Centennial Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were discharged in a manner that protected health, safety, and psychosocial well-being, as required. The facility failed to develop and implement an effective discharge planning process for 2 residents (#'s 112 and 113) out of 2 residents reviewed for discharge, resulting in an unsafe and inappropriate discharges. Specifically, the facility failed to:1. Identify and address each resident's post-discharge care needs;2. Ensure required services, referrals, and equipment were arranged prior to discharge;3. Assess and confirm caregiver availability, capacity, and training;4. Involve resident representatives in discharge planning and decision-making;5. [...]

Inspectors wroteBased on record review and interview, the facility failed to comply with PASRR Pre-admission Screening and Resident Review - requirements by not incorporating the PASRR Level II determination into the resident's assessment, care planning, and discharge planning for 1 Resident (#113), out of one resident reviewed for PASRR documentation. The PASRR Level II evaluation identified the need for continued nursing facility services and required specialized mental health services. The facility did not ensure the Level II report was available at admission, did not initiate specialized services during the stay, did not revise the care plan to reflect PASRR findings, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, were provided for the treatment of pressure ulcers. Specifically, the facility failed to ensure a resident with a facility acquired pressure ulcer received appropriate treatment interventions, to include timely higher level of care, for 1 Resident (#110), out of 3 residents with pressure ulcers reviewed. These failed practices contributed to Resident #110 being hospitalized with sepsis and passed away from this complication

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a safe, comfortable and homelike environment was provided for all residents (based on a census of 97). Specifically, the facility failed to ensure: 1) the elevator flooring was properly installed; 2) windows were functional to keep wind and cold from entering resident bedrooms; and 3) room temperature level was within 71 degrees Fahrenheit (F) to 81 degrees F. These failed practices denied all residents the right to have a safe and comfortable homelike environment

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1) accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and2) to provide clear instructions on how to file and submit grievances, since grievance forms and admission information did not include submission instructions and the primary posted notice contained incorrect grievance officer information. These failed practices resulted in residents and resident representatives not having reliable access to the grievance process due to inaccurate grievance officer identification and unclear submission instructions, placing residents at risk for delayed reporting and resolution of concerns, creating a facility-wide system failure that limited residents' ability to access and use the grievance process

Inspectors wroteBased on record review and interview, the facility had failed to ensure the activities program was directed by a qualified professional. This failed practice placed all residents (based on a census of 97) at risk of not having an activities program directed by a qualified professional that met their physical, mental, and psychosocial needs

Inspectors wroteBased on record review, interview, and observation the facility failed to ensure sufficient nursing staff to meet residents' needs, (based on a census of 97) as established by the facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs). Specifically:The facility assessment identified minimum staffing requirements for weekends; however, actual staffing schedules showed fewer certified nursing assistants (CNAs), and licensed nurses (LNs) than defined. Residents reported dissatisfaction with care, including delays in call light response times and provision of hygiene. These deficient practices resulted in delays in care and unmet needs for residents and had the potential to negatively impact residents' health, safety, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and maintain a system to ensure licensed nursing staff were competent and practiced within their authorized scope of practice in accordance with the State Nurse Practice Act and professional standards. This deficient practice occurred for 4 of 6 licensed nurses reviewed and placed all residents (based on a census of 97) at risk for inaccurate assessment, inappropriate care planning, and delayed identification of changes in condition FindingsRecord review of Resident Care Manager [RCM] (LVN/LPN[Licensed vocational nurse/licensed practical nurse]) dated 8/2025, revealed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were prepared, stored, and labeled in accordance with professional standards and/or manufacturer instructions for food service safety for 87 residents (#1, #2, #3, #5, #8, #9, #10, #11, #12, #13, #15, #17, #18, #19, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #35, #36, #37, #38, #39, #40, #41, #43, #44, #45, #47, #48, #50, #51, #52, #53, #54, #55, #56, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #69, #70, #71, #73, #74, #75, #76, #77, #78, #79, #80, #82, #83, #84, #85, #87, #88, #89, #90, #92, #94, #95, #96, #97, #102, #103, #104, #105, #106, #107, #108, #109) out of 97 residents that received meals from the kitchen. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. The facility failed to use available data to identify trends, failed to prioritize high-risk issues, and failed to implement and sustain corrective actions. Specifically, the facility failed to identify and/or address ongoing patterns of deficient practice related to staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. [...]

