Continuing Healthcare at Willow Haven

Inspectors wroteBased on observation, medical record review, facility investigation review, interviews and Hoyer lift user instructional guide review, the facility failed to ensure a safe transfer when mechanical lifts were not maintained in good repair. This affected one resident (#40) of three residents reviewed for mechanical lift use. The facility census was 62. Findings Include:Review of the medical record for Resident #40 revealed an admission date of [DATE] with the latest readmission date of [DATE]. Diagnoses included chronic respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, obesity, congestive heart failure, chronic obstructive pulmonary disease, anxiety disorder, osteoarthritis, dependence on supplemental oxygen, angina pectoris, depression, overactive bladder, constipation, pain, anemia, hyperlipidemia, gastro-esophageal reflux disease and hypertension. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure storage of resident toileting equipment was maintained in a manner to prevent the potential spread of infection. This affected one resident (#40) of six sampled residents. The facility census was 62. Findings Include:On 06/09/26 at 10:12 A.M., an observation of Resident #40's bathroom revealed a peach bariatric bedpan and a gray fracture bedpan laying on the floor under the resident's sink without a protective barrier. On 06/09/26 at 11:15 A.M., an observation of Resident #40's bathroom revealed the peach bariatric bedpan and the gray fracture bedpan laying on the floor under the resident's sink without a protective barrier. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate when the nursing staff failed to document the continency status and meal consumption percentages of residents in their electronic medical records (EMR's) on each of the three shifts daily and when they occurred. This affected seven (Resident #7, #8, #13, #24, #58, #70, and #71) of seven residents reviewed.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure a resident representative was notified of a change in condition. This affected one resident (Resident #7) of eight residents reviewed for notification of change. The facility census was 69.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure meal intakes were monitored and recorded for every meal, as per the plan of care. This affected three (Resident #7, #8 and #71) of three residents reviewed for nutrition/ weight loss.

Inspectors wroteBased on closed record review, interview, and policy review the facility failed to prevent significant medication errors. This affected one resident (Resident #72) of eight residents reviewed for medications. The facility census was 69.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure residents received diets per orders to meet the resident's needs. This affected one resident (Resident #7) of three residents reviewed for nutrition. The facility census was 69.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure infection control interventions were implemented related to maintenance of a nephrostomy collection bag. This affected one resident (Resident #7) of one residents reviewed for nephrostomy maintenance. The facility census was 69.

Inspectors wroteBased on observations, review of purchase order history and interviews, the facility failed to ensure water temperatures in the shower rooms were at the appropriate temperature. The facility also failed to ensure a shower, sink, exhaust fan, and ceiling light were working appropriately and in good repair. This had the potential to affect 56 residents residing on Units 200, 300, 400 and 500. Facility census was 76.

Inspectors wroteBased on medical record review, review of a self-reported incident, facility investigation review, interview and policy review, the facility failed to complete a thorough investigation related to an allegation of misappropriation. This affected one resident (#78) of three residents reviewed for misappropriation. The facility census was 76.

Inspectors wroteBased on record review, interview and review of facility's medication administration policy, the facility failed to ensure medical records were accurate and complete regarding the administration of controlled substances. This affected two (Resident #55 and #56) of 25 residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on staff schedule review, payroll-based journal review, facility assessment review, policy review and interview, the facility failed to ensure adequate staffing to meet the needs and staffing as identified in the facility assessment. This had the potential to affect all residents residing within the facility. The census was 68. Findings Include: Review of the Facility Assessment Tool revised 03/24/25 revealed the facility average daily census was 69 to 78 residents. The facility staffing plan was based on the resident population and their varying needs for care and services, the general approach to help the facility gauge sufficient staff to assist in meeting the needs of the residents at any given time involves various factors including: [...]

Inspectors wroteBased on payroll-based journal review, staffing schedule review, policy review and interview, the facility failed to provide eight hours of consecutive registered nurse (RN) hours per day. This had the potential to affect all 68 residents residing within the facility.

Inspectors wroteBased on observation, manufacturer review, policy review and interview, the facility failed to maintain a safe and sanitary kitchen. This had the potential to affect all 68 residents that received food from the kitchen.

