan of care for the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for two residents (Resident #4 and #7) and failed to consistently use a dignity bag for one (Resident #7) out of 2 sampled residents. The facility census was 49. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014 showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; -If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered; - Infection Control, use standard precautions when handling or manipulating the drainage system, be sure the catheter tubing and drainage bag are kept off the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of nasal cannulas when not in use for two residents (Resident #27 and #42) and failed to follow oxygen orders for one resident (Resident #42) out of four sampled residents. The facility census was 49. Review of the facility's policy titled, Oxygen Administration, revised, July 2010, showed: - Verify there is a physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - Assemble the equipment and supplies as needed; - The nasal cannula (plastic tubing placed in the nostrils to provide supplemental oxygen) is a tube that is placed approximately one-half inch into the resident's nose. [...]

Inspectors wroteBased on interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #43) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 49. Review of the facility's policy titled, Trauma-Informed and Culturally Competent Care (TIC), dated 2019, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 32 opportunities with two errors made, for an error rate of 6.25%. This practice affected two residents (Resident #17 and #19) outside of the seven sampled residents. The facility census was 49. Review of facility's policy titled, Insulin Administration, revised 09/2014, showed staff to check the expiration date if drawing from a multi-dose vial. Review of facility's policy titled, Storage of Medications, revised 04/2019 showed nursing staff is responsible for maintaining the medication storage. Review of Novolog (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure opened, multi-use vials were discarded after the opened expiration date. The facility census was 49. Review of the facility's policy titled, Storage of Medications, revised 04/2019 showed the nursing staff is responsible for maintaining the medication storage. Review of Novolog (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. Review of insulin aspart (type of insulin) manufacturer's instructions, revised 02/2023, showed: - Throw away opened vials after 28 days, even if they still have insulin left in them; - Do not use insulin past 28 days after opened. Review of Fiasp (type of insulin) manufacturer's instructions, revised 06/2023, showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper infection control practices during incontinent care for four residents (Resident #4, #5, #6 and #43) out of six sampled residents, catheter care for one resident (#4) out of two sampled residents, and wound care for two residents (Resident #4 and #303) out of three sampled residents. The facility census was 49. The facility did not provide a policy regarding infection control. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub or soap and water for: [...]

Inspectors wroteBased on interview and record review, the facility failed to document pertinent education provided to the residents or the resident's representative regarding benefits, side effects or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for four residents (Residents #6, #23, #43, and #44) out of five sampled residents. The facility's census was 49. The facility did not provided policy regarding the influenza and pneumonia immunizations. 1. Review of Resident #6's medical record showed: - admission date of 08/30/22; - Influenza vaccine administered on 11/20/23; - No documentation the facility provided information and education to the resident or the resident's representative of the influenza vaccine. 2. Review of Resident #23's medical record showed: - admission date of 04/10/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 40. Record review of the facility's Maintenance Service Policy, revised 12/2009, showed: - Maintenance service shall be provided to all areas of the building, grounds and equipment; - The Maintenance Department will be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Functions of the maintenance personnel include maintaining the building in good repair and maintaining the building in compliance with the regulations; - The Maintenance Director will be responsible for maintaining the work order requests. Observation on 11/18/22 at 8:45 A.M., of the Men's shower room showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in five occupied resident room sinks and a community shower, which put residents at an increased risk of injuries from exposure to the hot water. The facility also failed to ensure residents were transferred by staff with safe transfer techniques for one resident (Resident #4) out of two sampled residents, and one resident (Resident #10) outside of the sample. This practice had the potential to affect all the residents at the facility. The facility census was 40. Record review of the Safety of Water Temperatures policy, revised 12/2009, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of dependent residents by failing to keep the call lights within reach for two residents (Resident #8 and #36) out of 12 sampled residents. The facility census was 40. Record review of the facility's Call Lights policy, dated 5/2013, showed: - Each resident will have a readily accessible means to obtain needed assistance; - Each resident will be provided with a call light; - Call lights will be kept within reach of residents. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 8/3/22, showed: - Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for one resident (Resident #4) out of one sampled resident. The facility census was 40. Record review of Resident #4's medical record showed: - Diagnoses of intellectual disability, schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), bipolar disorder (a mental disorder that causes unusual shifts in mood), and difficulty walking; -Severely impaired cognitive status; - A Physical Restraint Assessment, dated 12/20/21, with benefits outweighing the risks for the use of the merry walker (an enclosed framed wheeled walker). The staff will reevaluate quarterly and as needed; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete a comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframes for one resident (Resident #27) out of 12 sampled residents and one resident (Resident #28) outside the sample. The facility's census was 40. 1. Record review of Resident #27's MDS records showed: - admission to the facility on 9/5/20; - An annual MDS, dated [DATE]; - An annual MDS, dated [DATE], with a completion date of 9/28/22, and a submission date of 11/17/22; - The facility did not complete an annual MDS for the resident within 12 months of the last comprehensive MDS. 2. Record review of Resident #28's MDS records showed: - admission to the facility on [DATE]; - An annual MDS, dated [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, within 14 days of a discharge from hospice for one resident (Resident #22) out of three sampled residents. The facility census was 40. 1. Record review of Resident #22's medical record showed: - discharged from hospice on 4/7/22. Record review of the resident's MDS records showed: - No significant change MDS dated on or after 4/7/22; - The facility failed to complete a significant change MDS within 14 days of the resident's discharge from hospice. During a phone interview on 11/18/22 at 1:05 P.M., the MDS Coordinator said a significant change MDS should be completed within 14 days of a resident's discharge from hospice services. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for five residents (Resident #13, #21, #29, #30 and #35) outside the 12 sampled residents. The facility's census was 40. 1. Record review of Resident #13's MDS records showed: - admission to the facility on 4/21/20; - A quarterly MDS, dated [DATE]; - An incomplete quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 2. Record review of Resident #21's MDS records showed: - admission to the facility on 6/8/19; - A quarterly MDS, dated [DATE]; - An incomplete quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Data Set assessments (MDS), a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for four residents (Resident #21, #29, #30, and #35) outside of the 12 sampled residents. The facility's census was 40. 1. Record review of Resident #21's medical record showed: - A quarterly MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, dated [DATE], completed 10/23/22, and not submitted; - The facility failed to submit the resident's quarterly MDS, dated [DATE], within 14 days of the completion date. 2. Record review of Resident # 29's medical record showed: - A significant change MDS, dated [DATE], completed and submitted; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan (the initial plan for delivery of care and services) included specific interventions and the resident and/or representative received a written summary of the baseline care plan for one resident (Resident #196) out of one sampled resident. The facility census was 40. Record review of the facility's Care Plans - Preliminary policy, revised 8/2006, showed: - A preliminary plan of care to meet the resident's immediate needs should be developed for each resident within 24 hours of admission; - The interdisciplinary team (team members from different disciplines working together) will review the attending physician's orders and implement a nursing care plan to meet the resident's immediate care needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to include the residents and/or the representatives during care plan meetings for five residents (Resident #4, #8, #22, #33, #36) out of 12 sampled residents. The facility also failed to ensure the care plan showed the most current Activities of Daily Living (ADL) requirement for one (Resident #4) out of 12 sampled residents. The facility census was 40. Record review of the facility's Care Plans - Comprehensive, revised 9/2010, showed: - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs will be developed for each resident; [...]

