Continental Nursing & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R3) was free from abuse from another resident (R8). This failure resulted R3 being evaluated at the hospital and diagnosed with a closed head injury, sprain of right wrist and sprain of left shoulder.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper discharge planning by not verifying placement and not arranging services for one resident (R4) in a total of 14 residents.

Inspectors wroteBased on observation, interviews and review of records facility failed to provide residents with proper equipment (wheelchair) per therapy recommendation for 1 out of 3 residents (R2) for a total of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on review of records and interviews the facility failed to follow reporting procedures of injury of unknown origin or source for 1 out of 3 residents (R8) total sample of 3 residents reviewed for right of every resident to be free from all forms of abuse. These failures are not in accordance with facility's abuse policy applicable to 1 resident (R8) who sustained injuries of unknown origin or source.

Inspectors wroteBased on review of records and interviews the facility failed to timely and accurately assess 1 out of 3 residents (R8) on identifying pressure injuries and update R8's care plan after the identification. These failures are not in accordance with facility's pressure injury prevention policy guidelines that affected 1 resident (R8) who sustained bilateral heel deep pressure injuries (deep tissue injuries).

Inspectors wroteBased on observation, interview and records review, the facility failed to provide a safe mechanical lift transfer for one dependent resident (R9), of 5 residents reviewed for transfers out of a total sample of 10 residents. Findings Include:R9's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebral palsy, chronic obstructive pulmonary disease, obesity, muscle wasting and atrophy, hypertensive heart disease without heart failure. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R9 has an Interview for Mental Status (BIMS) score of 10, indicating that R9 has moderate cognitive impairment. Minimum Data Set Section (MDS) section GG (dated [DATE]) documents that R9 is dependent on staff for transfers. Care plan (dated 12/23/2025) documents that R9 is dependent on staff for transfers and requires a mechanical lift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to record the daily refrigerator temperature log on a personal refrigerator for one (R1) in a total sample of 3 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that menus are followed when staff did not use the appropriate utensil to serve/plate the food. This deficient practice has the potential to affect all residents that receive meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) monitor the call light system and answer call lights within a timely manner for two residents (R1, R5), b.) provide incontinence care for two (R5, R8) residents, and c.) ensure one (R1) resident have access to their personal belongings. These failures affect three residents in a sample of six residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy to ensure a safe and healthy living environment for the 59 residents residing on the third floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident the right to free of abuse for one (R2) of three residents included in a sample of 8 who was physically assaulted by R1, resulting in R2 sustaining a laceration to the top of head requiring 8 staples.

Inspectors wroteBased on interview and record review, the facility failed to administer intravenous (IV) antibiotic medication as ordered by Physician for one (R3) resident with diagnosis of Osteomyelitis. This failure affected one (R3) of three residents reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interview, and review of records, the facility failed to ensure that smoking was done in required designated area. These practices are not in accordance with their policy and State laws and can affect all 144 residents living in the facility as it pertains to their safety and comfort related to smoking effects.