Inspectors wroteBased on review of the facility surety bond, review of fund balance form, and interview the facility failed to ensure the surety bond had not lapsed. This affected 42 residents (Resident #11, #12, #13, #15, #16, #17, #19, #22, #23, #26, #27 (two accounts), #2 (two accounts), #28, #29, #31, #33, #34, #3, #39, #40, #5, #42, #43, #45, #47, #48, #49, #51, #52, #54, #8, #55, #10, #58, #59, #60, #61, #62, #65, #64, #9 (two accounts), and #67 out of 68 residents identified as having a resident funds account. [...]

Inspectors wroteBased on observation, policy review and interview, the facility failed to maintain a clean and sanitary physical environment, failed to ensure a homelike dining experience and failed to ensure adequate supplies/linens were available for resident use. This affected 16 residents observed eating in the main dining room (Resident #2, #3, #6, #8, #15, #18, #19, #20, #25, #28, #29, #31, #44, #45, #47, and #52), three resident's (#9, #69 and #80) air conditioner unit, nine resident rooms (Resident's #2, #6, #8, #18, #19, #45, #47, #65 and #80) and had the potential to affect all 68 residents residing within the facility. 1. On 08/11/25 between 11:28 A.M. and 11:35 A.M., observation and interview with Resident #59 revealed upon entering the room the floor was sticky causing your shoes to make a snapping noise as you walked across the floor. [...]

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure dependent residents were assisted with nailcare and shaving. This affected four residents (#2, #5, #10 and #19) of seven residents reviewed for activities of daily living. The census was 68. Findings Include:1. Review of Resident #2's medical record revealed a 07/12/25 admission with diagnoses including fracture of left femur, vascular dementia, hypertensive heart disease, congested heart failure, depression, muscle wasting and atrophy, abnormalities of gait and mobility, weakness, history of falling, anxiety disorder, Vitamin B deficiency, chronic stage III kidney disease, gastroesophageal reflux disease, disorientation, hypertension, spondylolisthesis lumbar region, and cardiac murmur. [...]

Inspectors wroteBased on medical record review and interview the facility failed to ensure medical records were complete and accurate. This affected four residents (#48, #72, #77, and #80) of 27 resident records reviewed. Findings Include: 1. Closed record review revealed Resident #72 was admitted to the facility on [DATE] from another long-term facility. The resident admission diagnoses included malignant neoplasm of right and left female breast, atrial fibrillation, anemia, hyperlipidemia, hypocalcemia, anxiety, insomnia, essential hypertension, constipation, psoriasis, osteoporosis, chronic kidney disease, pain, use of anticoagulants, and difficulty walking. The resident expired in the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, observation, interviews, and policy reviews the facility failed to ensure enhanced barrier precaution (EBP) were implemented/maintained and infection control practices were maintained during incontinence care. This affected three residents (#1, #32, and #42) of four residents observed on 100-unit for EBP and two residents (#20 and #77) of two residents observed for incontinence care. Findings Include: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube. Review of Resident #32' EBP plan of care dated 07/23/25 revealed to use appropriate EPB when performing the following care: dressing, bathing, showering, transferring, hygiene care, changing linen, toileting, and peri care. Dispose of EBP in the appropriate containers. [...]

Inspectors wroteBased on observation, record review, review of manufacturer guidelines and interview, the facility failed to ensure an exit door, clothes dryer, air conditioner and refrigerator were maintained. This had the potential to affect all 68 residents in the facility. The census was 68. Findings Include:1. Review of an elopement investigation dated 05/19/25 revealed the facility determined the 100 hall door was not locked as the key panel indicated. Interview on 08/21/25 at 8:51 A.M. with Maintenance Staff #173 revealed the 100 hall exit door is an Advantage 500 DE System. It was not connected to a Wanderguard system. The door at the end of the 100 hall had a key pad. The door was hardwired with a battery back up. The doors had a red and green light on the keypad. Red means locked and green open. The door was pushed to see if it opened during weekly door checks. [...]

