Colonial Heights Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, clinical record review and facility document review, the facility staff failed to ensure the resident's right to be free from abuse for 2 residents (R111 and R 110) in a survey sample of 18 residents. For R111 the facility staff failed to protect R111 from physical assault by R 118. Resident 111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to acute respiratory failure, anxiety disorder, anemia, underweight, poisoning by unspecified medications and biological substance, hypotension (low blood pressure), psychoactive substance dependence with psychoactive substance induced persisting dementia, seizures, anoxic brain damage, cognitive communication deficit. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to have five medications available for administration for one resident (Resident #8-R8) in a survey sample of ten residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy with regards to allegations of abuse involving one resident (Resident #1-R1) in a sample of ten residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to report incidents/allegations of abuse to the required agencies involving one resident (Resident #1-R1) in a survey sample of ten residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to administer medications in accordance with physician orders and failed to notify the doctor when medications were not available for administration affecting one resident (Resident #8-R8) in a survey sample of ten residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct post fall assessment and monitoring following a fall with a head injury for one resident (Resident #9-R9) in a survey sample of ten residents.

Inspectors wroteBased on medical record reviews and staff interviews the facility failed to ensure residents received adequate supervision for two (2) of 17 Residents (Resident's #102 and #103) in the survey sample. The findings Included: 1. Resident #102, the facility failed to maintain 1:1 supervision for a resident performing unwelcome sexual advances on a cognitive impaired residents. Resident #102 was admitted to the facility on [DATE] with diagnosis of Dementia, Severe with other Behavioral Disturbance, Psychotic Disorder with delusions due to known physiological condition, Depressive Disorder, Hypertensive Heart, and chronic kidney disease. Resident #102 Minimum Data Set (MDS) dated [DATE] coded the resident as having short and long term memory problems. Resident was coded for being short tempered, easily annoyed 7 to 11 days during the MDS timeline for this assessment. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to report allegations of physical abuse but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for one (1) of 17 residents in the survey sample, Resident #114.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure a resident received physician ordered treatment to promote healing and prevent infection for one (1) of 17 residents in the survey sample (Resident #101).

Inspectors wroteBased on staff interview, facility document review and clinical review, it was determined the facility staff failed to provide supervision and to implement safety procedures to prevent injuries for five (5) of 33 residents in the survey sample, Resident #1, #27, #8, #24, and #2. For Resident #1, the facility staff failed to ensure a resident was transferred in a manner to prevent a fracture of the distal fibula (lower end, near the ankle, of the small bone in the lower leg) that resulted in harm.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain adequate staffing to consistently meet the needs of the residents on three of three facility units.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to maintain three of three dumpsters in a sanitary manner.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to accommodate resident needs for four(4) of 33 residents in the survey sample, Resident #8, #19, #5 and #12.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the requirements for a resident room change for four (4) of 33 residents in the survey sample, Resident #25 (R25), R26, R27, and R28.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician and/or responsible party of a change in condition for four of 33 residents in the survey sample, Resident #8, #16, #1 and #4.

Inspectors wroteBased on observations, interviews and clinical record reviews, the facility staff failed to ensure a clean comfortable homelike environment on two of three facility units, [NAME] and [NAME].

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility failed to protect four (4) of 33 residents in the survey sample from resident-to-resident abuse, Residents #33, #30, #18 and #9.

Inspectors wrote2. For Resident #33 (R33), the facility staff failed to implement their abuse policy to ensure R33 was free of abuse from Resident #9 (R9) and complete and thorough investigation of a resident-to-resident altercation on 8/14/24. On R33's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 9/21/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The prior MDS with an ARD of 6/21/24 documented a score of 15 out of 15 on the BIMS assessment also. Review of a facility synopsis of events dated 8/14/24 for R33 documented a resident-to-resident incident between R33 and Resident #9 (R9). It documented in part, Residents observed in activity event and had an incident. Residents immediately separated . [...]