Inspectors wroteBased on observation, interviews and review of record the facility failed to re-ordered medication on a timely manner for 1 out of 3 residents (R2) reviewed for pharmaceutical services. This practice is not in accordance with their policy and may affect 1 resident (R2) in ensuring pharmaceutical supplies are available to meet the needs of resident.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy for smoking safety and failed to ensure that residents are not smoking inside a shared residents' room near oxygen equipment where oxygen is in use which affected 5 residents (R2, R7, R8, R9 and R10) of 12 residents reviewed for odors from smoking within the facility. This failure resulted in R10, who uses nasal cannula oxygen from an oxygen tank, experiencing psychosocial harm from sharing a room with R4 who was found on 5/31/25 by staff with a lit, half smoked cigarette in their shared room with visible smoke in the air and on 6/1/25 when R10 smelled cigarette smoke in their shared room, alerted staff, and staff confiscated a box of 14 cigarettes from R4's dresser drawer. Subsequently, R10 was transferred to a different room on the floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their dental policy to meet the need for dental services and to address negative dental findings immediately for one [R61] resident out of a sample of 28 reviewed for dental services. This failure resulted in a delay of a recommended dental procedure resulting in ongoing dental pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) maintain sanitary kitchen conditions, b.) ensure proper working order of freezer, c.) ensure food items were properly labeled and dated, d.) maintain cleanliness of kitchen equipment. These failures have the potential to affect all 139 residents who receive food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure on multiple occasions medications were administered as scheduled per physician orders for one (R109) of four residents reviewed for medication administration. Findings Include: On 5/27/25 at 10:29 AM, R109 stated he does not get his Amlodipine on time on certain days. R109 stated for five days in the last twenty days, R109 did not receive his Amlodipine as scheduled in the morning. R109 remembers not getting it on time yesterday, Sunday, and other days but R109 does not remember exact days. R109 stated Amlodipine is ordered once a day to take in the morning. R109 stated some days the nurses don't give the medication to him until evening time. [...]

Inspectors wroteBased on observation, interview and record review, the facility (a) failed to properly discard multi-dose insulin pen on expiration date and to properly store unopened insulin pen for 1 resident (R10), (b) failed to label and date opened multi-dose inhalers for 2 residents (R121, R95), and (c) failed to discard house stock medication on expiration date from two of three medication carts inspected for medication storage and labeling. This failure had the potential to affect all 28 residents receiving medications from third floor medication cart one. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect eight residents (R11, R27, R53, R65, R72, R99, R102, R115) receiving pureed diets prepared in the facility's kitchen. Findings Include: On 05/28/25 at 11:10 AM, during pureed preparation observation V15 (Cook) stated he follows a recipe so that he know how to prepare the pureed food. V15 pointed to a recipe titled Pureed Beef Lasagna located in a binder near the prep area. V15 stated the consistency of the pureed should be smooth with no lumps and the consistency should be in between nectar and honey consistency. On 05/28/25 at 11:15 AM, V15 stated he needed to prepare eleven portions of pureed lasagna and was going to do the process in two batches. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect eight residents (R11, R27, R53, R65, R72, R99, R102, R115) receiving pureed diets prepared in the facility's kitchen based on list of residents receiving pureed diets dated 05/27/25. Findings Include: On 05/28/25 at 11:10 AM, during pureed preparation observation V15 (Cook) stated he follows a recipe so that he know how to prepare the pureed food. V15 pointed to a recipe titled Pureed Beef Lasagna located in a binder near the prep area. V15 stated the consistency of the pureed should be smooth with no lumps and the consistency should be in between nectar and honey consistency. On 05/28/25 at 11:15 AM, V15 stated he needed to prepare eleven portions of pureed lasagna and was going to do the process in two batches. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to obtain a physician order and to determine if self-administration of medication was appropriate for one (R117) out of one resident observed for safety on the total sample of 28. Findings Include: R117's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (12) indicates R117 is moderately cognitively intact. R117's Face sheet shows he is [AGE] years old, admitted to the facility on [DATE] with diagnosis not limited to Guillain-Barre syndrome, disorder of the autonomic nervous system, sixth nerve palsy right eye, pain in right knee, and pain in left knee. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedure by not obtaining a physician's order for code status and develop a comprehensive person-centered care plan for one (R114) reviewed for advance directives on the total sample of 28. Findings Include: R114's face sheet shows an initial admission date of 11/12/24 and the advance directive section was blank. R114's minimum data set (MDS) dated [DATE] shows R114 is cognitively intact with BIMS (Brief Interview for Mental Status) of 114. R114's order summary report printed on 5/28/25 shows no physician order for R114's code status. R114's comprehensive care plan does not address R114's advance directive/code status. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and ensure the accuracy of three (R70, R81, R112) residents' MDS (Minimum Data Set) assessments for 3 of 28 residents reviewed for assessments.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow professional standards of care for one (R117) resident out of a sample of 28 reviewed for medication administration. Findings Include: R117's Physician Order Sheet (POS) with active orders as of 5/27/25 shows Gabapentin oral capsule 300mg (milligrams), give 1 capsule by mouth three times a day for nerve pain, start date 4/19/25. On 5/27/25 at 11:35 AM, R117 was up in bed working on the computer, surveyor and V6 (Registered Nurse/RN) observed a medication bottle containing thirty-four yellow oblong capsules on R117's bed side table, and V6 acknowledged the capsules as being Gabapentin 300 milligram/mg that had been administered to him. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to coordinate services for a resident (R81) with diagnoses of chronic liver disease and Hepatitis C and failed to follow physician order and policy and procedure to ensure peripherally inserted central catheter (PICC) line dressing was changed weekly for R246. These failures affected 2 out of a total sample of 28 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fire hazard equipment was not located in a resident's room for one (R7) of one residents reviewed for accidents and hazards in a sample of 28 residents. Findings Include: R7's clinical records show an admission date of 2/11/25. R7's Minimum Data Set, dated [DATE] shows R7 is cognitively intact. On 5/27/25 at 10:48 AM, surveyor entered R7's room and noted two countertop microwaves at bedside. R7 stated [R7] uses them to warm up his food. On 5/27/25 at 12:59 PM, V1 (Administrator) stated residents cannot have microwave in their rooms because it is not safe and it's a fire hazard. V1 stated there's microwave available in the break room that the nurse can use to heat up residents' food. V1 stated will remove R7's microwaves from [R7's] room immediately. [...]

