Columbia Crest Center

Inspectors wroteBased on interview and record review, the facility failed to ensure wound care practices were maintained in accordance with professional standards of nursing practice for 1 of 2 residents (Resident 1) reviewed for wound care. This deficient practice placed residents at risk of receiving inadequate wound care, delays in healing or potential worsening of wounds.

Inspectors wroteBased on interview and record review the facility failed to ensure 4 of 4 staff (Staff C, D, E, F) reviewed for abuse allegations, implemented the facility policy for identifying abuse and reporting to the state agency and administrator of an allegation of abuse involving Resident 1. This failure disallowed the facility administration with the ability to protect residents, report to state survey agency (SSA, State Survey Agency- responsible for oversight of Medicare certified Nursing Homes), investigate, and take corrective action. Further, the failure placed residents at risk for further abuse, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from physical abuse for 1 of 2 residents (Resident 1) reviewed for allegations of abuse. This failure placed residents at risk for further abuse, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 4 staff (staff C, D, E, F) immediately reported suspected abuse to the State Survey Agency (SSA, responsible for oversight of Medicare certified nursing homes) and the facility Administrator according to CFR S483.12(c)(1) for 1 of 2 residents (Resident 1) reviewed for abuse reporting. This failure placed residents at risk for further abuse, potential for harm, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were given the opportunity to formulate advanced directives (AD) nor periodically notified of their right to formulate an AD for 3 of 4 residents (Resident 56, 8 and 61) reviewed for AD. This failure denied residents the right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care.

Inspectors wroteBased on observation, interview, and record review the facility failed to review, and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were correct on admission or corrected and updated for 3 of 5 residents (Residents 50, 7 and 35) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with food preference/substitute meal choices for 3 of 5 residents (Residents 61, 16 and 47) reviewed for dining. This failed practice put residents at risk for decreased intake and nutritional complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections for, 1) hand hygiene and glove change for 4 of 10 staff (Staff T, V, L, and Q) observed during resident cares and, 2) use of Personal Protective Equipment (PPE) in an enhanced barrier precaution (EBP, indicated with high contact resident care activities with an infection, a long term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) rooms for 2 of 5 staff (Staff L and Q) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were educated on the potential risk versus benefits when offering the pneumococcal and influenza immunization (specific vaccines that protects against pneumococcal bacteria and viruses that can lead to lung, nose and throat infections) nor documentation that indicated vaccinations were accepted or refused for 4 of 5 residents (Resident 61, 2, 72 and 35) residents reviewed for immunizations and infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risk/benefits in order to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (a specific vaccine for the COVID-19 virus) benefits/risks and potential side effects associated with the COVID-19 vaccine for 5 of 5 sampled residents (Resident 61, 2, 72, 35 and 56) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents on psychotropic medications (a collective term used for medication classes that affect brain activities associated with mental processes, emotions and behavior, like antipsychotics or anxiolytics) were being monitored for individualized behaviors prior to administration to reflect the adequate need of the medication for 1 of 2 residents (Resident 4) reviewed for psychotropic medication side effects. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to provide the resident and their representative with a summary of a baseline care plan that included the initial goals of the residents, a summary of the residents medications and dietary instructions and services and treatments to be administered by the facility staff for 2 of 4 newly admitted residents (Residents 35 and 37) reviewed for baseline care plans. This failure placed the residents and their representatives at risk for a lack of knowledge regarding the initial care plan for delivery of care and services and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Residents 25) reviewed for activities of daily living (ADLs), received adequate dressing, grooming, nail, and oral care according to the resident's care plan. This failure placed the residents at risk for unmet hygiene needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently offer or provide repositioning for a dependent resident for 1 of 2 residents (Resident 25) reviewed for quality of care. This failure placed all residents at risk for discomfort, skin breakdown, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide specialized services for footcare for 1 of 2 residents (Resident 25) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of skin breakdown, infections, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was consistently supervised during smoking for 1 of 2 sampled residents (Resident 52) reviewed for smoking. This failure placed the resident at risk for avoidable accidents, injuries, and the potential risk of fire.