Inspectors wrote8. For Resident #5 (R5), the facility staff failed to implement the comprehensive care plan to administer medications as ordered. The comprehensive care plan for R5 documented in part, - Antipsychotics: the resident is at risk for adverse reactions related to the use of antipsychotics secondary to diagnosis of schizophrenia. Created on: 09/26/2023. Revision on: 01/23/2024. Under Interventions it documented in part, administer medications as ordered. Date Initiated: 09/26/2023. Created on: 09/26/2023. Revision on: 01/23/2024 . - Medications: the resident is at risk for complications related to psychoactive medication use secondary to diagnoses of insomnia. Created on: 10/04/2023. Revision on: 05/02/2024. Under Interventions it documented in part, administer medications as ordered. Date Initiated: 10/04/2023. Created on: 10/04/2023. Revision on: 05/02/2024 . - Anticoagulant: [...]

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for four (4) of 33 residents in the survey sample, Residents #1, #23, #5 and #3.

Inspectors wrote2. For Resident #21 (R21), the facility staff failed to provide showers at least twice a week per the resident's preferences. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/18/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section GG documented R21 requiring substantial to maximal assistance with showering/bathing. On 12/20/24 at 10:36 a.m., an interview was conducted with R21 in their room. R21 stated that they had only had about three showers since their admission. She stated that on admission she was wearing a neck brace and was not allowed to take it off until the doctor cleared her later in October. R21 stated that getting a shower was like pulling teeth in the facility. [...]

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services per the physician orders for five of 33 residents in the survey sample, Residents #1, #4, #23, #21, and #16.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for pressure injuries for four of 33 residents in the survey sample, Residents #1, #17, #13 and #14.

Inspectors wroteBased on employee record review, staff interview and facility document review, it was determined that the facility staff failed to ensure that four out of 10 CNA (certified nursing assistant) records reviewed evidenced training that included the required abuse and neglect, dementia, resident rights, infection control, communication, and/or behavioral health.

Inspectors wroteBased on staff interview, and clinical record review, and facility document review, it was determined that facility staff failed to obtain physician ordered laboratory tests for two of 33 residents in the survey sample, Residents #16 (R16) and R4.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve palatable food for one of three facility units, [NAME] Unit.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to act upon a reported grievance in a timely manner, for two (2) of 33 residents in the survey sample, Resident #21 and Resident #5.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report an injury of unknown origin for one (1) of 33 residents (Resident #8) in the survey sample.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to fully investigate an allegation of abuse and/or injury of unknown origin for three (3) of 33 residents, Resident #33, #8 and #1.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a feeding tube for one of 33 residents in the survey sample, Resident #13.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to store a nebulizer mouthpiece in a sanitary manner for one of 33 residents in the survey sample, Resident #11.

Inspectors wroteBased on resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program for one (1) of 33 residents in the survey sample, Resident #21.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure medications were available for administration for three (3) of 33 residents in the survey sample, Residents #1, #4, and #21.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for three (3) of 33 residents in the survey sample, Residents #1, #4 and #13.

Inspectors wroteBased on observations, staff and resident interviews, clinical record reviews, and facility documentation, the facility staff failed to ensure the facility was free of pests.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow standards of practice affecting 7 residents (Resident # 4, #12. #14, # 2, #21, #18, & #9 ) in a survey sample of 23 residents.

Inspectors wroteBased on staff interview, facility document review, clinical record review, the facility staff failed to ensure incontinence care was provided timely for 1 resident (Resident # 12) in a survey sample of 24 residents. The Findings Included: For Resident #12, the facility staff did not provide timely incontinence care. For Resident # 12, the facility staff failed to identify a severe yeast rash on the buttocks and thigh that was identified by the nurse practitioner and failed to provide incontinence care to meet the needs of Resident # 12. Resident # 12 was admitted to the facility on [DATE] with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), Diabetes, Hypertension, Pulmonary Embolism, and VRE (Vancomycin Resistant Enterococcus) of urine. Resident # 12 was discharged to home with family on 7/26/2024. [...]

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure three Residents (Resident #14, #4 and #21) of 23 residents in the survey sample were free of significant medication errors.

Inspectors wroteBased on staff interview, facility documentation, and clinical record review, the facility staff failed to obtain laboratory specimens as ordered and notify the physician of the delay in obtaining the specimens for 1 Resident (#9) in a survey sample of 23 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to consult with the resident's physician, and notify, the resident representative when there is a change in physical, mental or psychosocial status for 1 Resident (#20) in a survey sample of 23 Residents.

Inspectors wroteBased on interview, clinical record review, and facility documentation, the facility staff failed to implement the abuse policy for 1 Resident, (#20), in a survey sample of 23 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete a 48-hour baseline Care Plan for one Resident (Resident #18) in a survey sample of 23 Residents.