Inspectors wroteBased on observations, interviews, and record reviews, facility failed to follow their policy to ensure residents received medications according to the physician order for 3 residents (R1, R2, R6) out of of 3 residents reviewed for medication administration in a total sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the dosage of one (R6) resident's antibiotic order. This failure has the potential to affect one (R6) resident out of six residents reviewed for professional standards.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient dietary staff to carry out the functions of the food and nutrition service by not following posted mealtime schedule resulting in residents receiving their meals late for six (R4, R6, R7, R12, R13 and R17) residents reviewed for Dietary Services. These failures have the potential to affect all 141 residents receiving oral diets from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve adequate food portions as documented on the recipes and spreadsheets. This failure has the potential to affect all 141 residents receiving food prepared in the facility's kitchen. Findings Include: On 03/25/25 at 12:10 PM, surveyor entered kitchen and observed lunch tray line in progress. V23 (Cook) stated the residents were receiving Country Fried Steak, Mashed Potatoes, Peas, and Vanilla Pudding for lunch today. Observed V24 (Cook) using the following serving utensils to serve food on the tray line including #10 scoop for Mashed Potatoes, #16 scoop for Pureed Country Fried Steak, #20 scoop for Ground Country Fried Steak. The Vanilla Pudding had already been pre-portioned into bowls. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide meals as per posted mealtime schedule and to ensure there are no more than 14 hours between the evening meal and breakfast the following day with a substantial or nourishing bedtime snack available/offered to everyone for six (R4, R6, R7, R12, R13 and R17) residents reviewed for Dietary services. These failures have the potential to affect all 141 residents receiving oral diets from the facility's kitchen.

Inspectors wroteOn 3/25/25 At 11:24am Observed R7 lying in bed, on moderate high back rest, alert and oriented x 3, verbally responsive. She stated food temperature is terrible, she was served with cold food instead of being warm / hot. R7's admission record showed initial admit date on 4/18/2024 with diagnoses not limited to Quadriplegia, Epilepsy, Iron deficiency anemia, Chronic respiratory failure with hypoxia, Essential (primary) hypertension. MDS (Minimum Data Set) dated 2/11/2025 showed R7's cognition was intact and needed total assistance with eating. R7's order summary report dated 3/26/25 showed order not limited to General diet, Regular texture, Thin Liquids consistency. Resident Council Meeting Minutes dated 02/26/25 documents in part, residents noted that meals and coffee are not consistently served hot. [...]