Inspectors wroteBased on record review, interview, and policy review, it was determined the facility failed to ensure residents' code status' were accurate. This affected two residents (#2, #72) of 28 residents reviewed for accurate code status. Findings Include: 1. Closed record review revealed Resident #72 was admitted to the facility on [DATE] from another long-term care facility. The resident admission diagnoses included malignant neoplasm of right and left female breast, atrial fibrillation, anemia, hyperlipidemia, hypocalcemia, anxiety, insomnia, essential hypertension, constipation, psoriasis, osteoporosis, chronic kidney disease, pain, use of anticoagulants, and difficulty walking. The resident expired in the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure pharmacy recommendations were addressed including a rationale for declining gradual dose reductions. This affected one resident (#67) of five residents reviewed for unnecessary medications. The census was 68. Findings Include:Medical record review revealed Resident #67 was admitted on [DATE] and readmitted on [DATE] with diagnoses including depression, anxiety disorder and traumatic subdural hemorrhage. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact for daily decision-making and had an anxiety disorder. Review of the Pharmacist's Recommendation to Prescriber dated 12/09/24 revealed Resident #67 had a PRN (as needed) order for the psychotropic medication, Lorazepam (anxiolytic) 0.5 milligrams. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to complete an admission comprehensive assessment timely as required. This affected one resident (#80) of 24 residents sampled. The census was 68. Findings Include: Medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including fractured vertebrae, end stage renal disease, dependence on renal dialysis and dysphagia. The resident was discharged from the facility on 08/18/25. Review of Resident #80's Minimum Data Set 3.0 (MDS) assessments in the electronic medical record revealed no completed MDS assessments were available for review. Both the admission MDS assessment dated [DATE] and a 5-day MDS assessment dated [DATE] were not completed or submitted as required within 14 days of admission. [...]

Inspectors wroteBased on medical record review and interview the facility failed to ensure a significant change of condition Minimum Data Set (MDS) was completed timely. This affected one resident (#3) of one record reviewed for hospice. Findings Include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, peripheral vascular disease, heart failure, urinary retention, depression, and was admitted to hospice on 07/07/25. Review of Resident #3's orders dated 07/07/25 revealed the resident was admitted to hospice. Review of Resident #3's hospice plan of care dated 07/10/25 revealed the resident/responsible party had elected to utilize hospice/end-of-life care services. Review of Resident #3's MDS revealed no evidence of significant change of condition MDS was completed. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected one resident (#54) of 24 residents reviewed for comprehensive assessments. The census was 68.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure residents maintained activities of daily living including range of motion and ambulation. This affected one resident (#59) of six residents reviewed for activities of daily living (ADL). The census was 68.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to obtain treatment orders and comprehensively assess skin alterations. This affected two residents (#19, #77) of three residents reviewed for care and treatment. Findings Include: 1. [...]

Inspectors wroteBased on medical record review, observation, policy review, and interview the facility failed to complete comprehensive assessment of pressure ulcer skin impairments, failed to provide pressure prevention interventions, and failed to follow infection control practices during the changing of a pressure ulcer dressing. This affected one resident (#77) of three residents reviewed for pressure ulcers. The facility census was 68. Findings Include:Medical record review revealed Resident #77 had multiple admissions to the facility and was most recently admitted on [DATE] with diagnoses including peripheral arterial disease, diabetes mellitus, bilateral below the knee amputations (BKA) and multiple wounds. Review of the census revealed the resident was discharged to the hospital on [DATE] with a diagnosis of encephalopathy and returned to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, review of hospital records, and interview the facility failed to ensure a resident gastrostomy tube was properly managed. This affected one resident (#32) of one resident reviewed for gastrostomy tube. The facility census was 68. Findings Include: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including unspecified protein-calorie deficit, gastrostomy, gastro-esophageal reflux disease, bariatric surgery status, peritoneal abscess, pain, vitamin deficiency, nausea with vomiting, hypokalemia, insomnia, muscle spasms, vitamin D deficiency, sepsis, chronic obstructive pulmonary disease, drug induced subacute dyskinesia, type diabetes, muscle wasting, muscle weakness, depression, attention-deficit hyperactivity, venous insufficiency, and atherosclerotic heart disease. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and failed to assist with the application of a respiratory device. This affected three residents (#5, #45 and #48) of three residents reviewed for respiratory care. The census was 68. Findings Include:1. Review of Resident #48 revealed a 05/18/22 admission with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, Obstructive sleep apnea (OSA), diabetes, asthma, hemiplegia, and anxiety disorder. Review of the 06/30/25 Quarterly Minimum Data Set Assessment included the resident was moderately impaired for daily decision, on oxygen and a non invasive mechanical ventilator. Physician orders included an order dated 03/25/22 for non-invasive home ventilator (Trilogy machine) Settings: AVAPS-AE Breath Rate: [...]

