Community Manor

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of two gift cards from one resident (Resident #1) out of a sample of five residents when a staff member took possession of the resident's $200 Amazon gift card and $300 Visa gift card. The facility census was 98. The administration was notified on 06/04/26 of the Past Non-Compliance which occurred between 05/29/26 through 06/01/26. On 06/01/26, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 06/01/26, as the facility completed disciplinary action for CNA A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds for the operating account in a timely manner for six residents (Residents #1, #2, #3, #4, #5 and #6). The facility census was 66.1. Record review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated [DATE], showed the following residents with personal funds held in the facility operating account: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents (Resident #25 and #77) out of three sampled residents who were discharged from Medicare Part A services with benefit days remaining. The facility's census was 97. The facility did not provide a policy for SNF ABN or NOMNC forms. 1. Review of Resident #25's medical record showed: - The resident discharged from Medicare Part A services on 02/28/25; - The resident remained in the facility; - The facility failed to issue a NOMNC to the resident. 2. Review of Resident #77's medical record showed: - The resident discharged from Medicare Part A services on 04/30/25; - The resident remained in the facility; - The facility failed to issue a SNF ABN to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital for four residents (Resident #15, #23, #49, and #67) out of 20 sampled residents and failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #49, and #67) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy, Bed-Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for one resident (Resident #23) out of 20 sampled residents and two residents (Resident #31 and #60) outside the sample. The facility's census was 97. Review of the facility's policy, Resident Assessments, revised October 2023, showed: - A comprehensive assessment of each resident is completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act of 1987 are comprehensive evaluations of a resident's needs and condition within a nursing home, conducted by the facility staff) regulations and PPS (Prospective Payment System-a method of healthcare reimbursement where the Centers for Medicare and Medicaid Services (CMS) pays a provider a fixed amount based on the type of service rendered) requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for three residents (Resident #6, #48, and #85) out of 20 sampled residents. The facility's census was 97. Review of the facility's Comprehensive Person-Centered Care Plan policy, revised March 2022, showed: - A comprehensive, person-centered plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial, and functional needs will be developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or follow physician orders in a timely manner after the pharmacist made recommendations for specific medications for one resident (Resident #31) outside of the 20 sampled residents and failed to ensure a Certified Nursing Assistant (CNA) did not perform duties outside the scope of practice. The facility's census was 97. Review of the facility's Medication Regimen Reviews (MRR) policy, revised May 2019, showed: - The consultant pharmacist reviews the medication regimen of each resident, at least monthly; - The goal of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #15) out of one sampled resident. The facility's census was 97. Review of the facility's policy, Suctioning the Trachestomy Tube, revised October 2023, showed: - The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract; - Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning; Review the resident's care plan to assess for any special needs of the resident; Obtain baseline vital signs and oxygen saturation; [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain correct orders from the physician for dialysis (a process for removing waste and excess water from the blood) care, specifically for a port access (a medical device implanted for easy access to a vein), instead of a fistula (a surgically created connection between an artery and a vein, used for dialysis access) for one resident (Resident #48) out of one sampled resident. The facility's census was 97. Review of the facility's Care of a Resident With End-Stage Renal Disease (ESRD) policy, revised September 2010, showed: - Staff caring for residents with ESRD, including residents that receive dialysis care outside of the facility, shall be trained in the care and special needs of the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less. There were four medication errors out of 30 opportunities for errors, resulting in an error rate of 13.33%. This practice affected resident (Resident #39) out of 20 sampled residents and one resident (Resident #91) outside the sample. The facility's census was 97. Review of the facility's policy, Administering Medications, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility's census was 97. Review of the facility's Food Receiving and Storage policy, revised November 2022, showed: - Food shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in refrigerator or freezer are covered, labeled, and dated with a use by date; - Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. Review of the facility's Sanitation policy, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to keep a urinary catheter drainage bag off the floor for one resident (Resident #15) out of 20 sampled residents. The facility failed to use enhanced barrier precautions (EBP) for one resident (Resident #39) out of 20 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection during peri (washing the genital and anal areas of the body) and urinary catheter (a flexible tube that is placed to drain urine from bladder) care for two residents (Resident #47 and #75) out of 20 sampled residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in five rooms. Storing items on the overbed light creates a hazard of the items falling on resident below and does not utilize the light fixture as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility's census was 97. The facility did not provide a policy regarding overbed light safety. Observation on 06/06/25 showed: - At 6:00 P.M., room W12 with a decorative Blessed sign stretching across the light fixture; - At 6:05 P.M., room W16 with a decorative Welcome sign and paper picture of a horse on top of the light fixture; - At 6:06 P.M., room W20 with a sound bar for the television on top of the light fixture; [...]