Inspectors wroteBased on Resident interviews, staff interviews, and facility documentation review, the facility staff failed to act promptly to Resident grievances in July 2022 and August 2022.

Inspectors wroteBased on observations, staff interviews and facility documentation review, the facility staff failed to ensure that expired medications were discarded on one of two medication carts on the [NAME] unit, and in one of three medication storage rooms, the [NAME] unit medication room.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in accordance with professional standards for food service safety in one of one kitchen inspected.

Inspectors wroteBased on observations, Resident interview, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain an effective pest control program to mitigate the presence of pests on for one of 55 residents in the survey sample, Resident #195; and in three out of three units of the facility in October 2022.

Inspectors wroteBased on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to communicate the Resident's choice for advanced directives for one Resident (Resident #396) in a sample size of 55 Residents.

Inspectors wroteBased on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure an accurate MDS (minimum data set)/RAI (resident assessment instrument) was completed for two residents (Residents #142 and #152) in a survey sample of 55 residents.

Inspectors wroteBased on interview, facility record review and facility documentation, the facility staff failed to ensure Preadmission Screening and Resident Review (PASARR) was completed prior to admission to the facility for one Resident (#53) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to follow the nursing standard of practice for two Residents (Resident #21 and 117) in a survey sample of 55 Residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to assist Residents who were dependent upon staff for ADL (activities of daily living) assistance, affecting 3 Residents (Residents #82, 163, and 53) in a survey sample of 55 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to administer a medication per a physician's order for one of 55 residents in the survey sample, Resident #99.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement interventions to prevent and treat pressure ulcers for one Resident (Resident #152) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide adequate supervision to prevent accidents and hazards for one Resident (#78) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to administer oxygen in a manner to prevent the spread of infection for three Residents (Residents # 179, # 105 and # 28) in a survey sample of 55 Residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to use the services of a registered nurse for one day (01/08/2022) out of the 6 days reviewed.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed for one resident (Resident # 21) of 55 residents in the survey sample to ensure medications were available for administration.

Inspectors wroteBased on Resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure one Resident (Resident #38) was free of significant medication errors, in a survey sample of 55 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunizations for 2 residents in a survey sample of 5 residents reviewed for pneumococcal vaccination.

Inspectors wrote2. Resident #78 had two episodes of impaction without timely treatment, resulting in nausea and vomiting and admissions to the hospital. Resident #78, was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses included; stroke, anxiety, history of small bowel obstruction and hypothyroidism. Resident #78's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-8-19 was coded as a significant change in status assessment. Resident #78 was coded as having no memory deficits, did not refuse care, and was able to make own daily life decisions. The Resident was also coded as needing extensive assistance of one to staff members to perform his activities of daily living, except for independent locomotion, both on and off the units. On 2/20/19 at 1:30 PM: An interview was conducted with Resident #78. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation the facility failed to ensure Residents were free from accidents and hazards for 2 Residents (#212 and #72) in a survey sample of 59 Residents resulting in harm for Resident #212. 1. For Resident #212 the facility failed to adequately supervise and monitor closely for pulling at dialysis port resulting in Resident pulling off the caps of the port and subsequently bleeding out which resulted in death. This is harm. 2. For Resident #72, the facility staff failed to follow physician's orders for No straws associated with aspiration risk. Resident #72 was observed drinking water at bedside, unsupervised, through a straw. Also, the discharge diet recommendation from occupational therapy dated 11/26/2018 included supervision.

Inspectors wroteBased on staff interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility staff failed to implement their abuse/neglect policies for 1 Resident (Resident #210) in a survey sample of 59 residents. The facility failed to verify if disciplinary action in effect against professional license before hire for 6 of 25 employees and failed to provide training/orientation programs that include topics such as abuse prevention for 6 of 7 employees. 1. For Resident #210, the facility staff failed to report an allegation of neglect. The allegation of neglect was bought to the attention of the facility staff by a family member of the Resident, who filed a grievance with them on 11-22-18. It was never reported to the State Agency, and the investigation was not timely, taking at least 12 days. 2a. [...]