Inspectors wroteBased on observation, medical record review, dialysis contract review, policy review and interview, the facility failed to ensure ongoing communication with the dialysis center, failed to fulfill the dialysis center contract as agreed upon and failed to ensure dialysis orders were acted upon timely and administered. This affected one resident (#80) of one resident reviewed for dialysis. The census was 68.

Inspectors wroteBased on observation, medical record review, job description review and interview, the facility failed to timely provide psychiatric services as indicated by mood symptoms. This affected one resident (#46) of five residents reviewed for unnecessary medications. The census was 68.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure expired insulin was discarded. This affected one resident (#77) of three residents with insulin pens observed in the 200-medication cart. The facility census was 68. Findings Include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] from a sister facility with diagnoses including diabetes, heart disease, and chronic kidney disease. Review of Resident #77 orders dated 08/2025 revealed Humalog Kwikpen subcutaneous pen injector inject per sliding scale before meals. There was no evidence the resident was ordered Novolog. Review of Resident #77 Medication Administration Records (MAR) revealed Resident #77 received Humalog per sliding scale 11 times from [DATE] to [DATE]. [...]

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to adequately monitor for appropriate use of opioids. This affected one resident (#67) of five residents reviewed for unnecessary medications. The census was 68.

Inspectors wroteBased on medical record review, review of hospital discharge orders, and interview the facility failed to ensure laboratory testing was performed per orders. This affected one resident (#82) of six residents reviewed for medication review. Findings Include:Closed medical record review revealed Resident #82 was admitted to the facility on [DATE] and discharged on 06/30/25 with diagnoses including osteomyelitis, diabetes, methicillin susceptible staphylococcus aureus, and absence of left foot. Review of Resident #82's discharge hospital notes dated 06/16/25 revealed orders for the following laboratory work: weekly complete blood count (CBC), basic metabolic profile (BMP), and creatine Kinase (CK) weekly until 07/16/25. Review of Resident #82's medical record revealed no evidence a CBC, BMP, or CK was performed. [...]

Inspectors wroteBased on medical record review, review of infection control log, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected two residents (#1 and #83) of four residents reviewed for antibiotic stewardship. Findings Include: 1. Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including sepsis of unspecific organism, metabolic encephalopathy, diabetes, respiratory failure, heart disease, and pressure ulcer. Review of Resident #83's orders revealed on 06/01/25 the resident was ordered Cefdinir 300 milligrams (mg) by mouth twice daily for wound infection. On 06/03/25 the order was changed to Cefdinir 300mg by mouth twice daily for sepsis, likely respiratory until 06/05/25. [...]

Inspectors wroteBased on record review, review of the facility's Resident Welcome Packet, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to have their mail delivered to them unopened. This affected two residents (#19 and #69) of three residents reviewed.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure timely resolution of a concern regarding missing resident property. This affected one (Resident #10) of three residents reviewed for misappropriation. The facility census was 74.

Inspectors wroteBased on closed medical record review and interview, the facility failed to ensure comprehensive resident information was provided to the receiving facility regarding a transfer. This affected one (Resident #10) of three residents reviewed for death. The facility census was 74.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of a facility investigation and follow up, and staff interview the facility failed to ensure coordination of care for Resident #79 related to a gynecology appointment to timely address medical symptoms. This affected one resident (#79) of three residents reviewed for appointments. The facility census was 76.

Inspectors wroteBased on record review, review of concern reports, review of dental treatment plan quotes, email correspondence between facility staff and the corporate office, resident interview, family interview, staff interview, and policy review, the facility failed to ensure a resident's concern pertaining to missing upper dentures were addressed timely for a resolution. This affected one (Resident #17) of three residents reviewed for missing property.