Inspectors wroteBased on record review and interview, the facility failed to review, revise, and implement comprehensive, person-centered care plans in accordance with resident needs. Specifically, the facility failed to:1. ensure residents or resident representatives participated in and that the facility conducted and documented required quarterly interdisciplinary care plan reviews for 3 residents (Residents #1, #3, and #64) of 20 sampled residents; and2. revise the comprehensive care plan to reflect a significant change in condition for 1 closed record (Resident #99), including the addition of appropriate interventions following the onset of a seizure disorder and initiation of anticonvulsant therapy. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an ongoing program of individualized, meaningful activities in accordance with resident assessments and care plans for 3 residents (#12, #27, and #67) of 20 sampled residents. Specifically, the facility failed to consistently offer activities aligned with each resident's identified interests and documented activity goals over extended periods of time, as evidenced by prolonged gaps in activity offerings and participation. This failed practice resulted in residents not being provided opportunities for socialization, engagement, and cognitive stimulation consistent with their assessed needs, placing the affected residents at risk for social isolation, decreased psychosocial well-being, and decline in quality of life

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure treatment and care was provided, based on physician orders and comprehensive person-centered care plans, for 2 residents (#23 and #27), out of 20 sampled residents. This failed practice had the potential to diminish overall health and wellbeing, placing Resident #23 at risk for unrecognized blood pressure instability related to antihypertensive therapy and Resident #27 at risk for impaired skin integrity due to failure to implement ordered offloading and pressure reduction measures

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy services met professional standards of practice and facility policy for the accountability and documentation of controlled substances. Specifically, the facility failed to ensure licensed nursing staff consistently completed required shift to shift narcotic count documentation, as evidenced by repeated missing required signatures in narcotic tracking books over a three-month period. This failed practice resulted in incomplete controlled substance records and compromised accountability for narcotic medications, placing 50 out of 97 residents (census) at risk for medication diversion and administration errors.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 48 and 64), out of 20 sampled residents. Specifically, the facility failed to:1) provide Resident #48 a bed bath at a reasonable time of day;2) maintain Resident #48's dignity and privacy by leaving the catheter urine collection bag uncovered and visible in common areas; and3) maintain Resident #64's dignity and privacy by failing to cover the resident's buttocks while transporting the resident to the resident's room from the shower room through 2 separate courts on 2 separate floors. These failures subjected residents to distressing and undignified care practices and placed them at risk for emotional distress and reduced quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC - an official notice, issued by Medicare-certified healthcare facilities to inform beneficiaries when their coverage will end, with appeal right information) was provided to and signed by the resident's legally authorized Power of Attorney (POA) for 1 Resident (#113), out of 2 discharged residents reviewed. The resident had a documented POA with authority over insurance and government benefit decisions. The facility obtained the resident's signature on the NOMNC but failed to include the POA's signature, did not document review of the notice with the POA, and did not ensure the POA was informed of appeal rights prior to discharge. This failure denied the POA the opportunity to exercise Medicare appeal rights, resulting in the loss of a protected procedural right .

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive, person-centered care plans were developed and implemented to address identified needs for 2 residents (#'s 27 and 111) out of 2 residents reviewed for comprehensive care plans. Specifically, the facility failed to develop and implement dementia-related care plan interventions for Resident #27 and failed to develop and implement fall-risk-specific care plan interventions for Resident #111. These failed practices placed Resident #27 at risk for unmet cognitive and behavioral needs and placed Resident #111 at risk of injury

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident on wander guard elopement precautions received adequate supervision for 1 Resident (#90), out of 2 residents reviewed for wander guard supervision. This failed practice contributed to the resident's ability to leave the facility in a cab, become stranded at a local store, and returned to the facility by entering a stranger's privately owned vehicle, placing him/her at risk for abuse, exploitation, and/or death .