Inspectors wroteBased on observation, interview and record review the facility failed to implement and ensure their system of records for controlled substances (CS, categories of drugs, regulated and classified based on their potential for abuse and potential to cause physical or mental dependence) disposition (the process of returning and/or destroying unused medications) and accurate reconciliation (a system of recordkeeping that ensures an accurate inventory of CS received, administered or destroyed) was completed in sufficient detail to enable the accurate accounting with these types of medications for 1 of 2 medication carts/CS logbooks (West hallway medication cart) reviewed for storage/disposition of controlled medications. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a sanitary environment by not providing scheduled maintenance services for cleaning for ceiling vents for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness, and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to establish a valid basis for discharge for 2 or 3 residents (Resident 1 and 2) who were not permitted to return to the facility after hospitalization and/or therapeutic leave. This deficient practice displaced residents from a safe home and placed them at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident rooms and bedside urinals in a sanitary and homelike manner for 2 of 3 residents (Resident 1 and 2) reviewed for environment. This deficient practice placed residents at risk for compromised dignity, diminished quality of life and potential infection control issues.

Inspectors wroteBased on interview and record review, the facility failed to implement, monitor effectiveness, modify, and supervise interventions meant to reduce the risk of avoidable accidents related to alcohol consumption for 1 of 3 residents (Resident 3) reviewed for accidents and hazards. This deficient practice placed the resident at risk for negative outcomes related to over consumption of alcohol including driving a motor vehicle while under the influence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were able to use personal possessions in their room, specifically a personal refrigerator, that did not infringe on the rights of other residents for 1 of 3 residents (Resident 2) reviewed for resident rights. This deficient practice placed residents at risk of feeling emotional distress and retaliated against.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision, monitoring and/or modification of interventions related to safe smoking for 1 of 2 residents (Resident 1) reviewed for accidents and hazards. This deficient practice placed Resident 1 at an increased risk for avoidable smoking accidents, injuries, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify, prevent, protect, investigate, and report abuse/neglect allegations for 3 of 3 residents (Residents 2, 38, and 62) who had reported allegations of abuse and neglect by filing out grievance forms. Review of the facility's Grievance/Concern forms, dated 06/01/2024 to 11/14/2024, showed 10 additional allegations of abuse/neglect involving 7 of 7 residents (Residents 226, 228, 227, 2, 54, 11, and 40) reviewed for abuse/neglect. The facility did not have a process to identify allegations of abuse/neglect, that were written as grievances and required thorough and timely investigations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 11 residents (Resident 35) reviewed for neglect. Resident 35 experienced harm when staff failed to provide Resident 35 water when requested, failed to assess skin excoriation (loss of the top layer of the skin and a portion of the middle layer of the skin due to scratching or an injury) to Resident 35's coccyx (tailbone) and perineum (the area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), and administer pain medications as needed at their end of life per Resident 35's advanced directive (a legal document that outlines preferences for medical care in the event you are unable to communicate your wishes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from avoidable accident hazards for 1 of 5 residents (Resident 4) reviewed for accidents with injury. This failed practice placed the residents at risk for avoidable accidents when Resident 4 experienced actual harm when their fifth toe on their right foot was broken while being pushed in their wheelchair. Additionally, the facility failed to ensure a safe smoking area and storage of smoking paraphernalia (items or equipment associated with a particular activity, hobby, or lifestyle) for 3 of 3 residents (Residents 13, 27, and 45) reviewed for safe smoking. The failure to ensure a safe smoking environment and storage of smoking paraphernalia placed the residents at risk for dissatisfaction with their smoking activity experience and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 12 of 12 residents (Resident 62, 26, 49, 8, 9, 14, 2, 51, 55, 5, 19, and 50) reviewed for resident rights, social services, activities, and restorative nursing programs. These failures placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the contracted Dietary Manager (DM) was certified and qualified for that position. This failure placed residents at risk of receiving unsafe dietary services from staff that did not have the required competencies and skills to carry out food and dining services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a process was in place to ensure 4 of 6 residents (Resident 62, 26, 49, and 8) reviewed for resident rights, had the opportunity to exercise their constitutional right to vote as a citizen of United States during the 2024 Presidential election. This failure placed the residents at risk for disappointment, frustration, and psychological distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the State Long-Term Care Ombudsman [(ombudsman) an advocate for resident's rights in long term care) program was reviewed with residents and information was discussed on how to contact the ombudsman for 5 of 5 residents (Resident 31, 9, 11, 8, and 2) reviewed for required notices and contact information. The failure to not provide accessible ombudsman information left residents at risk for not having rightful resources and advocate available to them.