Inspectors wroteBased on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 96. Review of the facility policy, Refrigerators and Freezers, revised November 2022, showed: - Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41° F and freezers keep frozen foods frozen solid; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken. The last column will be completed only if temperatures are not acceptable; [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #36) out of 20 sampled residents. The facility's census was 96. Review of the facility policy, Certifying Accuracy of Resident Assessment, revised November 2019, showed: - Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge; - Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #48) outside of the sample. The facility census was 96. Review of the facility policy titled, Medication and Treatment Orders, last revised 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; - Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis; - All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #7 and #30) out of two sampled residents. The facility census was 96. 1. Review of Resident #7's medical record showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietician's (RD) recommendations for weight loss were provided to the physician which affected one resident (Resident #7) out of 20 sampled residents. The facility census was 96. Review of the facility policy, Weight Assessment and Intervention, revised March 2022, showed: - Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month - 5% weight loss is significant; greater than 5% is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe; Six months - 10% weight loss is significant; greater than 10% is severe. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center for one resident (Resident #33) out of one sampled resident receiving dialysis. The facility census was 96. Review of the facility's policy titled, Hemodialysis Catheters-Access and Care of, dated 02/2023, showed: Care of the AVF's and AVGs: - Do not use access arm to take blood pressure; - Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals; - Check patency of the site at regular intervals. Palpate the site to feel the thrill,or use a stethoscope to hear the whoosh or bruit of blood flow through the access; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices while providing care for two residents (Resident #1 and #36) out of 20 sampled residents and failed to provide appropriate documentation of tuberculosis (TB-an infectious bacterial disease that affects the lungs) testing for five residents (Resident #12, #24, #28, #30 and #76) out of five sampled residents. The facility census was 96. Review of the facility's policy, Personal Protective Equipment-Using Gloves, last revised September 2010, showed: - Use gloves when touching excretions, secretions, blood, body fluids, or non-intact skin; - To prevent spread of infection; - To protect hands from potentially infectious material; - Wash hands after removing gloves. Review of the facility's policy, Screening Residents for Tuberculosis, last revised August 2019, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility census was 96. The policies provided by the facility did not address who is required to attend QAPI meetings. 1. Review of the QAPI sign in sheets, provided by the Administrator, showed the Medical Director did not attend any meetings from August 2023 through May 2024. During an interview on 06/21/24 at 10:10 A.M., the Administrator said QAPI meetings are held monthly and the previous month is reviewed. The Medical Director has not attended QAPI meetings in quite some time, but she would expect him to.

Inspectors wroteBased on observation, record review and interview, the facility failed to notify a resident's family or next of kin for two of three sampled residents, (Residents #1 and #2) after a change in condition. The facility census was 98. 1. Record review of the facility policy, Change in a Resident's Condition or Status, dated February 2021 shows; Unless otherwise instructed by the resident, a nurse will notify the residents representative when; - The resident is involved in any accident or incident that results in an injury including injuries of unknown source. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 03/04/24 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a cover on the trash containers within the kitchen and failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpsters. This had the potential to affect all residents. The facility census was 95. 1. Observation of the kitchen on 2/19/23 at 11:40 A.M. showed the following: - One uncovered 32 gallon trash receptacle partially full of refuse near the dishwashing station; - One uncovered 32 gallon trash receptacle partially full of refuse near the food slicer; - One uncovered 32 gallon trash receptacle filled with cardboard refuse near the back kitchen exit. 2. Observation of the kitchen on 2/19/23 at 12:00 P.M. showed the following: - One uncovered 32 gallon trash receptacle partially full of refuse in the food preparation area; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for two residents (Resident #27 and #36) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for one resident (Resident #47) out of three sampled residents. The facility's census was 95. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change assessment for three residents (Resident #58, #64, and #90) out of 19 sampled residents. The facility's census was 95. Record review of the facility's policy titled, Resident Assessments, dated 11/2019, showed: - A significant change assessment is completed within 14 days of the interdisciplinary team determining that the resident meets guidelines for major improvement or decline; - The significant change assessment is required when a resident: - Enrolls in a hospice program; - Changes hospice providers and remains in the facility; - Discontinues hospice services; - Experiences a consistent pattern of changes with two or more areas of decline from baseline. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) for three residents (Residents #44, #51, and #64) out of 19 sampled residents and one resident (Resident #41) outside of the sample. The facility census was 95. 1. Record review of Resident #41's annual MDS, dated [DATE], showed: - Resident on an anticoagulant. Record review of the resident's Physician Order Sheet (POS), dated 2/2023, showed: - An order, on 10/12/22, for aspirin (an antiplatelet medication that prevent blood cells from clumping together); - No order for an anticoagulant (a medication that help prevent prevent blood clots by slowing down the body's process of making clots). During an interview on 2/22/23 at 12:38 P.M., the MDS Coordinator said aspirin should not be coded as an anticoagulant. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #20, #29, #76, and #85) out of 19 sampled residents. The facility census was 95. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - A comprehensive , person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident; - The care plan will be consistent with the resident rights, professional standards of practice, medical provider orders and resident's goals and preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with personal hygiene for two residents (Resident #151 and #401) out of 19 sampled residents. The facility's census was 95. Record review of the facility's policy titled, Resident Hygiene, not dated, showed: - Staff will ensure residents are neat, clean and well groomed at all times; - Residents will be scheduled a shower/bath at least twice per week as needed; - Hair will be shampooed during shower or at the beauty shop; - Hair will be brushed/combed during AM care, after naps and as needed to maintain a neatly groomed appearance; - Oral hygiene is performed during AM care, PM care and as needed to maintain good oral hygiene; - Face and hand washing are performed during AM care, PM care, after toileting, after meal/snacks and other times as needed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #29) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 19 sampled residents. The facility's census was 95. Record review of the facility's Trauma Informed Care policy, undated, showed: - Facility must ensure that trauma survivors receive trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers leading to re-traumatization; - Facility social service/interdisciplinary care team will determine through assessment upon admission, annually and as needed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects or warnings of those immunizations. This effected four residents (Resident #1, #31, #39, and #90) out of 19 sampled residents. The facility census was 95. Record review of the facility's policy titled, Vaccination of Residents, revised October 2019, showed: - Prior to vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations; - Provisions of such education shall be documented in the resident's medical record; - All new residents shall be assessed for current vaccination status upon admission; [...]