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 residents (#'s 10, 68 and 88), out of 3 residents reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure blood pressure measurements were taken on the appropriate extremity. This failed practice placed the residents at risk for damage to their AV (arteriovenous) fistula (connection made between an artery and vein that is used for dialysis access)

Inspectors wroteBased on record review and interview, the facility failed to ensure continuity of rehabilitative services for 1 resident (#111) reviewed for rehabilitative services. Specifically, the facility failed to ensure physical therapy services were provided as ordered when the facility's physical therapist went on leave. This failed practice resulted in an interruption of ordered rehabilitative services and placed the resident at risk of negative impacts to their functional status and rehabilitation outcomes

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record accurately and completely reflected the resident's current clinical condition for 1 resident (#99) of 3 closed records reviewed. Specifically, the facility failed to update the resident's active diagnosis list and practitioner documentation to include seizure disorder, despite hospital documentation identifying seizure disorder as the primary diagnosis and the continued administration of anticonvulsant medications for that condition following readmission. This failed practice resulted in an incomplete and inaccurate medical record, which placed the resident at risk for inconsistent clinical decision-making, ineffective care coordination, and incomplete communication among caregivers responsible for implementing and monitoring seizure-related treatment and precautions

Inspectors wroteBased on record review and interview, the facility failed to ensure their facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs) was up to date and accurate. This failed practice had the potential to place all residents (based on a census of 97) at risk of not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and medical supplies were properly stored and labeled. Specifically, the facility failed to: 1) remove expired and/or opened medications and supplies from use and 2) maintain emergency medications under safe temperature control. These failed practices had the potential to place all residents (census of 92) at risk of receiving expired and/or compromised medications which may result in reduced efficacy or adverse reaction.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS (Minimum Data Set, a federally required assessment) was accurately coded for venous ulcers for 1 resident (#5), out of 8 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services .

Inspectors wroteBased on record review and interview, the facility failed to ensure provision of necessary care and services were provided in accordance with standards of practice and/or resident care plan for 2 residents (#1 and #3) out of 8 sampled residents. Specifically, the facility failed to ensure escalation of care and interventions that included:1) notifying the physician of a leaking gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) per facility's standard of practice.2) notifying the physician of acute hypotension and altered mental status per facility's standard of practice as established by policies and resident's care plan. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to discontinue a medication order when wound care orders had changed for 1 resident (#5) out of 8 sampled residents. Specifically, the facility continued administering Santyl (prescription enzymatic debriding agent used topically to remove dead tissue from chronic skin ulcers promoting healthy wound healing) ointment after the wound care plan was revised to discontinue its use. This failed practice led to thirteen administrations of a medication that was no longer required and further placed the resident at risk for unnecessary treatment, potential adverse effects, and harm .

Inspectors wroteBased on record review and interview, the facility failed to ensure proper care for invasive devices such as the gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) to prevent the development of infections, for one resident (#1) out of 8 sampled residents. Specifically, the facility failed to implement proper techniques for troubleshooting a leaking G-Tube, including using methods such as rubber bands and soiled tape to secure the tube, failing to clean the site with sanitary technique, and not following standard precautions to manage gastric leakage and prevent contamination. This failed practice placed the resident at risk for skin breakdown and infection, which could have affected their overall health and wellbeing

Inspectors wroteBased on record review and interview, the facility failed to ensure provision of necessary care and services for one resident (#1) out of 20 sampled residents. Specifically, the facility failed to:1) monitor and evaluate the resident's response to the IV fluid bolus ordered on [DATE];2) educate and inform the resident of the risks and benefits after he/she declined vital sign measurements while in a life threatening condition;3) notify the attending provider of the resident's refusal of care, sustained hypotension and continued altered mental status; and4) ensure the resident was transferred to the emergency room for a higher level of care. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure timely reporting of abuse allegations for two residents (#s 8 and 15) out of 20 sampled residents. Specifically, the facility failed to report the allegations of abuse within 2 hours from the occurrence of the incident to the State Survey Agency. This failed practice placed all residents based on a census of 94 at risk for continued potential abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 Facility Reported Incidents (FRI) for residents (#8, #9 and #15) out of 4 FRIs for allegations of abuse were thoroughly investigated. Specifically, the facility failed to provide evidence of the interventions identified in their investigations. This failed practice placed these residents at risk of having injuries or harm that were not adequately addressed and treated.