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect for 6 of 11 residents (Resident 2, 62, 38, 4, 52, and 49) reviewed for allegations of abuse/neglect. Failure to thoroughly investigate the allegations of abuse/neglect placed the residents at risk for further abuse/neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, individualized, meaningful activities for 5 of 6 residents (Resident 5, 14, 26 ,41, and 51) reviewed for activity participation. This failure placed the residents at risk for boredom, social isolation, and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services programs were implemented for 4 of 6 residents (Resident 5, 9, 19, and 50), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, pain, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 medication storage rooms (North, East, and [NAME] Hall) ensured proper disposal of expired and/or discharged resident's medications, and 1 of 3 medication carts (East Hall) were locked when left unsupervised by nursing staff. These failures placed residents at risk for receiving expired and/or compromised medications, access to potentially harmful medications, and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility administrative staff failed to effectively manage the facility in compliance with state and federal regulatory requirements. The facility failed to ensure there was active and engaged oversight and monitoring of systems related to recognizing abuse/neglect, accident hazards, activities, restorative therapy programs, and sufficient staffing. These failures placed the residents at risk for continued abuse/neglect, injury, decline in physical function, and dissatisfaction with their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control interventions intended to mitigate the risk for transmission of infectious diseases for 3 of 3 residents (Resident 320, 35, and 19) reviewed for infection control. This failure placed the residents at risk for cross contamination and transmission of infectious disease.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike dining room experience, including the choice to eat meals in the dining room, for 4 of 9 residents (Resident 9, 14, 51, and 2) reviewed for choices. This failed practice placed residents at risk for unmet care needs, isolation and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to return the balance of funds to the Office of Financial Recovery [(OFR) responsible for the recovery of financial, medical, social services, and food assistance overpayments from the Department of Social and Health Services clients] for 3 of 4 residents (Resident 232, 60, and 231) reviewed for conveyance (the legal process of transferring property from one owner to another) of personal funds. This failure placed the state department at risk for loss of funds and interest accumulated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to privacy, security, and confidentiality, when a video/audio camera was placed in their room, for 1 of 2 residents (Resident 55) reviewed for privacy and confidentiality. This failed practice placed residents at risk for the loss of personal privacy.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and homelike environment for 3 of 3 shower rooms (North Hall, [NAME] Hall, and East Hall), 1 of 3 hall kitchenettes (East Hall), and 3 of 6 resident rooms (rooms [ROOM NUMBER]) reviewed for environment. These failures place the residents at risk of unpleasant living conditions and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review [(PASARR) a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] Level II comprehensive evaluation was obtained for 1 of 3 residents (Resident 41) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan, within 48 hours of admission, that documented resident-specific goals and treatment plans for 4 of 7 residents (Resident 62, 35, 26, and 55) reviewed for baseline care plans. Failure to develop a baseline care plan placed the residents at risk for unmet care needs and possible complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure policies were implemented to ensure staff responsible for providing cardiopulmonary resuscitation [(CPR) an emergency procedure consisting of chest compressions combined with giving breaths of air] had current CPR certification for 2 of 9 staff (Staff C and G), reviewed for CPR. Additionally, the documentation on the CPR/automated external defibrillator (AED) - a medical device that can help restore a normal heart rhythm in someone experiencing sudden cardiac arrest) Flow Sheet was incomplete/inaccurate. The facility lacked current records of CPR certification status for all staff that responded to an emergent situation requiring CPR. This failure had the potential to result in a lack of staff that were properly trained in CPR, readily available to respond in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream) services met professional standards of care for 1 of 2 residents (Resident 27), reviewed for dialysis. The facility did not have an effective or coordinated process for