Clearwater Nursing & Rehabilitation Center

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R)14, who the facility identified as at high risk for wandering. On 05/15/2026 at approximately 11:35 AM, R14 exited the unsecured smoking area in the facility parking lot after Certified Nurse Aide (CNA) M turned to assist another resident. At approximately 01:43 PM, Dietary Staff BB went to R14's room to pick up his lunch tray and identified that the resident was not in his room and had not eaten lunch. Dietary Staff BB notified other staff, and they began searching for R14 at 01:45 PM. At approximately 02:04 PM, staff located R14 approximately 0.8 miles from the facility and returned him to the facility without injuries. The weather outside at that time ranged from 82 degrees to 88 degrees Fahrenheit (F). [...]

Inspectors wroteBased on record review and interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on record review and interview, the facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk of impaired care. Findings Include:- The facility's employment records documented eleven nurse aides were employed at the facility for at least one year. The facility's in-service records documented that 5 of those nurses' aides reviewed had not completed the required 12 hours of in-service training in the past year. Certified Nurse Aide (CNA) N, hired 01/29/2024, lacked the required number of in-service hours and in-services based on performance evaluations. CNA O, hired 05/29/2025, lacked the required number of in-service hours and in-services based on performance evaluations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety, and failed to consistently document food temperatures, refrigerator and freezer temperatures, and the dish machine PPM (Parts Per Million-a unit of measure used to indicate the concentration of a chemical sanitizer in the wash or rinse water) sanitizer log.

Inspectors wroteBased on interview, and record review, the facility failed to consistently provide a nourishing evening snack to the 33 residents, who resided in the facility, 11 of whom have diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure their (QAA) Quality Assessment and Assurance Committee adequately identified deficient areas of practice and develop and implement appropriate plans of action to correct the deficient practices for the 68 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Resident (R) 22, with written information regarding the facility's bed hold policy when they were transferred to the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive care plan with instructions to staff on providing surgical wound cares for Resident (R) 46.

Inspectors wroteBased on observation, record review, and interview, the facility failed to apply the standards of practice when staff intentionally documented that they had provided treatments to Resident (R) 39, though they had not actually provided the treatments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to apply the standards of practice as related to dependent edema when staff failed to wrap Resident (R) 39's legs to decrease the edema (swelling resulting from an excessive accumulation of fluid in the body tissue) in his legs as ordered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide infection control practices for Resident (R)16, when staff left her nebulizer mouthpiece (a device that changes liquid medication into a mist easily inhaled into the lungs) on the bed and left her BIPAP (-Bilevel Positive Airway Pressure is a noninvasive ventilation device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) tubing, that was unattached from the oxygen concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen), directly on the floor.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff possessed the skills and competencies required when Licensed Nurse (LN) G failed to prime a Humalog (rapid-acting hormone that lowers the level of glucose in your blood) Kwik Pen (a pre-filled, disposable insulin injection device). prior to administration to Resident (R)19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label Resident (R)6 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired and failed to discard R43's insulin flex pen that had expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to change gloves and wash hands during incontinence care for Resident (R) 42. Staff also failed to store R12's breathing treatment mask and tubing in a sanitary manner.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives of residents.

Inspectors wroteThe facility reported a census of 40 residents. The sample of seven residents included three residents reviewed for social/medically related social services. Based on observation, interview, and record review, the facility failed to provide care in a respectful and dignified manner for a dependent, cognitively impaired Resident (R)7 when staff shaved his beard off.

Inspectors wroteThe facility had a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide supervision, treatment, services, and physical well-being for Resident (R) 2, who had dementia (a progressive mental disorder characterized by failing memory and confusion) with intrusive wandering behaviors by going into R6, R4, R3, and R5's rooms uninvited.

Inspectors wroteThe facility had a census of 40 residents. The sample included three residents reviewed for medications. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 1 who did not receive medications as ordered Additionally, the facility failed to notify the physician of the error.

Inspectors wroteThe facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from physical and sexual abuse. On 05/12/25 Resident (R) 1 admitted to the facility with a history of inappropriate behaviors. On 05/14/25, R1 grabbed and hit cognitively impaired R2 and staff placed R1 on one-to-one until he discharged to a behavioral health hospital on [DATE]. R1 returned to the facility on [DATE], and the facility did not implement interventions for R1 to prevent further resident abuse. On 06/01/25, R1 bit R2's finger, causing it to bleed. R1 went to a behavioral health unit on 06/05/25 and returned to the facility on [DATE]. On 06/21/25, R1 and R2 had an altercation where they slapped each other, and R1 grabbed R2's arm. [...]