Inspectors wroteBased on interview and record review, the facility failed to update and revise the care plan for 1 resident (Resident #21) out of 1 resident reviewed for care plan. Specifically, the facility failed to update and revise the care plan to reflect new interventions and/or monitoring to address aggressive or escalating behaviors. This failed practice placed the resident at risk for not receiving appropriate and/or accurate care and services.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 1 resident (#5) out of a census of 94, had supervised access to an unauthorized location in the facility. This failed practice had the potential to place the Resident at risk of injury due to inadequate supervision and the lack of security measures posed the possibility of hazard including the potential for elopement through unsecured exits.

Inspectors wroteBased on record review, interview and observation, the facility failed to protect the resident's right to be free from deprivation of goods and services by facility staff. Specifically, the facility failed to ensure an anticonvulsant medication was available and administered per physician's order for one resident (#1) out of three sampled residents. This failed practice of deprivation of goods and services resulted in Resident #1 not receiving medication causing the resident to endure multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1) provide multiple doses of routine anticonvulsant medication to Resident #1 per physician's order, and 2) provide accurate acquiring, and receiving of medications for one resident (#1) out of three sampled residents. These failed practices resulted in: 1) untimely acquisition and administering of medication for Resident #1; 2) Resident #1 enduring multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization; [...]

Inspectors wroteBased on record review, observation , and interview, the facility failed to ensure one resident (#1) out three sampled residents was free of a significant medication error. Specifically, the facility failed to provide multiple consistent doses of an anticonvulsant medication per physician's order. This failed practice resulted in: 1) a significant medication error due to the omission of administering multiple doses of anticonvulsant medication for Resident #1; 2) Resident #1 enduring multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an incident of multiple missed doses of anticonvulsant medication that resulted in multiple seizure episodes and subsequent hospitalization for one resident (#1) out of three sampled residents was reported to the appropriate officials in accordance with State law, including the facility's Administrator and the State Survey Agency, within timeframes specified by the 42 CFR 483.12(c)(1). Specifically, the facility failed to notify the facility's Administrator and the State Survey Agency immediately, but not later than 2 hours, or not later than 24 hours of the incident. This failed practice had the potential to cause future harm to the resident and a delay of necessary actions.

Inspectors wroteBased on record review and interview, the facility failed to ensure an incident of multiple missed anticonvulsant medications that resulted to multiple seizure episodes and subsequent hospitalization for one resident (#1) out of three sampled residents was thoroughly investigated and the results were reported to the State Survey Agency within 5 working days as specified by the 42 CFR 483.12(c). Specifically, the facility failed to investigate neglectful deprivation of goods and services by facility staff and report results within 5 working days of the incident to the facility's Administrator or his/her designated representative and the State Survey Agency. Additionally, staff interviews, and record reviews and subsequently corrective actions had not been completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication and/or medical supplies in two medication storage rooms (the main medication storage room and in [NAME] Court), out of five medication storage rooms, and two medication carts (located on the Birch Court and [NAME] Court), out of three medication carts, were unexpired. Specifically, the facility failed to discard expired medications and/or medical supplies. These failed practices placed all residents (based on census of 99) at risk for adverse effects or complications from receiving expired medications and/or medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation and food handling practices in the main kitchen; 2) the kitchen was kept in a clean, sanitary condition. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 99.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure electrical equipment was maintained in safe operating conditions. Specifically, the facility failed to ensure: 1) All patient care related electrical equipment (PCREE) had regular, routine preventative maintenance (PM) inspections to ensure they were in safe operating condition; 2) All non-patient care related electrical equipment (N-PCREE) was inspected to ensure it was safe for operation in resident care areas and used in a safe manner; and 3) Space heaters used in non-resident care areas were inspected by maintenance and used in a safe manner. These failed practices placed all residents, based on a census of 99, at risk for: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (#41), out of one resident reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure: 1) blood pressure measurements were taken on the appropriate extremity; 2) medications used to treat blood pressure were administered according to the medical provider's orders; and 3) documented assessments were completed before and after dialysis treatments. This failed practice placed the resident at risk for: [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure two residents out of 22 sampled residents, and one resident out of 6 unsampled residents were provided care in a manner that promoted dignity and respect. Specifically, the facility failed to: 1) provide covering of the urinary catheter bags (a tube inserted through the urinary tract into the bladder, connected to a drainage bag) for 2 residents (#1 and #96); and 2) provide unsampled resident #40 a dignified dining experience. This failed practice placed the residents at risk of poor self-esteem and/or self-worth and a potential for poor quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure self-administration of medication evaluation was completed for three residents (#s 14, 83, and 87) out of three residents reviewed. This failed practice placed the residents at risk of adverse effects of the medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure a homelike environment was maintained in resident rooms for 3 unsampled residents (#s 34, 47, and 251), out of 6 unsampled residents reviewed. This failed practice denied the residents a functional, maintained, and homelike environment.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set - a federally required assessment for long term care residents) accurately represented two residents (#37 and #97) out of 22 sampled residents. This failed practice placed the residents at risk for inadequate care planning and services to achieve their highest practicable and functional well-being.