Inspectors wroteBased on record review, review of the facility's timeline and related investigation, review of staff education records, resident interview, staff interview, and policy review, the facility failed to ensure nursing staff were adequately trained and knowledgeable on the use of Negative-Pressure Wound Therapy (NPWT) (wound vac) and were able to maintain, monitor, and intervene appropriately when complications arose. They also failed to implement a physician's order to obtain a CT scan and refer a resident to a surgeon when he showed signs of an infected abdominal wound. This affected one resident (#10) of one resident reviewed for wound vac therapy management. [...]

Inspectors wroteBased on observation, maintenance log review, weather history review, policy review and interview, the facility failed to maintain a comfortable and safe living environment. This affected five residents (#105, #108, #110, #111, and #114) in the facility. The census was 71.

Inspectors wroteBased on observation, policy review and interview, the facility failed to maintain a safe and hazard free environment. This had affected 14 residents (#101, #109, #114, #115, #117, #119, #125, #130, #138, #140, #156, #164, #166 and #171) identified by the facility as cognitively impaired and independent with mobility. The census was 71.

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure residents had a homelike environment. This affected two (Residents #3 and #38) of five residents reviewed for physical environment. The facility census was 78.

Inspectors wroteBased on record review, review of the facility's resident concern log and related reports, resident interview, staff interview, and policy review, the facility failed to ensure resident grievances/ concerns were responded to timely. This affected two (Resident #10 and #38) of two residents reviewed for personal property.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to implement a care plan related to refusal of pressure ulcer interventions. This affected one (Resident #15) of four residents reviewed for pressure ulcers. The census was 78. Findings Include: Record review revealed Resident #15 was admitted to the facility on [DATE]. Her diagnoses were encounter for other orthopedic aftercare, presence of right artificial hip joint, displaced fracture of posterior wall of right acetabulum, atrial fibrillation, hypo-osmolality and hyponatremia, post traumatic stress disorder, vitamin D deficiency, morbid obesity, insomnia, hypertension, bipolar disorder, hyperkalemia, major depressive disorder, acute kidney failure, hyperlipidemia, osteoporosis, anxiety disorder, dorsalgia, and osteoarthritis. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide oral care to a resident dependent on staff for care. This affected one (Resident #43) out of four reviewed for activities of daily living. The facility census was 78. Findings Include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including dysphasia, cognitive communication deficit, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was severely cognitively impaired and required staff assistance with oral care. Review of functional abilities and goals assessment dated [DATE] revealed Resident #43 required supervision or touch assistance with oral hygiene. Review of the self-care task, question #2 between 03/25/24 and 03/27/24 for Resident #43 revealed oral care was provided on: [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident's bruise was timely identified and monitored as per his plan of care. This affected one (Resident #60) of two residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide options for vision and hearing services to all residents, and failed to timely schedule all vision/hearing appointments as desired by the residents. This affected three (Residents #49, #35, and #66) of three residents reviewed for ancillary services. The census was 78. Findings Include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review, interview, and observation the facility failed to monitor and provide appropriate incontinence care for Resident #8's urostomy. This affected one resident (Resident #48) out of one reviewed for bowel and bladder. The facility census was 78. Findings Include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] due to Alzheimer's, chronic kidney disease, major depressive disorder, and cancer of the urinary tract system. The resident had an urostomy. Review of the Minimum Data Set (MDS) 3.0 completed on 03/12/24 revealed Resident #48 was severely cognitively impaired and required set up assistance for ADL's. Review of the Care Plan completed on 03/26/24 for Resident #48 revealed she was at risk for impaired skin integrity related to fragile skin and the ostomy or wound nurse were consulted for wound care. [...]

Inspectors wroteBased on record review and interview, the facility failed to effectively communicate with a dialysis provider for Resident #66. This affected one of one resident reviewed for dialysis (#66). The facility census was 78.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide pain parameters for as needed pain medications, and administered as needed pain medications without pain parameters. This affected two (Residents #22 and #49) of five residents reviewed for unnecessary medications. The census was 78. Findings Include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review, resident interview, staff interview, and policy review the facility failed to complete dental consents and/or timely schedule dental appointments for a resident. This affected one resident (Resident #35.) The census was 78.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain resident care equipment and furnishings in a safe and sanitary condition. This affected two (Resident #10 and #26) of 24 residents reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's Power of Attorney (POA) was provided with and signed an admission agreement upon the resident's admission into the facility that informed them of the resident's rights, services to the resident, and of the rules and regulations governing the resident's conduct and responsibilities during his stay in the facility. This affected one of one residents (#73) reviewed for the admission process.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure fall interventions were implemented and failed to complete a comprehensive fall investigation after a fall resulting in serious injury. Actual Harm occurred on 01/15/23 when Resident #28, who was assessed to have moderate cognitive impairment, required extensive assistance of one staff member for toilet use and transfers and was identified as a fall risk, was instructed by staff (while in the bathroom with the resident) to transfer from the sink to the toilet without staff assistance and while wearing improper footwear, resulting in a fall. The resident sustained a fractured left femur (thigh bone) and possible nondisplaced fracture of the left wrist. This affected one resident (Resident #28) of two residents reviewed for falls. The census was 71.