Inspectors wroteBased on interviews and record review the facility failed to follow their grievance policy. The facility [A] failed to immediately report all alleged lost or stolen items [B] failed to report missing items to administrator. The facility also failed to follow resident rights [C] failed to keep resident property from being lost or stolen. These failures affected one [R3] resident out of five reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe and sanitary environment for one resident (R12) reviewed for Physical Environment.

Inspectors wroteBased on observations, interviews, and review of records, the facility failed to accommodate resident rights per facility policy pertaining to basic needs for clothing for one out of one resident (R12) for a total sample of 3 residents reviewed for resident rights.

Inspectors wroteBased on interviews and review of records the facility failed to provide resident with a person-centered plan of care related to trachea infection and behavioral concern on suctioning of tracheostomy and care plan meeting for 1 out of 3 residents (R11) reviewed for interdisciplinary team care plan.

Inspectors wroteBased on observations, interviews and review of record, the facility failed provide an individual closet space for 1 out of 1 resident (R12) for a total sample of 3 residents reviewed for functional furniture to address residents' needs.

Inspectors wroteBased on observations, interviews, and records review the facility failed to protect the rights of a resident to be free of resident to resident abuse for one (R5) out of three residents reviewed for abuse. These failures were not in accordance with abuse policy of facility and resulted to one resident (R5) with cognitive impairment sustaining injuries in two separate incidents with (R6 and R9). R5 sustained scratches and abrasion on the neck on 01/13/2025 and right eye swelling and redness on 11/18/2024 which resulted in R5 being sent to the hospital.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow it's policy on investigating incidents of abuse for 1 out of 3 residents (R5) reviewed for the right of every resident to be free from abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing and nebulizer trach mask) and failed to properly contain oxygen equipment (nebulizer trach mask) per the facility policy. These failures affected one resident (R3) reviewed of oxygen care.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect one resident (R8) from resident-to-resident physical abuse by (R9) for two of three residents reviewed for physical abuse. This failure resulted in R8 being beaten with a walking cane while in the facility and sustaining a left hip fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and monitoring of residents to prevent residents from smoking in the facility and ensure residents practice safe smoking in the designated area for two (R2 and R4) residents and has the potential to affect (R5, R6, and R7) residents reviewed for smoking safety on the sample list of nine.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure the (3rd floor) medication cart was locked or attended by authorized staff. These failures have the potential to affect 48 (3rd floor) residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse. This failure resulted in R3 and R4 engaging in a verbal altercation that led to R3 hitting R4 while in the hallway. Findings Include: On 12/10/24 at 11:36 AM, R3 stated that R4 was cursing R3 in the hallway few weeks ago, and R3 used R3's foot to hit R4's jaw while R4 was sitting in wheelchair. On 12/11/24 at 10:04 AM, R4 received alert in bed, appeared weak. R4 stated that R4 was up in wheelchair in the hallway arguing with R3, and R3 hit R4 on the cheek. R4 stated that R4 did not hit R3. On 12/11/24 at 11:30 AM, V18 (CNA) stated that V18 worked 3PM-11PM shift with R3 and R4 on the date of the incident (11/01/24). V18 stated that V18 heard R3 and R4 arguing around 4 PM, and the argument turned to R3 fighting with R4, and R3 hit R4. V18 stated that hitting is a form of physical abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by involuntarily holding a resident in their room by blocking or holding the door closed with the use of a garbage bag. This failure affected 1 (R2) of 6 residents reviewed. Findings Include: R2 is a [AGE] year-old male. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is severely cognitively impaired and has a diagnosis of Unspecified Dementia, with other behavioral disturbance, other disorders of brain, Alzheimer's disease, Cognitive communication deficit, Type 2 diabetes mellitus, Essential hypertension, other abnormalities of gait and mobility, and need for assistance with personal care. On 12/10/24 at 11:54 AM, R2 was observed pacing in R2's room. R2 appeared to be confused. [...]