Inspectors wroteThe facility reported a census of 47 residents; the sample included 10 residents with three residents sampled for accommodation of preferences. Based on observation, interview, and record review the facility failed to ensure staff acknowledged and implemented Resident (R)6's preferences related to receiving his medications after his meals.

Inspectors wroteThe facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed submit a completed investigation for allegations of resident-to-resident abuse to the State Agency within five working days as required for allegations involving Resident (R) 1 and R2 on 06/21/25 and R1 and R3 on 06/28/25. Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving R1 and R2 in Incident KS00196132 and for R1 and R3 in Incident KS00196270. R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed R1 in the dining room with a female resident [R2]. The noted recorded staff witnessed both residents slapping each other on the arms, R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents. [...]

Inspectors wroteThe facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed to thoroughly investigate allegations of abuse for allegations involving Resident (R) 1 and R2 on 06/21/25 and R1 and R3 on 06/28/25. Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving R1 and R2 in Incident KS00196132 and for R1 and R3 in Incident KS00196270. R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed R1 in the dining room with a female resident [R2]. The noted recorded staff witnessed both residents slapping each other on the arms, R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents. The facility could not provide an investigation related to the 06/21/25 incident. [...]

Inspectors wroteThe facility reported a census of 39 residents. The sample included three residents who required transportation in the facility van. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remain free from accidents when Certified Medication Aide (CMA) R did not utilize the safety belt for R1 before transporting in the facility van. On 12/11/24 at approximately 03:00 PM, Certified Medication Aide R failed to secure dependent R1 in her wheelchair with the wheelchair safety belt in the facility van, prior to transporting. CMA R entered a busy highway with a speed limit of 60 miles per hour (MPH) and had to slam on the brakes to avoid an accident, which caused the resident to slide forward out of her wheelchair onto the floor of the van due to the lack of the seatbelt use. R1 sustained multiple injuries including skin tears and a laceration.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for behaviors and resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse, when Resident (R)22, who had a history of hitting other residents, continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which according to R195, caused pain. On 01/01/23, R22 hit R 196. On 02/06/23, R22, with a closed fist, hit R196 to the back of the head. [...]

Inspectors wroteThe facility reported a census of 43 residents with 15 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required. The facility failed to report two allegations of resident-to-resident abuse, when on 05/12/24 at 04:45 PM, R22, who had a history of hitting others, punched R17 on the left side of R17's jaw. On 05/20/24, R22 raised his closed fist to R2 and made contact with R2's face. Both notes from the electronic records revealed the staff notified management, however niether of the instances were reported to the state agency, as required. [...]

Inspectors wroteThe facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to investigate all allegations of resident-to-resident abuse to protect residents from further incidents of abuse. The facility failed to thoroughly investigate two abuse allegations regarding R22, who had a history of hitting other residents, and continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which caused R195 pain. On 01/01/23, R22 hit R196. On 02/06/23, R22, with a closed fist, hit R196 to the back of the head. [...]

Inspectors wroteThe facility reported a census of 43 residents, with 15 included in the sample. Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when the hot water in four resident rooms and a beauty shop measured at hazardous levels ranging between 138 and 157 degrees Fahrenheit (F). This failure affected six residents (Resident (R) 3, R15, R19, R22, R29, and R30) two of which were cognitively impaired and independently mobile, and any resident who received services in the beauty shop rinse sink. This failure placed the residents in immediate jeopardy to their health and safety and at risk for burns and injury related to hot water exposure. Furthermore, the facility failed to thoroughly document and place effective interventions for each of R24's 12 documented falls since 03/26/24 (approximately 2 months). [...]

Inspectors wroteThe facility census totaled 43 with 15 in the sample and two residents reviewed for pressure injuries. Based on observation, interview, and record review the facility failed to place interventions to prevent pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 30, and R3 who developed preventable, facility acquired, stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure injuries at the facility, and for R26, related to stage 3 pressure injury. The facility further failed to place interventions on the resident's care plans to prevent worsening of the wounds.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment throughout the facility for all residents of the facility, regarding four Residents (R)7, R 26, R 35 and R 145, who had no means to control the temperature of their rooms.