Inspectors wroteBased on observation, review of narcotic inventory sheet, interview, and policy review the facility failed to ensure contingency narcotics were reconciled every shift. This had the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, review of narcotic inventory sheet, review of control sheets, interview, and policy review the facility failed to ensure medications were properly stored and labeled. This affected one resident (Resident #63) but had the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately inform/specify in writing, the services that would be discontinued. This affected two residents (Resident #71 and Resident #72) of three resident beneficiary notices reviewed. The census was 71. Findings Include: 1. Resident #71 was admitted to the facility on [DATE]. His diagnoses were heart failure, cerebral infarction, type II diabetes, morbid obesity, obstructive sleep apnea, major depressive disorder, hypertension, atrial fibrillation, dementia, atherosclerotic heart disease, and facial weakness. Review of his minimum data set assessment, dated 04/18/23, revealed he had a significant cognitive impairment. Review of Resident #71 beneficiary notice form, dated 04/22/23, revealed a discontinuation of services would end on that day. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #21 and Resident #24) of three residents reviewed for PASRR documents. The census was 71. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, morbid obesity, nondisplaced fracture of greater trochanter of left femur, atrial fibrillation, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder (08/11/20), osteoarthritis, hypertension, and abnormal weight loss. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two residents (Resident #21 and Resident #24) of three residents reviewed for PASRR documents. The census was 71. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, morbid obesity, nondisplaced fracture of greater trochanter of left femur, atrial fibrillation, major depressive disorder, atherosclerotic heart disease, hyperlipidemia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder (08/11/20), osteoarthritis, hypertension, and abnormal weight loss. Review of her Minimum Data Set (MDS) assessment, dated 02/06/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure nail care was provided to Resident #55, who was dependent on staff for personal hygiene. This affected one resident (Resident #55) of two residents reviewed for activities of daily living (ADLs). The facility census was 71.

Inspectors wroteBased on closed record review, hospital record review, and interview the facility failed to timely provide intervention with a resident condition change resulting in hospitalization. This affected one resident (Resident #69) of one residents reviewed for hospitalization. The census was 71.

Inspectors wroteBased on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when it was above to Medicaid allowable limit. This affected three residents (Residents #39, #48, and #49) of six resident financial information reviewed. The census was 71. Findings Include: 1. Resident #39 was admitted to the facility on [DATE]. Her diagnoses were unspecified injury of head, type II diabetes, asthma, cerebral infarction, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hyperlipidemia, major depressive disorder, hypertension, cerebral aneurysm, obesity, osteoarthritis, and repeated falls. Review of her Minimum Data Set (MDS) assessment, dated 03/06/23, revealed she mad a mild cognitive impairment. [...]

Inspectors wroteBased on observation, medical record review, review of drug inserts instruction sheet, interview, and policy review the facility failed to ensure the medication administration error rate was not greater than five percent. Two medication errors out of 32 opportunities were observed resulting in a 6.25% medication error rate. This affected two residents (Resident #24 and #31) of four residents observed for medication administration.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure medication and glucose monitoring were completed to maintain sanitary conditions to prevent the spread of infections. This affected one resident (Resident #47) of four observed for medication administration.

Inspectors wroteBased on medical record review, McGeer Criteria for Infection Surveillance Checklist review and interview, the facility failed to ensure antibiotics administered for a urinary tract infection (UTI) met criteria prior to the administration of the antibiotic. This affected one resident (Resident #28) of three residents reviewed for urinary tract infection. The facility census was 71.