Inspectors wroteBased on record review, interview, and observation and the facility failed to implement care plans for two residents (#41 and #43) based on a sample of 22 residents. These failed practices placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes.

Inspectors wroteBased on record review, observation, and interview the facility failed to revise care plans to reflect the current level of care and services for two residents (#1 and #18) based on a sample of 22 residents. This failed practice placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes.

Inspectors wroteBased on interview, observation, and record review, the facility failed to communicate effectively with one resident (Resident #12) out of 22 sampled residents. This failed practice had the potential to negatively impact the resident's quality of life and overall activities of daily living (ADL's) due to communication barriers.

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide an ongoing resident-centered activity program for one resident (#43) out of 22 sampled residents. This failed practice placed the resident at risk of boredom, loneliness, and decreased quality of life and enjoyment.

Inspectors wroteBased on record review and interview, the facility failed to: 1) complete a quarterly smoking assessment for one resident (#19) out of one resident who smoked marijuana. Specifically, the facility failed to complete quarterly or annual smoking safety evaluations for Resident #19 since 7/19/23; and 2) maintain accessibility to a crash cart, for immediate use during a life-saving emergency for one resident unit (Spruce Court), out of 6 units reviewed. These failed practices: 1) had the potential for the facility to be unaware of a change in status with regards to the resident's safety while smoking, placing the resident and others at risk of burns and/or fire; and 2) placed all residents of the Spruce Court, based on a census of 16, at risk of potential delay of life-saving measures during an emergency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the drug regimen for one resident (#25), out of 22 sampled residents, was free from unnecessary medication. Specifically, the facility failed to prevent duplicate drug therapy was prescribed. This failed practice placed the resident at risk for potential adverse effects from unnecessary medication administration.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide nutritious food substitutions to accommodate the preferences for one unsampled resident (#40) out of a census of 90 residents who received meals from the kitchen. This failed practice had the potential to decrease nutrition and cause unnecessary weight loss.

Inspectors wroteBased on record review and interview the facility failed to ensure medical records were accurately completed in accordance with accepted professional standards of practice for one resident (#43) out of 22 sampled residents. Specifically, the facility failed to ensure activities staff accurately documented groups, one-on-one (1:1) and self-directed/independent activities as indicated in Resident #43's chart. This failed practice had the potential to affect the achievement of the resident's plan of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was followed for 1 resident (#6), for one record reviewed. Specially, Certified Nursing Assistant (CNA) (#12) failed to follow Resident #6's care plan for activities of daily living (ADLs) and the total number of staff needed for safe bed mobility and toileting. This failed practice resulted in a fall with serious physical injuries from the resident's bed, negatively impacting Resident #6 and potentially declining Resident's physical well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure direct care staff were provided appropriate competencies and skills sets to assure residents who express suicidal ideation (thoughts and/or plans to commit suicide) were safe. Specifically, the facility failed to: 1) provide training for knowledge of how to accurately perform a one-on-one observation; and 2) how to accurately document one-on-one observations for standard accountability. This failed practice placed all residents (based on a census of 96) at risk for improper or inconsistent one-on-one observation which could lead to self-harm, suicide attempt, or completed suicide.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a sufficient system in place for the accurate reconciliation of all controlled medications. This failed practice led to the diversion of controlled medications for approximately a year, without detection.

