Champion City Nursing and Rehabilitation Center

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of three residents (Resident R1, R4, and R5).

Inspectors wroteBased on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for three of five residents observed (Resident R1, R2, and R3), and failed to provide a backup tracheostomy tube (a hollow, curved tube inserted directly into the windpipe through a surgical opening in the neck - stoma) for one of two residents with a tracheostomy tube (Resident R2).

Inspectors wroteBased on review of facility policy, resident council grievance documentation, observations, resident and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two out of five floors (Third and Fourth floors).

Inspectors wroteBased on review of facility policy, resident council grievance documentation, pest control documentation, observations, resident and staff interviews it was determined that the facility failed to maintain an effective pest control program for two out of five floors (Third and Fourth floors).

Inspectors wroteBased on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for five of five residents (Resident R6, R7, R8, R9, and R10).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (Resident R4).

Inspectors wroteBased on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from physical restraints for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of resident-to-resident abuse to the local State field office for one of five sampled residents (Resident R2).

Inspectors wroteBased on review of facility documents, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for an allegation of resident-to-resident abuse for one of five residents (Resident R2)

Inspectors wroteBased on review of facility policy, clinical record review, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold for an agreed upon rate during a hospitalization) for one of three residents (Resident R4).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform post-fall documentation of assessment and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of five residents (Residents R3).

Inspectors wroteBased on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluation for one of three records (Nurse aide (NA) Employee E2).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to appropriately document progress notes in the clinical record for one of three residents (Resident R5).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products and maintain proper infection control practices in the main kitchen and dish room which created the potential for cross contamination in the designated main kitchen, dish room. The facility policy entitled Food Preparation and Service dated 10/29/25, indicated Food and nutrition employees prepare, distribute, and serve food in a manner, that complies with safe food handling practices. During an observation of the main designated kitchen on 3/23/26, at 9:45 a.m. the following was observed: [...]

Inspectors wroteBased on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (March 2025, through February 2026)

Inspectors wroteBased on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for three out of three closed resident records (Closed Resident Records CR186, CR187, and CR188).

Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for four of five residents (Residents R13, R16, R37, and R139).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of six residents sampled with facility-initiated transfers (Residents R8, R12, R35, R180 and R184), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of six resident hospital transfers (Residents R12, R35, R180 and R184), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for five of six resident hospital transfers (Residents R12, R35, R168, R180, and R184).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for three of seven residents (Residents R28, R36, and R48).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the residents for three of four residents reviewed (Resident R6, R24, and R147).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform timely and accurate post-fall documentation and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of five residents (Residents R10 and R13), and failed to provide 1:1 supervision during a suicidal ideation for one of two residents (Resident R181). indings include: Review of facility policy Assessing Falls and Their Causes dated 10/29/25, indicated staff are to observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. [...]

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to obtain physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) for three of four residents (Resident R4, R9, and R125), failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for three of four residents (Resident R9, R125, and R180), and failed to ensure that care was provided in a manner which maintained resident dignity for two of four residents (Resident R125, and R180). The facility policy entitled Foley Catheter Insertion, male resident dated 10/29/25, indicated that the physician's order should be verified. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) for one of three residents (Residents R36), and that the facility failed to maintain oxygen equipment for two of three sampled residents (Residents R122 and R157).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of four residents (Resident R171), and failed to ensure that monitoring of residents' access site was completed for three of four residents (Resident R11, R47, and R171).

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for five of five residents (Residents R13, R16, R24, R37, and R139).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in four of five medication carts (Second Floor Medication Cart, Third Floor Medication Cart, Fourth Floor Front Medication Cart, and Sixth Floor Back Medication Cart) and one of three medication rooms (Sixth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of five medication carts (Fifth Floor East Front Medication Cart).

Inspectors wroteBased on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for two of two lunch meal (lunch meal Monday 3/23/26, and Tuesday 3/24/26). The facility policy entitled Food and Nutrition Services dated 10/29/25, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets hir or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Review of facility policy Tray Identification dated 10/29/25, indicated that appropriate identification shall be used to identify various diets. [...]

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarters (April 2025 through June 2025, July 2025 through September 2025, and October 2025 through December 2025).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents (Residents R180), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for nine of twelve months (March, April, May, September, October, November, and December 2025, and January and February 2026), and failed to prevent cross contamination during a dressing change for one of three residents (Resident R2).