Inspectors wroteBased on observation and record review, the facility failed to coordinate a plan of care with hospice (supportive comfort care to people in the final phase of a terminal illness) for one resident (Resident #196) out of two sampled residents. The facility census was 40. 1. Record review of Resident #196's medical record showed: - admitted to the facility on [DATE]; - Diagnosis of chronic respiratory failure; - admitted to hospice on 7/1/21, prior to the admission to the facility; - No documentation of a hospice coordinated plan of care to identify the specific hospice staff, the specific days for the hospice staff visits, any wound care services, any treatments with the responsible provider and the frequency provided, any medical supplies provided by the hospice, any medical equipment provided by the hospice, and communication between the facility and hospice staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for supplemental oxygen therapy for one resident (Resident #196) out of three sampled residents. The facility census was 40. Record review of the facility's Oxygen Administration policy, undated, showed: - Verify the physician's order for oxygen therapy; - Review the physician's orders or the facility protocol for oxygen administration; - Document the rate of the oxygen flow, route and rationale. 1. Record review of Resident #196's medical record showed: - admitted to the facility on [DATE]; - Diagnosis of chronic respiratory failure; - admitted to hospice on 7/1/21, prior to the admission to the facility; - An order for oxygen at 2 liters/min (L/min) via nasal cannula (NC) (supplemental oxygen through tubing into the nostrils) continuously, dated 11/14/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to document accurate immunization status, provide information and education to each resident or the resident's representative of the pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for five residents (Residents #6, #8, #26, and #39), and failed to provide and document the pneumococcal vaccinations for one resident (Resident #22) out of five sampled residents. The facility's census was 40. Record review of the facility's Pneumoccoccal Vaccine policy, revised 10/2014, showed: - All residents will be offered pneumococcal vaccines to aid in the prevention of pneumonia/pneumococcal infections; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide the required annual competency of Dementia Care, (care of a resident with an impaired ability to remember, think, or make decisions). This effected two out of two sampled certified nurse aides (CNA) (CNA G and CNA L) and had the potential to effect all staff and residents. The facility's census was 40. Record review of the facility's Nurse Aide In-service Training Program, revised September 2011, showed: - All personnel required to attend regularly scheduled in-service training classes; - The facility will complete a performance review of the nurse aides at least every 12 months; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the complete information in their grievance policy including how to file a grievance, who to contact along with the contact information. The facility also failed to follow their grievance policy by not making the information on how to file a grievance or complaint visible and available to all residents residing in the facility. This had the potential to affect all residents of the facility. The facility census was 40. Record review of the facility's Filing Grievances/Complaints policy, revised 4/2008, showed: - The facility will help residents, their representatives, other interested family members, or resident advocates file grievances or complaints when requests made; [...]