Inspectors wroteBased on interview and record review, the facility's administration failed to ensure training, competency, and documentation pertaining to behavioral health care was provided effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of residents. This failed practice placed all residents (based on a census of 96) at risk for receiving less than optimal care in a safe environment.

Inspectors wroteBased on record review, and interview, the facility failed to ensure medical records were complete, accurate, and reflected all services provided, for 2 residents (#s 3 and 14), out of two records reviewed. Specifically, the facility failed to: 1) document established one-on-one interventions in the medical record, that were initiated for safety measures due to suicidal ideation (thoughts and/or plans to commit suicide); and 2) document the exact date and time a Physical Therapy evaluation and also document that this evaluation was completed by telehealth appointment. These failed practices: 1) placed all residents (based on a census of 96) at risk of insufficient or inconsistent one-on-one observations, which could have contributed to risk of self-harm, suicide attempt, or completed suicide; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure training for one-on-one observation (a close and consistent observation, in line of sight, of a resident who is an imminent risk of harming self or others) was provided to direct care staff. This failed practice placed all residents (based on a census of 96) at risk for improper or inconsistent observation which could lead to self-harm, harm to others, suicide attempt, or completed suicide.

Inspectors wroteBased on record review and interview, the facility failed to present a Notice of Medicare Non-Coverage (NOMNC) and SNF Advance Beneficiary Notice of Non-Coverage (ABN) prior to the ending of Medicare Part A coverage for 1 resident (#16) and/or their legal representative, out of 6 records reviewed. This failed practice, to meet its obligation to inform the beneficiary of his or her potential financial liability, placed the resident denied the resident the timely opportunity to appeal and placed the resident at risk for financial hardship.

Inspectors wroteBased on record review and interview, the facility failed to ensure a post-discharge plan of care was established for 1 Resident (#9), out of one discharge reviewed. Specifically, the facility failed to ensure: 1) required follow up wound care services were properly arranged; and 2) an adequate supply of discharge medications was provided until the resident was established for medication management post discharge. These failed practices resulted in the resident not receiving needed daily wound care for four days and placed the resident at risk of running out of necessary medications which could have affected the resident's health and wellbeing.

Inspectors wroteBased on interview and observation, the facility failed to ensure satisfying, palatable meal choices were offered and individual resident's food preferences were honored for 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of 21 sampled residents. These failed practices denied the residents, who received meals from the facility's nutrition services, of their preferences and choices and placed the residents at risk for minimal food intake which could result in weight loss and/or poor health outcomes.

Inspectors wroteBased on interview and observation, the facility failed to make reasonable efforts to develop a menu based on resident requests and resident groups. The failure to obtain input had the potential to place 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of a sample of 21, at risk for loss of appetite, lower meal consumption, and a potential for decreased nutritional intake and/or weight loss.

Inspectors wroteBased on interview, observation, and record review, the facility failed to involve residents with menu planning, including alternative menu choices, for 3 residents (#'s 52, 83, and 84), out of 21 sampled residents. These failed practices denied these residents, who received food from the facility's kitchen, the opportunity to make choices that would improve their appetite and food satisfaction.

Inspectors wroteBased on record review and interview, the facility failed to ensure: 1) residents and/or their representatives received a written notice of transfer that contained the reason, place, and address of transfer for 1 resident (#19), out of 6 residents reviewed for hospitalization; and 2) ensure a copy of the residents' discharge notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 99, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication and medical supplies in one medication storage room, out of 4 medication storage rooms, and one medication cart, out of 3 medication carts, were properly labeled and stored. Specifically, the facility failed to: 1) discard expired medication and medical supplies; and 2) ensure the medication refrigerator temperature was within proper temperature controls. These failed practices placed all residents (based on census of 99) at risk of: 1) receiving expired medication and/or supplies; and 2) experiencing potential adverse reactions from medications not stored at proper temperatures.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure food served from the kitchen was palatable and at acceptable temperatures for service 7 residents (#'s 16, 52, 53, 62, 75, 83, and 86), out of 21 sampled residents. This failed practice placed all resident at risk of poor appetite and decreased nutritional intake and/or weight loss.