Inspectors wroteBased on review of records and interviews the facility failed to develop and implement a baseline care plan for falls upon admission and follow their incidents/accidents/falls policy to provide interventions for prevention of falls for 1 out of 3 residents (R6) with multiple falls. These failures affected 1 resident (R6) who had multiple falls in the facility without proper interventions and/or preventive measures.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R2) was free from staff to resident mental abuse. This failure affected one resident (R2) in a total sample of three reviewed for abuse. This failure resulted in (R2) experiencing mental anguish.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodations for a resident to easily get to the bathroom in the resident's room. This failure affects two residents (R1, R3) of the three residents reviewed for accommodations of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen equipment and preparation area was clean, follow cleaning schedule for the kitchen and equipment and label/ date stored food, and discard expired food. These deficient practices have the potential to affect all 139 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on interview, and record review the facility failed make arrangements for one [R7] of eight residents reviewed to attend religious services of their choice. Findings Include, R7's clinical record indicates in part; R7's medical diagnosis includes but not limited to cerebral infarction with hemiplegia/hemiparesis affecting left dominant side, type II diabetes, atherosclerotic heart disease, dementia, systemic lupus, nephrotic syndrome, anemia, chronic kidney disease, essential hypertension, thyrotoxicosis, atrial fibrillation. Dysphagia, need assistance with personal care, weakness, anxiety disorder, and bipolar disorder. R7's minimum data set brief interview mental status dated 8/7/24 indicate R7 is cognitively intact. R7's 2/11/22 [Latest Quarterly Activity Evaluation Completed] documents in part. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse (R2) by another resident that has documented aggressive behavior (R4) for two (R2,R4) of four residents reviewed for abuse. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of physical abuse for one (R2) of four residents who were reviewed for abuse. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R2's Physical Aggression Received dated 09/29/24 document in part: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide double portions as listed on the resident's meal ticket for 1 (R2) of 3 residents reviewed for nutrition. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Wednesday 10/09/24 menu document in part: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow physician's orders for therapy evaluation and treatment for one (R3) out of five residents reviewed for therapy services.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and ensure a complete and accurate accounting of a resident's (R1) funds and ensure that R1 was not charged for services that were already covered under Medicaid for one out of three residents reviewed for personal funds.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to follow their wound prevention policy to ensure one [R9] of three residents did not develop pressure wounds. This failure resulted in R9 developing a stage three pressure ulcer to R9's left hip. Findings Include: R9 clinical record indicates in part: R9 is a [AGE] year-old, with the following medical diagnosis includes but not limited to need for assistance with personal care, dementia, essential (primary) hypertension, weakness, legal blindness, cognitive communication deficit, and unsteadiness on feet. R9's Minimum Data Set (MDS) section [C] dated 7/2/24 score of [6] indicates R9 is moderately impaired. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store potentially hazardous food, ensure that the walk-in freezer remained securely closed, maintain a clean walk-in freezer and oven, cover prepared food, and serve milk that was not spoiled. This has the potential to affect all residents that receive their nutritional needs from the kitchen.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to have adequate staffing to ensure one [R9] resident's ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all 44 residents residing on the 4th floor. Findings Include: During the facility tour from 9AM to 11 AM, noted the fourth floor there was offensive odors, and residents in bed and not dressed. On 8/13/24 at 11:22 AM, V41 [R9's Family Member] waved surveyor into the R9's room. Entering R9's room, noted strong offensive odors. R9 was resting in bed lying on his left side. V41 stated, Please help me, R9 smells like feces and urine, I need someone to check him to see if R9 needs changing. Surveyor went into the hallway and asked V9 [Registered Nurse] for assistance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician medication orders were followed as written and medications were administered as ordered by the physician for 1 (R1) of 3 residents reviewed for physician orders. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Anxiety Disorder, Encephalopathy, Insomnia, Nutritional Anemia, Anorexia, Hyperosmolality and Hypernatremia, Disease of Esophagus, , Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Attention-Deficit Hyperactivity Disorder, Epilepsy, Vitamin D Deficiency, Gastrostomy Status, Adult Failure to Thrive, Esophageal Obstruction, Disorders of Electrolyte and Fluid Balance, Severe Protein-Calorie Malnutrition, Cellulitis of Abdominal Wall and Conversion Disorder with Seizures or Convulsions. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide timely incontinence care and assistance with turning and repositioning for one [R9] resident who requires assistance with activities of daily living in a total sample of 15 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate staffing to ensure two resident's (R8, R9) ADL (Activities of Daily Living) needs were met in a timely manner. The facility's short staffing has the potential to affect all 137 residents residing in the facility as of the census dated 08/06/24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient dietary staffing resulting in meals being delivered late, outside of posted meal schedule. These failures have the potential to affect all 135 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at a palatable temperature and appetizing taste. This deficient practice has the potential to affect all 135 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the diet spreadsheet was followed for 4 (R19, R20, R21, R22) out of 4 residents who were receiving mechanical and pureed diets. This failure has the potential to affect all 29 residents receiving mechanical and pureed diets in the facility's kitchen. Findings Include: On 8/7/24 at 9:50 AM, Surveyor observed menu posted in the kitchen. Lunch menu showed Herbed Pork Roast, [NAME] Pilaf, Steamed Broccoli, Cinnamon Scalloped Peaches, Dinner Roll/Margarine, and Beverage. At approximately 10:02 AM, V15 (Cook) was preparing mashed potato using powdered mix from a package. Surveyor asked V15 if that will be served that day to the residents for lunch or dinner. V15 answered that it will be served for lunch that day for residents who are on mechanical and pureed diets. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for dependent residents who required assistance with bladder and bowel incontinence for two residents (R8, R9) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order for G-tube (Gastrostomy) feeding, flushing, and dressing change for 2 (R5 and R6) of 3 residents reviewed for enteral feeding.