Inspectors wroteThe facility reported a census of 43 residents. Based on interview and record review the facility failed to ensure adequate staffing to meet the needs of the residents of the facility. In 2023 the facility lacked 8-hour Registered Nurse (RN) coverage for 29 days, as reported by the facility. In 2023 the facility lacked 24-hour Licensed Nurse (LN) coverage for 127 days, about 35% of the year. This deficient practice affected all residents in the facility. (See the citations found on current recertification survey to include 4 IJ, harm, and subsequent Substandard Quality of Care.)

Inspectors wroteThe facility reported a census of 43 residents. Based on observations, interviews, and record review the facility failed to ensure 8-hour Registered Nurse coverage each day, as required, in order to meet the needs of the residents. This failure had the potential to negatively affect all residents in the facility and placed them at risk for decreased quality of life, treatment, and care.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all the residents of the facility.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview and record review, the facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid was always closed.

Inspectors wroteThe facility identified a census of 43 residents. Based on observations, record reviews, and interviews the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. This deficient practice placed the residents at risk for decreased quality of care, quality of treatment, and sense of well-being.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report Registered Nurse (RN) coverage on 29 dates between January 1, 2023 and 09/30/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 2 2023 (January 1-March 31) revealed a lack of Registered Nurse (RN) coverage for eight hours every 24 hours on the following dates: [...]

Inspectors wroteThe facility reported a census of 43 residents. Based on the observations, interview, and record review obtained on the current survey IKSC11 and its numerous findings of deficient practice including 5 Immediate Jeopardy citations which constituted Substandard Quality of Care, and with several of the deficient practice areas noted as repeat citations from the prior survey, the facility failed to demonstrate an effective Quality Assurance and Performance Improvement (QAPI) program. This failure affected all 43 residents of the facility and placed them at risk for a decreased quality of life, decreased quality of care, and continued resident to resident abuse. (See all citations associated with IKSC11). Findings Included: [...]

Inspectors wroteThe facility identified a census of 43 residents. Based on interview, observations, and record review, the facility failed to maintain an effective infection control program when laundry services failed to maintain a closed clean linen cart while delivering laundry, and further failed to maintain enhanced barrier precautions (infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) (EBP) when providing cares to a resident with a chronic wound.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to ensure dignity in resident dining when the facility served seven residents their meals in Styrofoam containers, due to a lack of plates, cups, and flatware, for residents who chose to eat in their room.

Inspectors wroteThe facility census totaled 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five sampled residents. Resident (R)1, related to hospice and medications on the Care Area Assessment (CAA), R30 related to accidents not addressed on the CAA, R32, related to dialysis and nutrition not addressed on the CAA, and R39, related to medications not addressed on section N on the MDS. These deficient practices had the potential to lead to uncommunicated need for care and services to meet each individual residents' needs.

Inspectors wrote- Resident (R) 3's Electronic Health Record (EHR) revealed diagnoses that included a pressure ulcer of right heel stage three (full thickness pressure injury extending through the skin into the tissue below), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R3 required maximal assistance with activities of daily living (ADL's lower dressing). Total dependence for transfers and toileting. Partial to moderate assistance with wheelchair mobility, bed mobility, personal hygiene, bathing, and upper body dressing. R3 was incontinent of bowel and bladder. The Quarterly MDS dated 03/29/24, documented a BIMS of 15. No changes in ADL's. [...]

Inspectors wroteThe facility reported a census of 43 residents with 15 residents sampled. Based on observation, interview, and record review, the facility failed to ensure the right of R22's representative to be informed of changes, when the resident had an increase in behaviors and staff placed R22 on one-to-one observation due to his behaviors.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to recognize a significant change in a resident's physical condition and perform a comprehensive Minimum Data Set (MDS) assessment within the required 14-day period. This deficient practice had the potential to lead to uncommunicated needs and placed the resident at risk of further deterioration of his physical, mental, and psychosocial well-being. (Resident (R) 30)

Inspectors wroteThe facility reported a census of 43. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to revise the fall care plan with interventions for three residents. Resident (R)16, R24 and R30. This deficient practice placed all three residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide appropriate and timely Activities of Daily Living (ADLs) for one resident regarding untrimmed facial hair for one Resident (R)17.

Inspectors wroteThe facility totaled 43 residents, with 15 included in the sample, and one resident reviewed for Hospice care. Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards with the failure to coordinate resident care with hospice services.