Inspectors wroteBased on a review of facility policy, facility provided documentation, and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for seven of 12 months (February 2025, through September 2026).

Inspectors wroteBased on documents and observations and staff interviews it was determined the facility failed to maintain an effective pest control program related to fruit flies in the dish room (Main Kitchen). During an observation on 3/26/26 at approximately 9:35 a.m. in the dish room of the Main Kitchen there were three gold fly sticky traps full of fruit flies. As staff were doing dishes several fruit flies were observed in the area. Review of facility provided documentation included pest-control logs dated from 9/17/25-2/11/26. The following treatments to the kitchen area were provided on the following dates: [...]

Inspectors wroteBased on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R77).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five nursing units (Fifth Floor Nursing Unit).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five floors (Third floor).

Inspectors wroteBased on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for one of five personnel files reviewed (Nurse Aide (NA) Employee E6).

Inspectors wroteBased on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for one of three residents (Residents R9).

Inspectors wroteBased on facility policy, clinical records and staff interviews, it was determined that the facility failed to develop a care plan for one of four residents (Resident R6) to accurately reflect the current status of the resident.

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for two of six resident's reviewed (Resident R4, R159). Review of the clinical record indicated Resident R4 was admitted [DATE]. Review of Resident R4's MDS (minimum data set a periodic review of assessment needs) dated 2/18/26, indicated diagnosis of fracture left femur, chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and dysphasia (difficulty swallowing). Review of Resident R4's Multidisciplinary Care Conference sign in sheet dated 3/12/26, included the following disciplinary: social worker, dietary and activities. Review of clinical record indicated Resident R159 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R169).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Resident R9).

Inspectors wroteBased on observations, and staff interviews it was determined that the facility failed to provide a resident special eating equipment for one of five residents (Resident R35). Based on observations, and staff interviews it was determined that the facility failed to provide a resident special eating equipment for one of five residents (Resident R35). Findings Include: Review of the admission record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident 35 's MDS indicated the diagnosis of anemia (low iron in the blood), high blood pressure and hyperlipidemia (high fat in the blood). Review of Resident R35's physician orders dated 7/4/25 indicated Resident to use scoop dish for all meals. During an observation completed on 3/23/26, at 12:40 p.m. Resident R35 was observed with a regular white plate on his lunch tray. During an interview completed on 3/23/26 at 12: [...]

Inspectors wroteBased on facility policy, observation, and staff interview it was determined that the facility failed to properly contain garbage in two of four outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one, three). The facility policy entitled Food-Related Garbage and Refuse disposal dated 10/29/25, indicated all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. During an observation of the facility's outdoor trash receptacles on 3/23/26, at 9:30 a.m. Dietary Manager Employee E21 confirmed that the lid/covers were not closed on dumpster one and three. During an interview on 3/24/26, at 12:30 p.m. [...]

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for one of five residents (Resident R16).

Inspectors wroteBased on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of misappropriation of resident property in a timely manner to the local State field office for one of five sampled residents (Resident R2).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R1).

Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain professional podiatry services for four of two residents reviewed for skin conditions (Resident R1, R2, R3, and R4).

Inspectors wroteBased on review of facility documents, clinical record reviews and staff interview it was determined that the facility failed to initiate a thorough investigation for injury of unknown origin for one of three residents reviewed (Resident R6).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician s timely wrote, signed, and dated progress notes at each visit for one of four residents reviewed (Resident R4).

Inspectors wroteBased on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for two of four residents reviewed (Resident R2 and R5).

Inspectors wroteBased on staff interview it was determined that the facility failed to provide medical record access for one of seven residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22).

Inspectors wroteBased on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined that the facility failed to protect Resident R3 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R1 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident R2 on February 18, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R1 was found naked on top of Resident R3. (Resident R1, R2 and R3) Findings Include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2/3/25, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents to prevent sexual abuse for 2 of 2 residents (Resident R2 and R3), which created an immediate jeopardy situation for all 152 of 152 residents.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to ensure that residents' comprehensive care plans were reviewed and revised as needed to accurately reflect their current needs and services required by two of three residents sampled (Residents R1, and R2).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on policy, resident and staff interview interviews, and observations it was determined that the facility failed to make certain the grievance policy was posted prominently throughout the facility, failed to include an anonymous place and the address, email and phone number for the grievance officer for 5 of 5 nursing units.