Inspectors wroteBased on interviews and records review, the facility failed to supervise one (R1) resident while on outside physician appointment of three residents reviewed for supervision. This failure resulted in R1 missing for approximately six hours.

Inspectors wroteBased on interview and record review, the facility failed to complete pre-employment screening of a potential employee for one of three (V6 Certified Nursing Assistant) reviewed for health care worker background checks.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food prepared by methods that conserve palatability, and at a safe and appetizing temperature. This failure affects 139 residents who receive food from facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and food storage practices by food not properly labeled, food not properly stored, equipment used for food preparation not adequately sanitized. These deficient practices have the potential to affect all 139 residents receiving food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to lock one medication cart while unattended, label unsealed medications, and discard expired medications in four out of six carts reviewed for medication labeling and storage. These failures have the potential to affect ninety-one residents receiving medication from the third and fourth floors medication carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary and homelike environment for one (R118) out of 33 residents reviewed for environment in the sample of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to develop and/or implement a discharge care plan for one (R45) resident who had expressed a desire to discharge from the facility of 3 reviewed for discharge in the total sample of 33 residents.

Inspectors wroteBased on observation, interviews and records review, the facility failed to follow its oxygen tubing policy by failing to date the tubing for one (R59) of three residents reviewed for oxygen in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a resident from eating other resident's unfinished food during meal time for one resident (R139) out of five residents reviewed for infection control in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision for five of six residents (R3, R11, R12, R13, and R14) in the sample reviewed for supervision and falls. This failure affected R3, R11, R12, R13, and R14 who were observed in the dining room without visual staff supervision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were not left at the resident's bedside without physician order for one (R4) of 16 residents reviewed for safety.