Inspectors wroteThe facility identified a census of 43 residents, which included 15 residents sampled, and one resident reviewed for Dialysis. Based on interview, observation, and record review, the facility failed to develop a comprehensive person-centered care plan for Resident (R)32's related to hemodialysis (a procedure where impurities or wastes were removed from the blood) the resident received three times a week. This deficient practice had the potential to lead to uncommunicated needs regarding dialysis care which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

Inspectors wroteThe facility reported a census of 43 residents, with 15 residents in the sample, that included one resident reviewed for treatment/services/mental and psychosocial concerns. Based on observation, interview, and record review the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)39, who had a history of personal trauma and a diagnosis of post-traumatic stress disorder. This placed the resident at risk for impaired quality of life due to untreated and ongoing mental health concerns.

Inspectors wroteThe facility census totaled 43 residents with 15 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow up on pharmacy recommendations in a timely manner for one Resident (R)1, regarding as needed lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days, to minimize or prevent adverse consequences related to medication therapy.

Inspectors wroteThe facility census totaled 43 residents with 15 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure two Residents (R) 1, regarding as needed lorazepam (a medication used for severe agitation) and R24, regarding failure to monitor the use of an antipsychotic medication (medication used to treat psychosis).

Inspectors wroteThe facility reported a census of 44 residents, with 12 sampled, and one resident reviewed for nutrition. Based on observation, interview and record review, the facility failed to re-weigh or begin nutritional supplements as recommended by the registered dietician (RD), to prevent further weight loss for Resident (R)16. From 09/02/22 (156.8 lbs.) to 11/01/22 (141.2 lbs.) R16 lost 9.95% of her weight.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, interview, and policy review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility.

Inspectors wroteThe facility reported a census of 44, with 12 residents sampled. Based on observation, interview, and record review the facility failed to verify Resident (R)195's advanced directives (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether or not to withhold medical intervention in the even the resident's heart stops] order)

Inspectors wroteThe facility reported a census of 44 residents. The sample of 12 included two residents sampled for hospitalization. Based on observation, interview and record review, the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long- Term Care Ombudsman as required the two sampled residents, Resident (R)44 and R18 who discharged to the hospital.

Inspectors wroteThe facility reported a census of 44 with 12 residents sampled for review. Based on observation, interview, and record review the facility failed to complete a comprehensive assessment of the resident's functional capacity, within 14 days of admission, for one of the sampled residents Resident (R)145, to ensure the resident received required care assistance by the staff.

Inspectors wroteThe facility reported a census of 44 residents with 12 selected for review. Based on interview and record review the facility failed to develop a baseline care plan within 48 hours of admission to the facility to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for two of the 12 sampled Resident (R) 145 and R195, to ensure person centered cares provided by staff to the residents. Findings Include: - R145's pertinent diagnoses from the Electronic Health Record (EHR) documented: [...]

Inspectors wroteThe facility reported a census of 43 residents with 12 residents included in the sample, and one resident reviewed for discharge. Based on interview and record review the facility failed to document a recapitulation summary of the one sampled resident's stay upon discharge, Resident R 42.

Inspectors wroteThe facility reported a census of 44 residents. The 12 residents selected for review included two reviewed for personal hygiene care needs. Based on observation, interview, and record review the facility failed to provide necessary services to maintain good grooming for the two sampled Residents (R) 145 and R25. Findings Include: - R145's pertinent diagnoses from the Electronic Health Record (EHR) documented: heart failure (a condition with low heart output and the body becomes congested with fluid), Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and seizures (violent involuntary series of contractions of a group of muscles). As of 11/01/22 the staff failed to start the admission Minimum Data Set (MDS) for R145. [...]

Inspectors wroteThe facility reported a census of 44 residents with 12 residents in the sample. Based on observation, interviews, and record review the facility failed to monitor with weekly wound assessments as ordered for one sampled Resident R 18's, decubitus ulcer on the right and left ischial area (a bone that makes up the bottom of the pelvis).

Inspectors wroteThe facility census was 44. The 12 residents sampled included one for smoking safety. Based on observation, interview, and record review, the facility failed to ensure the one sampled Resident (R)32, remained as safe as possible from smoking accident hazards.

Inspectors wroteThe facility reported a census of 44 residents with 12 sampled including one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure oxygen tubing stored in a sanitary manner for the one sampled Resident (R) 145, to prevent respiratory infections.

Inspectors wroteThe facility census totaled 44 residents, with 12 residents sampled, including five for unnecessary medications. Based on interview, and record review the facility failed to ensure adequate follow up on the consultant pharmacist recommendations related to medications for one of the five sampled residents, Resident (R) 26. This failure placed the resident at risk for adverse effects related to medication use.