Inspectors wroteBased on staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of practice for medication and treatment administration for 4 Residents (Residents #49, #115, #510, and #211) in a survey sample of 59 Residents. 1. For Resident #49, the facility staff failed to ensure medications were documented as having been administered. 2. For Resident # 115, the facility staff failed to remain with the resident during administration of nebulizer treatments. 3. For Resident #510, the facility staff failed to obtain an Arterial Brachial Index (ABI), and to clarify the frequency of dosing for prednisone medication, which were ordered by a physician. 4. For Resident #211, the facility staff failed to obtain a physician's order for treatment of a skin tear.

Inspectors wroteBased on staff interview and facility documentation the facility failed to ensure staff have the appropriate competencies and skills sets for 6 of 7 employees, (CNA's B, I, K, M, N AND P). CNA B, CNA I, CNA K, CNA M, CNA N, and CNA P were found to have abuse training and other training on dates that they didn't work or were coded as having more inservice hours than they actually worked on the day of the inservice.

Inspectors wroteBased on observations, staff interview, and clinical record review, the facility staff failed to maintain respect and dignity for two residents (Resident #87, Resident #29) in a sample size of 59 residents.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review the facility staff failed for 1 resident (Resident #115) of 59 residents in the survey sample to ensure the resident had been assessed to self administer medications. 1) For Resident # 115, the facility staff failed to remain with the resident during administration of nebulizer treatment and failed to assess the resident to determine if self administration of medication was clinically appropriate and safe. 2) For Resident #510, the facility staff failed to provide supervision and oversight of medication administration during a nebulizer treatment and failed to assess the resident to determine if self administration of medication was clinically appropriate and safe. 3. [...]

Inspectors wroteBased on observation, resident and staff interview, facility documentation and clinical record review, the facility failed to, for one resident (Resident #78), in a survey sample of 59 residents, to allow the resident to choose his own preferred activities. Resident #78 stated the facility would not let him go outside in his wheel chair.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation, the facility staff failed to report to the state agency allegations of abuse or neglect for two residents (Resident #72, #210) in a sample size of 59 residents. 1. For Resident #72, the facility staff failed to report resident-to-resident altercation to the state agency. 2. For Resident #210, the facility staff failed to report an allegation of neglect. The allegation of neglect was bought to the attention of the facility staff by a family member of the Resident, who filed a grievance with them on 11-22-18. It was never reported to the State Agency, and the investigation was not timely, taking at least 12 days.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an accurate MDS (minimum data set) RAI (Resident Assessment Instrument) for one Resident (Resident #210) in a survey sample of 59 Residents. For Resident #210, the facility staff failed to accurately code her falls prior to admission in Section J-B, and weight loss in Section K-0300.

Inspectors wroteBased on staff interview, facility documentation and clinical record review and in the course of a complaint investigation the facility failed ensure they had (Pre admission Screening And Resident Review) PASARR screening prior to admission for 2 Residents (#69 & #212) in a survey sample of 59 Residents. 1. For Resident #212 the facility failed to ensure Resident had PASARR Screening prior to admission. 2. For Resident #69 the facility failed to ensure the Resident had PASARR Screening prior to admission.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation the facility failed to review and revise care plans for 2 Residents (#212 and #69) in a sample size of 59 residents. 1. For Resident # 212 the facility failed to develop and implement a care plan that addressed the behaviors of pulling at dialysis port and uncapping dialysis ports. 2. For Resident #69 the facility did not update care plan to add Resident is on thickened liquids and only family may give water / thin liquids.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to, for one resident (Resident 143) in a survey sample of 59 residents, to ensure wound care was provided in a manner to prevent infection. The wound care nurse did not clean her hands between moving from the sacrum to the heel.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide services to provide a left hand roll as ordered by physician to prevent reduction in range of motion for one resident (Resident #29) in a sample size of 59 residents.

Inspectors wroteBased on Resident interview, staff interview, clinical record review and facility documentation the facility failed ensure adequate pain management for 1 Resident (Resident # 151) in a survey sample of 59 Residents. For Resident #151, the facility failed to address the pain she was experiencing in her mouth and face, in spite of her complaining to facility staff and her Psychiatric Nurse Practitioner (NP).