communication between the facility and the offsite dialysis center for continuity of care. This failure placed residents receiving dialysis at risk for complications and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care, in accordance with professional standards of practice for 1 of 2 residents (Resident 62), reviewed for trauma informed care. The facility failed to accurately assess, monitor, and care plan Resident 62's experiences and preferences regarding their past trauma and potential triggers (a stimulus that could prompt a recall of a previous traumatic event, even if the stimulus itself was not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience). This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing them to serve as a nursing assistant for 2 of 6 staff (Staff N and OO), reviewed for staff qualifications. This failure placed the residents at risk for abuse/neglect and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals that were palatable and served at an appetizing temperature for 3 of 3 residents (Resident 17, 13, and 19) reviewed for food. These failures resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences for 2 of 2 residents (Resident 17 and 22) reviewed for dietary preferences. This failure placed the residents at risk for dissatisfaction with their dining experience and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) plan of care (POC) in collaboration with contracted hospice services, that identified the provider responsible for performing each or any specific services/functions for 1 of 3 sampled residents (Resident 17) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received assistance with activities of daily living (ADLs), related to bathing and grooming, for 5 of 7 residents (Resident 1, 2, 3, 4, and 5) reviewed for ADLs. This deficient practice placed residents at risk for unmet care needs, impaired skin integrity, and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly assess and monitor skin integrity concerns, in accordance with professional standards of practice, for 1 of 3 residents (Resident 2) reviewed for skin assessments. This deficient practice placed residents at risk for unmet care needs, discomfort, embarrassment, and the potential worsening of skin integrity conditions.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly and accurately assess pressure related skin impairments, in accordance with professional standards of practice, for 1 of 3 residents (Resident 4) reviewed for pressure injuries. This deficient practice placed residents at risk for discomfort and potential worsening of pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement pressure offloading interventions timely to prevent the development and/or worsening of pressure injuries for 2 of 3 residents (Residents 1 and 3) reviewed for pressure injuries. Resident 1 experienced harm when they developed a facility acquired pressure injury with infection to their coccyx (tailbone) and placed other residents at risk of new or worsening skin impairments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with standards of practice regarding thorough/accurate assessments, obtaining a medical evaluation, and implementing preventative measures to prevent the development or worsening of pressure injuries for 3 of 6 sampled residents (Residents 42, 45, and 15), reviewed for pressure injuries. This deficient practice resulted in actual harm to Resident 42 when avoidable, facility acquired pressure ulcers developed, and placed other residents at risk for worsening of pressure injuries, medical complications, and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) and mobility for 2 of 3 sampled residents (Residents 39 and 4) reviewed for restorative therapy. This failure resulted in actual harm to Resident 39 who developed, right and left leg contractures (a condition of shortening and hardening of muscles, tendons, or other tissue that leads to muscle stiffening and loss of range of motion of the effected body part)and placed other residents at risk for contractures, decreased mobility, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff in sufficient numbers to ensure residents' nursing and/or care needs were met in a timely manner for 15 of 15 residents (Residents 100, 41, 33, 23, 39, 300, 19, 1, 10, 32, 24, 9, 4, 35, 7 and 42) reviewed for care and services. This failure place residents at risk for unmet care needs and the inability to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement Plan program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to demonstrate evidence of an ongoing QAPI program that was completed on at least a quarterly basis, was documented, included systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities for 1 of 1 sampled program (QAPI) reviewed. This failure placed residents at risk for ongoing unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently serve meals that were palatable, at the proper temperature, or ensure resident satisfaction for 6 of 9 residents (Residents 7, 8, 18, 24, 23, and 300) reviewed for food. The failure to provide palatable and appropriate temperature foods resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with substitute meal choices for 4 of 4 residents (Residents 4, 24, 32, and 41) reviewed for nutrition. Additionally, the facility failed to ensure residents were provided with food preferences for 4 of 4 residents (Residents 1, 4, 10, and 32) reviewed for dining. This failed practice put residents at risk for decreased intake and nutritional complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of their Respiratory Protection Programs (RPP) annual staff fit testing (a test that verifies specific respirators fit and seal to a staff member's face allowing the respirator to protect against exposure to harmful viruses and bacteria) for 6 of 6 staff (Staff V, W, Y, R, M and N) reviewed for a National Institute for Occupational Safety and Health (NIOSH) approved (N95) fitted respirator. These failures placed residents and staff at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, clean, and comfortable homelike environment regarding residents and staff for 1 of 1 laundry rooms (LR 1), and 2 of 4 resident care units (West and East) reviewed for a homelike environment. This failure placed residents at an increased risk for not feeling safe and secure with their environment and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 7) reviewed for choices, was informed in writing, or given appropriate notice of a room change prior to the change. This failed practice placed the resident at risk of not being given the choice to make an informed decision, and placed them at risk for psychosocial decline and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident's freedom of movement) when applying foam wedges under the resident's bed linen which prevented the resident from getting out of bed, for 1 of 1 resident (Resident 23) reviewed for physical restraints. This failure placed the resident at risk for the inhibition of free movement and/or activity and at an increased risk for injury when attempting to get out of bed.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to their State Agency, for 2 of 2 residents (Residents 42 and 40), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a thorough investigation regarding allegations of abuse and/or neglect for 2 of 2 residents (Resident 42 and 40) reviewed abuse/neglect. This failure placed the resident at risk for unidentified abuse, unmet care needs, and the potential continued exposure to abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a screening process for individuals with serious mental illness [SMI] and/or intellectual disability/developmental disability [ID/DD]) assessment was accurately completed upon or prior to admission to the facility or updated during a change in condition for 2 of 6 residents (Residents 15 and 32) reviewed for PASARR. This failed practice placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or developmental disability care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dependent on staff for activities of daily living (ADLs) received assistance with eating, for 2 of 3 sampled residents (Residents 39 and 41), reviewed for ADLs. This failure placed the residents at risk for weight loss, choking, and aspiration (when food, liquid, or other material enters a person's airway or lungs) complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had an ongoing activity program that met the resident individual needs for 2 of 5 residents (Residents 23 and 39) reviewed for activities. This failure increased the resident's risk to become bored and not being provided with meaningfully engagement throughout the day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards for 3 of 4 residents (Residents 41, 100, and 33) reviewed for smoking. The facility failed to provide supervision, monitoring and/or modification of interventions related to safeguarding residents who had chosen to smoke within the facility's designated smoking area. This failure placed the resident at an increased risk for avoidable smoking accidents, significate injury, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care related to assessing for trauma and identifying triggers for residents with a history of sexual assault and Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops from experiencing a traumatic event) for 2 of 2 residents (Residents 7 and 15) reviewed for mood and behavior. This failed practice put residents at risk for re-traumatization, unidentified triggers, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents as needed (PRN) psychotropic medication (drugs that affect a person's mental state) were not ordered beyond 14 days or had the appropriate evaluation and documentation to extend it greater than the14 days for 1 of 5 residents (Resident 32) reviewed for unnecessary medications. The facility failed to assess pharmacist recommendations timely; and attempt non-pharmacological interventions prior to the administration of a psychotropic medication. This failed practice increased the risk of medical complications and unneeded medication use.

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration agreements provided the selection of a convenient venue (a location that agreed upon and suitable for both the resident or their representative and the facility) for 1 of 3 residents (Resident 12), reviewed for arbitration. This failure placed residents at an increased risk for an unfair arbitration proces and the resident or their representative not being able to exercise their rights under the agreement.

Inspectors wroteBased on interview and record review, the facility failed to ensure that abuse training which included recognizing, reporting, and preventing resident abuse was completed for 4 of 7 staff (Staff K, M, AA, and BB) reviewed for abuse training requirements. This failure placed residents at increased risk for unidentified abuse/neglect, and inadequate care from unqualified staff.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of the required annual 12-hours of in-service training for 1 of 9 sampled Nursing Assistants (Staff O) of reviewed employee files. This failure placed residents at risk of being cared for by inadequately trained staff, and unmet care needs.