Inspectors wroteBased on observation and interview, the facility failed to store food and prepare meals under proper sanitary conditions for residents, (based on census of 96), who received food from the kitchen. This failed practice placed residents at risk for foodborne illnesses and communicable disease.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection prevention and control protocols were performed for 13 residents (#'s 12, 19, 30, 31, 45, 48, 59, 68, 75, 81, 85, 90, and 298), out of 99 (census) residents. This failed practice had the potential to increase the development and transmission of communicable disease and infections.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 2 residents (#36 and #81), out of 24 residents observed for dining, were treated in a dignified manner that respected individuality and their care needs. This failed practice placed the residents at risk of feelings of poor self-esteem and/or self-worth and a potential for poor quality of life.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure a comfortable and clean homelike environment. Specifically, the facility failed to: 1) keep personal clothing items safe from loss for 1 resident (#71); and 2) keep the bathroom environment clean and sanitary for 2 residents (#'s 71 and 90), for 1 out of 6 survey days. These failed practices had the potential to cause a diminished self -worth and a reduced sense of well-being.

Inspectors wroteBased on record review and interview, the facility failed to document, investigate, and resolve a grievance for 1 resident (#84), out of 21 sampled residents. This failed practice violated this resident's right to have a grievance investigated and addressed.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the MDS (Minimum Data Set- a federally required assessment for long term care residents) assessment accurately represented residents' status for 3 residents (#'s 38, 83 and 96), out of 21 sampled residents and 4 closed records. This failed practice created a risk for inadequate care planning and inaccurate goals to improve the resident's functional abilities.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address all risk factors to meet 1 resident's (#83) psychosocial needs, out of 21 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was updated for 1 resident (#71), out of 21 sampled residents. Specifically, interventions to increase the resident's desire to attend activities he/she enjoyed were not included in the resident's care plan. This failed practice had the potential to place the resident at risk for not receiving necessary services to improve or maintain his/her quality of life.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the necessary services to maintain good personal hygiene were provided to 2 residents (#'s 16 and 149), out of 21 sampled residents. Specifically, the residents had not been offered or given showers. This failed practice denied the residents from maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure needed care and services were provided to 1 resident (#53), out of 21 sampled residents. Specifically, the resident's dressing changes were not provided according to the physician's orders. The failure to provide ordered dressing changes placed the resident at risk for infection and decreased wound healing.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure necessary services were provided to prevent a pressure ulcer for 1 resident (#73), out of 21 sampled residents. Specifically, skin checks were not documented for the month prior to the resident developing a heel ulceration. This failed practice had the potential to delay necessary treatments to prevent further damage to the resident's skin.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (#35), out of 9 investigated complaints/facility reported incidents, received adequate supervision and assistance to prevent accidents during resident's care. This failed practice resulted in physical injury to the resident and hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 resident's (#83) medical record and develop a trauma-informed care plan, out of 21 sampled residents. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the resident's ability to attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure an annual performance review was completed for 1 Certified Nurse Assistant (CNA) (#1), out of 2 CNA files reviewed. This failed practice failed to monitor the CNA's performance or provide potentially needed feedback/education for any possible sub-optimal care rendered to residents (based on a census of 99).

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure 2 residents (#3 and 81), out of 9 complaints/facility reported incidents investigated, were free from significant medication errors. Specifically, the residents received incorrect medications. This failed practice resulted in hospitalization for one resident and placed another resident at risk for adverse reactions.

Inspectors wroteBased on record review and interview, the facility failed to ensure meals were served according to the resident's therapeutic dietary order for 1 Resident (#298), out of 21 sampled residents. This failed practice had the potential to place the resident at risk for adverse medical complications.