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration for one Resident (Resident # 131) in a survey sample of 59 residents. Resident #131 was readmitted to the facility from the hospital on 1/22/2019 for treatment of Infection of PEG (Percutaneous Endoscopic Gastrostomy) tube and Urosepsis. The potassium reducing medication, Kayexalate, was unavailable from the pharmacy on 2/22/2019. Another potassium reducing medication, Veltassa, was ordered. Veltassa was not available until 2/25/2019 until 3:30 PM.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation and clinical record review the facility failed to ensure Residents were free from unnecessary psychotropic medications for 3 Residents (#120, #25 and # 212) in a survey sample of 59 Residents. 1. Resident #120's antipsychotic medication (Risperdal) had no GDR (gradual dose reduction), excessive doses; Resident #120 had a diagnosis of dementia (no psychotic disorders). 2. Resident #25 has been on the same dosage of Zyprexa (antipsychotic) since 11-22-17 for mood disorder. She has a diagnosis of dementia with no behaviors warranting the use of an antipsychotic. 3. For Resident # 212 the facility failed to ensure Resident had proper diagnosis for administration of Zyprexa (anti-psychotic medication) and no gradual dose reduction attempted.

Inspectors wroteBased on facility documentation review and clinical record review the facility staff failed to ensure residents are free of significant medication errors for 2 of 59 residents. 1. For resident # 510 the facility failed to provide insulin as per physician's orders on 4 occasions. 2. For Resident # 131, the facility staff failed to obtain medication prescribed to treat too much potassium in the body.

Inspectors wrote2. LPN A failed to lock and secure her assigned medication cart during the course of medication administration. On 04/10/2019 at approximately 11:05 AM, while performing the Medication Administration Task, LPN A was observed leaving her medication cart unlocked and unsecured in the common hallway on Unit 1, between rooms [ROOM NUMBERS], and entered room [ROOM NUMBER] to administer medications to Resident #103. When asked how the medication cart should be left while administering meds, she replied It should be locked when I am away from it. On 04/10/2019 at approximately 11:40 AM, the Unit Manager (RN A) verified that LPN A was the only staff member assigned to medication administration for the current shift on Unit 1 and was responsible for 2 out of 2 medication carts located on Unit 1. [...]

Inspectors wroteBased on Resident interview, staff interview, clinical record review and facility documentation the facility failed to provide dental care to 1 Resident (Resident # 151) in a survey sample of 59 Residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to administer medications in a manner to prevent the spread of infection for 1 resident (Resident #103) in a sample size of 11 residents. For Resident #103, LPN A failed to wash her hands prior to putting on non-sterile gloves in preparation for the administration of his eye drops.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility failed for one resident (Resident #40) in a survey sample of 59 residents, to maintain equipment in a safe operating condition. Resident #40's wheel chair pedals were padded with towels and duct tape.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to assess and implement interventions to prevent an unstageable pressure wound resulting in harm for Resident #5. This is a past non-compliance citation (PNC). The facility staff failed to monitor and assess Resident #5 resulting in the development of an unstageable pressure wound on her sacrum.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to prepare and distribute food in a sanitary manner from the main kitchen. Ten large baking pans, identified as ready for use, were stored nested and wet.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed, for 1 resident (Resident #13) in the survey sample of 24 residents, to ensure that Resident #13 was free of a physical restraint. The facility staff failed to ensure that Resident #13 was free of being restrained by a bed sheet tied around a Geri-chair.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow the professional standards of practice for documentation of medication administration for 1 resident (Resident #8) in the survey sample of 24 residents. For Resident #8, the facility staff failed to document the administration of a dietary supplement on two occasions in August, 2017.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide the highest practicable well-being for Resident #7. The facility staff failed to assure that physician ordered blood glucose testing was performed and documented, and insulin given, if necessary, for Resident #7.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure tubing for a urinary catheter was anchored for one of 24 residents in the survey sample. The tubing for Resident #4's urinary catheter was not anchored to minimize tension on the tubing as required in her plan of care.

Inspectors wroteBased on observation, Family and Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, facility staff failed to employ sufficient support staff to provide timely serving of meals and feeding assistance for 1 resident (Resident #9) in the survey sample of 24 residents. Facility staff failed to provide delivery of the Lunch meal tray and feeding assistance in a timely manner for Resident #9.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to ensure biologicals and medications were stored appropriately on three of three units. 1. On The [NAME] Unit , one PPD (purified protein derivative) dated as opened [DATE] was available for administration to Residents. A second vial was opened with no date when opened. PPD is only good for 30 days after opened and accessed; 2. On the [NAME] Unit, a vial of flu vaccine was opened without a date. 3. On the [NAME] unit, two vials of flu vaccine was open without a date.