Inspectors wroteBased on interview and record review the facility failed to follow their change of condition policy and assess one resident [R2] with an acute change in condition and failed to call 911 when the resident's condition worsened. This failure resulted in R2 experiencing an acute change in condition, and a delay in receiving a higher level of care. This was identified as an Immediate Jeopardy which began on [DATE]. On [DATE] at 10:09 AM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE]. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan.

Inspectors wroteBased on observation and interview, the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment related to offensive odors, unclean floors, and walls in resident rooms. This failure affects R1, R4, R5, R6, R7, R8, R9, R10 and R11 and has the potential to affect all 44 residents residing on the third floor. Findings Include, During the survey dates of 1/2/24 and 1/3/24, surveyor noted offensive odor on the third floor, hallway floors, bedrooms floors, walls, and resident's personal bathrooms floors, and walls, bed side tables were not clean, swept, or mopped. On 1/2/24 at 12:02 PM, R1 stated, I lived on the third floor then moved to the second floor. The third floor always smelled terrible. Now when I go up to the third floor to play bingo, the odor is so offensive. It smells like urine and feces during bingo. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff properly documented on the medication administration record. This failure affected one resident (R1) in the sample of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to manage R2's pain by not following physician orders to schedule a consultation at the pain clinic. This failure resulted in R2 experiencing dental pain rated as 10 out of 10 on a numerical rating pain scale, resulting in the pain radiating and R2 experiencing headache.

Inspectors wroteBased on interview and record review, the facility failed to ensure continuity of care after discharge for one resident (R4) by not setting up home health services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the appropriate discharge information, discharge date and time, for one resident (R4) was communicated to the receiving resident representative or Power of Attorney.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one resident (R4).

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and supervise residents; failed to implement post fall, fall prevention interventions and update a resident's care plan; failed to implement their policy to immediately report a resident found on the floor and assess a resident found on the floor for 2 of 3 residents (R2 and R4) reviewed for accidents and hazards on the sample list of four. These failures resulted in R2 falling and sustaining a left eyebrow laceration requiring repair at a local emergency room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess for pain and failed to monitor the effectiveness after pain medication administration. These failures apply to 1 of 3 residents (R3) reviewed for pain management on the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic consent form was filled out with the correct diagnosis and classification related to the prescribed antipsychotic medication was documented on the consent form for 1 of 3 residents (R1) reviewed for unnecessary medications on the sample list of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss Mattresses were set based on the residents' weight and failed to ensure the Low Air Loss Mattresses were layered with linens per facility policy. These failures affected 4 (R9, R107, R117, and R123) residents reviewed for pressure ulcer/injury prevention and treatment in a sample of 51 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change. This failure has the potential to affect all 20 residents on the 4E unit of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 4 East medication cart was free of loose pills which has the potential to affect all 20 residents in 4East and failed to ensure staff food item was not stored at the 4th floor's medication storage room refrigerator which has the potential to affect all 44 residents residing in 4th floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light device was within reach of the 2 residents (R56 and R80). This failure affected 2 residents out of the sample of 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident's room (R123) provides a homelike environment free of odors. This failure affected one resident out of a sample of 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff primed a new insulin pen to give the right initial dose of insulin during administration and failed to ensure staff administer dose of insulin per physician's order. These failures affected one resident (R80) reviewed for quality of care in a total sample of 51 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure g-tube placement was checked prior to flushing the g-tube and prior to administration of medication via a g-tube. This failure affected 1 of 4 (R80) residents reviewed for administration of medications in a total sample of 51 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that oxygen tubing is labeled when it is changed for 3 residents (R107, R111, R123). This failure has the potential to affect 3 residents (R107, R111, R123) out of a sample of 51 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5% for 3 out of 4 (R26, R80, and R110) residents reviewed for medication administration. There were 25 opportunities and 5 errors resulting in 20% medication administration error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain safe refrigerated food storage (refrigerator not defrosted) for one resident (R51); and failed to properly log refrigerator temperatures for three residents (R29, R51, and R104,). These failures have the potential to affect all 51 residents in the sample.