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with facility-initiated transfers (Residents R80, R105 and R124).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for four of 12 residents (Residents R51, R90, R117, and R164).

Inspectors wroteBased on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for five of seven residents (Residents R15, R22, R43, R45, and R50).

Inspectors wroteBased on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to report, implement infection monitoring and management for COVID-19, and test residents timely for respiratory illnesses for two of two residents (Resident R80 and R369) and failed to prevent cross contamination during a medication pass for one of two residents (Resident R37).

Inspectors wroteBased on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to determine the ability to safely self-administer medications for two of six residents reviewed (Resident R143, and R318).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R24).

Inspectors wroteBased on review of facility policies, and clinical records, facility documents, as well as staff interviews, it was determined that the facility failed to ensure documentation was timely entered for a resident after an unwitnessed fall occurred for one of three residents (Resident R24).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of an abnormal Capillary Blood Glucose (CBG) levels for one of four residents reviewed (Resident R134), and failed to appropriately respond to a resident's change in condition for one of four residents (Resident R368).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner and failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of seven (Resident R121) records reviewed.

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined the facility failed to provide appropriate care and services to residents receiving tube feedings for two of five residents reviewed (Residents R121, and R269). Findings Include: Review of facility policy Enteral Nutrition dated 1/15/24, indicated adequate nutrition support through enteral nutrition is provided to residents as ordered. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: - The enteral nutrition product; - The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.); - Administration method (continuous, bolus, intermittent); - Volume and rate of administration; [...]

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen management for one of four residents (Resident R122).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for three of 11 residents reviewed (Resident R23, R45, and R85).

Inspectors wroteBased on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of eleven residents (Resident R23).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 35).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for two of five sampled residents (Resident R35 and R43).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to properly store medical supplies and biologicals in one of five medication carts (5th floor front hall medication cart) and one of three medication rooms (6th floor medication room).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for four of ten months (April 2024, May 2024, June 2024, July 2024).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain an effective call system for 12 of 20 resident restrooms on one of five floors (6th floor).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education for three of five employee files (Nurse Aide (NA) Employees E3, E14, and E15).

Inspectors wroteBased on review of facility documentation and staff interviews it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents personal funds for three of three months (November 2024, December 2024, and January 2025).

Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of seven residents (Resident R1, R7).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for four of seven residents reviewed (Residents R1, R2, R3 and R4). Review of Resident R1's admission record indicated the resident was admitted to the facility 6/18/24, with the diagnoses of dementia(a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), anemia and COPD (chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident R1's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission). [...]

Inspectors wroteBased on pest control service logs, observations, and staff interview it was determined that the facility failed to maintain an effective pest control program for one out of two nurses stations (2nd floor) and two out of three rooms (2nd floor).

Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly monitor food expiration dates on four of five nursing unit food pantries (Third, Fourth, Fifth, and Sixth Floor Nursing Unit Food Pantries), and properly store utensils for food on one of five nursing units (Fourth Floor) creating the potential for food-borne illness.

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86).

Inspectors wroteBased on review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for injuries of unknown origin for one of six residents (Residents R38).

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to post traumatic stress disorder status for one of three residents (Residents R114).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to obtain a physician order and notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for two out of three residents (Resident R119 and R148).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of five residents (Resident R15).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R107) and securely store oxygen for one of two storage locations.

Inspectors wroteBased on review of clinical record review, and staff interviews it was determined that the facility failed to provide a resident with necessary behavioral interventions as ordered to maintain the highest practicable mental and psychosocial well-being for one out of eight sampled resident records (Resident R144).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for four of five resident nursing units (Second floor, third floor, fourth floor, and fifth floor).

Inspectors wroteBased on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to provide tracheostomy (tube surgically placed in the windpipe for breathing) care and services consistent with professional standards of practice for one of four residents (Resident R1).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for 2 of 3 residents (Resident R2 and R3) and failed to have physician orders for care and identification of access sites for two of three residents (Resident R2 and R4).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 53 residents who were identified as high risk for elopement (Resident R1).

Inspectors wroteBased on review of facility financial documents, interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted.