Continuing Healthcare of Cuyahoga Falls

Inspectors wroteBased on record review, review of the facility ombudsman notification log and staff interview, the facility failed to ensure the State Long Term Care (LTC) Ombudsman Office was notified of resident discharges from the facility. This affected one resident (Resident #61) of one resident reviewed for discharge. The facility census was 56.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within fourteen days of completion as required. This affected one resident (Resident #18) of one resident reviewed for resident assessments. The facility census was 56.

Inspectors wroteBased on medical record review, staff interviews, and an interview with a representative from the State Pre-admission Screening and Resident Review (PASRR) authority (The Ohio Department of Mental Health and Addiction Services), the facility failed to ensure PASRR recommendations for placement and related services were implemented and incorporated into the resident's comprehensive care plan. This deficient practice affected one resident (Resident #42) of two residents reviewed for PASRR assessments. The facility census was 56.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer masks and tubing were dated and stored appropriately. This affected two residents (Residents #55 and #56) out of two residents reviewed for respiratory care. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to ensure parameters for Resident #49's blood pressure medications were monitored before administration. This affected one of five residents reviewed for unnecessary medications. The total census was 56.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory medications were stored securely. This affected one resident (Resident #55) out of six residents reviewed for medication administration. The facility census was 56.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure all doors of the secured unit remained in functioning order and failed to ensure Resident #18 was accurately assessed for risk of falls. This affected 17 residents (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #46, #47, #49, #51, and #53) of 17 residents residing on the secured unit and one resident (Resident #18) of three residents reviewed for falls. The facility census was 55. Findings Include:1. Observation of the secured unit on 03/29/26 at 1:57 P.M. revealed there were three entry and exit points. The Assistant Director of Nursing (ADON) was present during the observation and confirmed there were three entry and exit points to the unit. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide the necessary dementia care and treatment to maintain the safety and well being residents on the dementia unit. This affected Resident #56 and had the ability to affect all 17 residents residing on the secured unit (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #47, #46, #49, #51, and #53). The facility census was 55. Findings Include:Resident #56 was admitted to the facility on [DATE] with diagnoses including vascular dementia severe without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol induced persisting dementia, anxiety disorder, restlessness and agitation, and generalized anxiety disorder. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure all doors of the secured unit remained in functioning order. This affected 17 residents (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #46, #47, #49, #51, and #53) of 17 residents residing on the secured unit. Findings Include:Observation of the secured unit on 03/29/26 at 1:57 P.M. revealed there were three entry and exit points. The Assistant Director of Nursing (ADON) was present during the observation and confirmed there were three entry and exit points to the unit. The door leading to the Buckeye unit and dining room/kitchen area would not open even after being pressed on for over one minute. No alarms sounded while the doors were pushed on. A code had to be entered to access/leave the unit. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to report an injury of unknown origin to the State Agency for Resident #18. This affected one (Resident #18) of three residents reviewed for reporting alleged violations. The facility census was 55.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to investigate an injury of unknown origin for Resident #18. This affected one (Resident #18) of three residents reviewed for investigation. The facility census was 55.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Resident #56's immediate discharge was documented accurately and included in the medical record. This affected one resident (Resident #56) of one resident reviewed for discharge. The facility census was 55. Findings Include:Resident #56 was admitted to the facility on [DATE] with diagnoses including vascular dementia severe without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol induced persisting dementia, anxiety disorder, restlessness and agitation, and generalized anxiety disorder. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurately completed. This affected three (Residents #18, #42 and #48) of seven residents reviewed for assessments. The facility census was 55.

Inspectors wroteBased on record review and interview, the facility failed to ensure dependent residents received showers as scheduled. This affected one (Resident #18) of three residents reviewed for showers. The facility census was 55.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure to audiology services and intervention were implemented properly. This affected two (Residents #21 and #32) of three residents reviewed for audiology services. The facility census was 55.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received pain medications as ordered. This affected one (Resident #21) of one reviewed for pain management. The facility census was 55.

Inspectors wroteBased on interview, record review, policy review, and job description review, the facility failed to ensure Resident #21 and Resident #32 received ancillary services timely. This affected two residents (Residents #32 and #21) of four residents reviewed for medically related social services. The facility census was 55. Findings Include:1. Resident #32 was admitted to the facility on [DATE] with diagnoses including a right ilium fracture, a motor vehicle accident with injuries, chronic obstructive pulmonary disease (COPD), major depressive disorder, acute pain due to trauma, bipolar disorder with psychotic features, anxiety disorder, history of malignant carcinoid tumor of bronchus and lung, malignant neoplasm of the bladder, and a urostomy (a surgical opening created in the abdominal wall to divert urine outside the body when the bladder is removed, commonly due to cancer or injury). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #32's medical record accurately reflected ostomy care. This affected one resident (Resident #32) of one resident reviewed for ostomy care. The facility census was 55. Findings Include:Resident #32 was admitted to the facility on [DATE] with diagnoses of a motor vehicle accident with multiple fractures, chronic obstructive pulmonary disease, major depressive disorder, bipolar disorder with psychotic features, obstructive and reflux uropathy, anxiety disorder, artificial openings of urinary tract status, malignant neoplasm of bladder, and history of malignant carcinoid tumor of the bronchus and lung. Review of the physician's orders dated 09/12/25 revealed Resident #32 was to have urostomy care on day shift every three days. [...]

Inspectors wroteBased on observation, review of the facility menus, interview with staff, and review of facility policy, the facility failed to follow the lunch menu for the residents. This affected all 63 residents in the facility who received their meals from the dining room. The facility census was 63. Findings Include:Review of the menu for 02/25/26 revealed the facility was to serve a corn dog, cheesy mashed potatoes, mixed vegetables, white bread and yellow cake for lunch. Observation of meal service on 02/25/26 at 11:40 A.M. revealed [NAME] #130 was serving corn dogs, regular mashed potatoes, mixed vegetables and vanilla pudding. There was no cheese in the mashed potatoes, no bread was given to the residents and they did not have yellow cake. On 02/25/26 at 12:15 P.M. an interview with [NAME] #130 revealed she did not make the mashed potatoes cheesy and there was not a reason why she did not. [...]

Inspectors wroteBased on observations, interview, and review of facility policy, the facility failed to maintain a safe sanitary kitchen. This affected all 63 residents who ate their meals from the facility kitchen. The facility census was 63. Findings Include: Observations of the kitchen with Corporate Dietary Manager #128 on 02/25/26 at 10:10 A.M. revealed the following concerns:a. There were two 50-gallon trash cans with no lids on them. b. The utensil drawer with the scoops and ladles had a red, sticky substance spilled down inside the drawer with the scoops and ladles laying in it.c. The stainless stain shelf under the steam table had food and a yellow liquid spilled on it.d. There were three three-tiered red food carts which were soiled with food debris and a white liquid dried on them.e. Two-large tubs of rice crispy cereal were not labeled as to when they were opened.f. [...]

Inspectors wroteBased on observation, review of the medical record, interview with the staff, and review of the facility policy, the facility failed to knock on the door before entering the room of Resident #26. This affected one resident (Resident #26) of five residents observed during medication administration. Findings Include:Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive and post-traumatic stress disorder. Observation on 02/25/26 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #133 prepared the medication for Resident #26 at the medication cart in the hallway and then walked right into his room without knocking on the door. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the bathroom of Resident #10 was maintained in a safe, comfortable manner. This affected one resident (Resident #10) of eight residents observed for environment. Findings Include:Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, severe protein calorie malnutrition, peripheral vascular disease, hypertension, depression, chronic kidney disease, and left eye blindness. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #10 had moderately impaired cognition, no psychosis, and no behaviors. The assessment stated the resident required setup or clean-up assistance for toileting and she was occasionally incontinent of urine and always continent of bowel. Observation on 02/25/26 at 11:10 A.M. [...]

Inspectors wroteBased on review of the medical record and interview, the facility failed to ensure accurate acquiring, receiving, dispensing, and administering of Resident #32's eye drops. This affected one resident (Resident #32) of three reviewed for administering medication per physician's orders. Findings Include:Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included heart failure, protein-calorie malnutrition, nontraumatic subdural hemorrhage, Wernicke's encephalopathy, macular degeneration, cataracts, diverticulosis, alcohol abuse, fatty liver, hypothyroidism, pancreatitis, and adrenal gland disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #32 had intact cognition. Further review of the medical record revealed Resident #32 had cataract surgery on 02/25/26. [...]

Inspectors wroteBased on observation, review of the medical record, interview, and review of facility policies, the facility failed to maintain appropriate infection control while administering medication to Resident #21 and #26 and failed to ensure feces-soiled linens were properly contained during care for Resident #20. This affected three residents (Resident #20, #21, and #26) of eight observed for infection control and medication administration. Findings Include:1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, visual loss, mood disorder, psychosis. Prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive and post-traumatic stress disorder. Observation of medication administration on 02/25/26 at 9:00 A.M. [...]

Inspectors wroteBased on record review, interviews, Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure timely and accurate documentation of COVID-19 outbreak identification and reporting. Residents tested positive for COVID-19 between 01/02/26 and 01/03/26; however, documentation reflected delays in notifying residents' responsible parties until 01/06/26 and the county health department until 01/07/26. This affected three residents (#11, #60 and #64) who tested positive for COVID-19 and were not timely notified, 24 residents (#1, #6, #7, #9, #12, #14, #17, #19, #20, #22, #26, #27, #31, #34, #37, #38, #43, #45, #48, #53, #55, #59, #62, #63) who were neither tested nor had documented outbreak notification. The facility census was 63.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served per the dietitian approved menu. This finding affected seven (Residents #14, #21, #22, #27, #40, #44 and #57) residents and had the potential to affect all residents who eat meals in the facility. The facility census was 65.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure sufficient supervision and intervention was implemented to prevent Resident #11's from eloping, failed to ensure Resident #71 was transferred with staff assistance in a safe and dignified manner, and failed to ensure proper smoking procedures were implemented for five residents (#32, #34, #42, #48 and #52). This finding affected one (Resident #56) of three residents reviewed for elopement; one (Resident #71) of three residents reviewed for transfers; and five residents (#32, #34, #42, #48 and #52) of 17 smokers who reside in the facility. Facility census was 65.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the safe handling, transport, and separation of laundry to minimize the risk of exposure to contaminated items. This had the potential to affect all 65 residents who resided in the facility at the time of the survey.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure resident advance directives matched across paper and electronic medical records (EMR). This affected four residents (#8, #12, #32, #42) of four residents reviewed for advance directives. Facility census was 65.

Inspectors wroteBased on review of medical records, facility policies and interviews the facility failed to ensure resident weights were recorded and monitored to ensure nutritional needs were met. This affected four residents (Residents #5, #38, #59, and #63) of five reviewed for nutrition. The facility census was 65.

Inspectors wroteBased on observation, interview, facility policy review and facility assessment review, the facility failed to ensure adequate staffing was provided for the memory care unit. This affected 20 residents (Residents #5, #11, #14, #19, #21, #22, #24, #31, #36, #38, #40, #41, #44, #46, #54, #57, #59, #61, #63 and #65) of 20 residents on the memory care unit. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #15 was offered a care conference meeting quarterly or as needed. This affected one resident (Resident #15) of one reviewed for care conference meetings. The census was 65.

Inspectors wroteBased on medical record review, interview, review of the United States (U.S.) Food and Drug Administration (FDA) latest approved labeling information for Zyprexa, and review of facility policy, the facility failed to ensure antipsychotics were prescribed only as indicated and the resident was monitored appropriately for potential side effects. This affected one Resident (Resident #9) of seven residents who were reviewed for unnecessary medications. The facility census was 65.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure comprehensive care plans were completed for one resident (Resident #63) of six reviewed for care plans. The facility census was 65.

Inspectors wroteBased on record review, interviews, and facility bathing policy, the facility failed to ensure bathing was provided and documented for one independent resident (Resident #61) of three reviewed for bathing. The facility census was 65.

Inspectors wroteBased on record review, interviews, and facility bathing policy, the facility failed to ensure bathing was provided and documented for two dependent residents (Residents #14 and #63) of three reviewed for bathing. The facility census was 65.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two residents (#6 and #10) of five residents reviewed for unnecessary medications. Facility census was 65.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 28 medications were administered with two errors for a medication error rate of 7.14%. This finding affected two (Residents #11 and #49) of six residents observed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were provided per preference. This affected one resident (#42) of seven residents observed at meals and reviewed for nutrition. Facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse prevention policy and procedure to ensure new staff were checked on the Nurse Aide Registry as required. This has the potential to affect all 65 residents in the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete employee physical screenings prior to employment. This had the potential to affect all 65 residents at the facility.

Inspectors wroteBased on interview, facility policy and assessment review, the facility failed to ensure the facility assessment was comprehensive as required. This had the potential to affect all residents residing at the facility. The facility census was 65.

Inspectors wroteBased on observation and interviews, the facility failed to maintain resident rooms in a safe and sanitary condition. This affected six residents (#18, #20, #22, #24, #55, and #56) of 12 residents observed for environment. The facility census was 56.

Inspectors wroteBased on record review, observations and interview, the facility failed to provide therapeutic activities in the secured memory care unit to meet the physical, mental and pscyho-social wellbeing of the residents. This affected all 18 residents in the memory care unit. The facility census was 56.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure medications were labeled, unexpired, and stored in an appropriate manner. This had the potential to affect all residents served from two of two storage rooms, two of two treatment carts, and two of three medication carts available for medication storage in the facility.

Inspectors wroteBased on observation, interview and facility policy, the facility failed to provide food at appetizing temperatures. This had the potential to affect 55 of 56 residents as the facility identified Resident #17 as receiving no food by mouth. Facility census was 56.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure appropriate infection control procedures were followed. This affected three residents (Resident #18 Resident #20, and Resident #52) out of three residents reviewed for infection control procedures. The facility census was 56.1. Review of Resident #20's medical record revealed an admission date of 10/01/21. Diagnoses included dementia, dysphagia, psoriatic arthritis, essential hypertension, neuromuscular dysfunction of bladder, anxiety and colostomy. Review of Resident #20's physician order dated 12/16/24 for Enhanced Barrier Precautions (EBP) revealed orders for protective personal equipment (PPE): gloves/gown during high-contact resident care activities. Review of Resident #20 Care Plan dated 04/22/25 revealed resident was at risk for malnutrition and weight loss and required the use of an ostomy. [...]

Inspectors wroteBased on record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure residents received adequate nutritional and communication assistance. This affected one Resident (#20) of three reviewed for activities of daily living (ADL's). The facility census was 56. Review of Resident #20's medical record revealed an admission date of 10/01/21. Diagnoses included dementia, dysphagia, psoriatic arthritis, essential hypertension, neuromuscular dysfunction of bladder, anxiety and colostomy. Review of Resident #20 Care Plan dated 04/22/25 revealed resident was at risk for malnutrition and weight loss and required interventions including providing assistance with all meals, snacks and supplements. Resident had a communication impairment with interventions that included using communication tools, terms, gestures the resident can understand. [...]

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure Resident #55 blood sugar was monitored appropriately. This affected one resident (Resident #55) of three residents reviewed for quality of care. Facility census was 56. Resident #55 was admitted to the facility on [DATE] and had diagnoses including heart failure, type 2 diabetes, atrial fibrillation (abnormal heart rhythm), and low back pain. Resident #55 had an order dated 06/20/25 for a Dexcom G7 Sensor (a wearable continuous blood sugar monitor) for blood sugars every ten days. Review of the Medication Administration Record (MAR) for 08/01/2025 to 08/31/25 revealed on 08/20/25 Resident #55 did not receive the Dexcom G7 Sensor due to being out of the facility without medications and on 08/30/25 nothing was indicated on the MAR; the entry was blank. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #22 received treatment to maintain vision. This affected one resident (Resident #22) of three residents reviewed for vision. The facility census was 56. Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome of bilateral lacrimal glands and bilateral combined forms of age-related cataract. Review of an annual Minimum Data Set (MDS) 3.0 assessment completed on 08/01/25 revealed Resident #22 was alert and oriented with intact cognition. Further review revealed Resident #22 vision was severely impaired. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Resident #44 was free from significant medication error. This affected one resident (Resident #44) of three residents reviewed for medications.

Inspectors wroteBased on medical record review, staff interview, review of imaging reports, review of hospital records, and facility policy review, the facility failed to ensure complaints and origins of pain were comprehensively evaluated and timely reported to a physician. This resulted in Actual Harm on 07/11/25 when Resident #150, who had severely impaired cognition and who was dependent on staff for all activities of daily living (ADLs), was identified to have bruising and pain in her right hip and was observed by staff grabbing her right thigh. Resident #150's pain medication was changed from as needed to routine, and Resident #150 continued to have pain with no evidence of a thorough pain assessment or assessment of range of motion to the affected extremity. Between 07/11/25 and 07/16/25, Resident #150 continued to have breakthrough pain. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#112) out of three residents reviewed for insulin administration. The facility identifieid ten residents who required insulin. The facility census was 50.

Inspectors wroteBased on observations, resident and staff interviews and record reviews, the facility failed to ensure resident refrigerators were monitored for sanitary conditions and that food was maintained at temperatures safe for consumption. This affected 17 (#6, #8, #9, #12, #13, #17, #19, #20, #25, #29, #30, #31, #32, #36, #40, #41 and #45) of 17 residents identified by the facility as having personal refrigerators. The facility census was 49.

Inspectors wroteBased on medical record review, staff interview, review of the facility investigation and facility policy review, the facility failed to thoroughly investigate the root cause of Resident #27's repeated falls on 03/16/25, 03/30/25, and 04/08/25, and failed to implement appropriate fall prevention interventions for Resident #27 to prevent further falls. Actual Harm occurred on 04/08/25 when Resident #27 fell attempting to transfer herself to the bathroom unsupervised resulting in a fall requiring hospitalization with a distal left tibia fracture. This affected one (Resident #27) of two residents reviewed for falls. The facility census is 50.

Inspectors wrote2. Review of the medical record for Resident #9 revealed an admission date of 10/24/19. Diagnoses included weakness, gastro-esophageal reflux disease without esophagitis, vitamin D deficiency, and age-related osteoporosis without current pathological fracture. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 had intact cognition. Observation on 06/09/25 at 10:35 A.M. in the Resident #9's room revealed an opened store brand bottle of an antacid chewable, with more than 50% gone, sitting on the resident's bedside table. Interview at this time, Resident #9 stated she had a friend bring it in for her. Resident #9 stated they don't have it here and were too busy with other residents. Observation on 06/11/25 at 4:53 P.M. in Resident #9's room the bottle of store brand antacid was no longer on the bedside table. [...]

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility failed to maintain a safe, clean, comfortable and homelike environment for all residents. This affected one resident (Resident #29) of three residents reviewed for environment on the Cascade unit, and had the potential to affect an additional 35 residents (Resident #1, #2, #5, #6, #8, #10, #11, #12, #13, #15, #17, #18, #21, #22, #23, #24, #26, #28, #30, #31, #34, #36, #37, #38, #40, #41, #42, #43, #45, #48, #49, #50, #33, #19,and #32) the facility identified as living on the Buckeye and Memory Care (MC) units. The facility census was 51.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure staff performed hand hygiene and implemented proper glove use during medication administration for Resident #6, Resident #13, and Resident #22, and failed to disinfect the glucometer after using it to check Resident #13's blood sugar. This affected three residents (#6, #13 and #22) out of six residents reviewed for medication administration. In addition, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) during wound care for Resident #47. This affected one resident (Resident #47) out of three residents reviewed for wound care.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure facility staff did not neglect Resident #5 when in need of staff assistance to meet care needs. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure an allegation of neglect of Resident #5 was reported to the state agency and administrator as required. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure an allegation of neglect of Resident #5 was thoroughly investigated and corrective action taken as required. This affected one resident (Resident #5) of three residents reviewed for abuse/neglect. The facility census was 51.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff provided the physician ordered wound treatment during Resident #47's wound treatment procedure. This affected one resident (Resident #47) out of three residents reviewed for wounds. The facility census was 51.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the staff administered medications with a less than five percent error rate. Three errors occurred within 24 opportunities for error resulting in a medication error rate of 12.5 percent. This affected two residents (Resident #13 and Resident #28) out of six resident observed for medication administration. The facility census was 51.

Inspectors wroteBased on observation and interview the facility did not ensure food served to Resident #5, #46 and #47 was palatable and attractive. This affected three residents (#5, #46 and #47) of seven residents reviewed for food and nutrition. The facility census was 51.

Inspectors wroteBased on observation, review of the diet order report, and interview, the facility failed to serve food at an appetizing taste and temperature. This had the potential to affect all 59 residents who received meals from the kitchen. The census was 59.

Inspectors wroteBased on observation, review of the food temperature log, review of the FoodSafety.gov website, review of the diet order report, policy review and interview, the facility failed to store and prepare food in a sanitary manner. This affected all 59 residents who received meals from the kitchen. The census was 59.

Inspectors wroteBased on the observation, review of the Centers for Medicare and Medicaid (CMS) 802 Matrix form, review of the nursing staff assignment sheets, review of the education in-service attendance record, and interview, the facility failed to ensure sufficient nursing staff to provide appropriate supervision to residents residing on the secured memory care unit. This affected 19 residents (Resident #29, #53, #48, #12, #34, #30, #56, #38, #16, #44, #17, #58, #9, #42, #19, #2, #13, #45 and #20) who resided on the [NAME] Hills unit (the secured memory care unit). Facility census was 59.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all residents in the memory care unit received appropriate dementia care and services. This affected three of three residents (Residents #9, #58 and #12) reviewed for dementia care and had the potential to affect 19 (Resident #29, #53, #48, #12, #34, #30, #56, #38, #16, #44, #17, #58, #9, #42, #19, #2, #13, #45 and #20) residents residing in the memory care unit.

Inspectors wroteBased on observation, review of diet order report, policy review, and interview, the facility failed to follow the menu to ensure nutritional adequacy. This affected 12 residents (Residents #1, #3, #9, #15, #19, #24, #25, #41, #42, #48, #51, and #53) who were ordered a mechanical soft diet or a pureed diet. The census was 59.

Inspectors wroteBased on medical record review, review of the Centers of Disease Control and Prevention (CDC) COVID-19 vaccination guidelines, policy review and interview, the facility failed to offer any 2024-2025 COVID-19 vaccinations to residents. This affected five (Residents #9, #43, #38, #17 and #34) residents reviewed for COVID-19 vaccination. The census was 59.

Inspectors wroteBased on observations, staff interviews, review of nursing schedules, review of Self-Reported Incidents (SRI), review of personnel files, review of concern logs, review of resident council minutes, and review of the facility assessment, the facility failed to provide sufficient nursing staff to meet the total care needs of the residents and failed to provide adequate nursing coverage on each shift. This had the potential to affect all 59 resident in the facility. The facility census was 59.

Inspectors wroteBased on observations, resident interviews, staff interviews, job description review, review of resident diet order list, and review of personnel files, the facility failed to ensure adequate and appropriate dietary staff to meet the dietary needs of the residents. This had the potential to affect all residents except one resident (#45) who received nothing by mouth. The facility census was 59.

Inspectors wroteBased on observation, policy review, resident interviews, and staff interviews, the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect all residents except one resident (#45) who received nothing by mouth. The facility census was 59.

Inspectors wroteBased on observations, resident interviews, family interviews, staff interviews, review of resident council minutes, and policy review, the facility failed to ensure a clean, functional and sanitary environment. This had the potential to affect all 59 residents. The facility census was 59.

Inspectors wroteBased on medical record reviews, observations, review of self-reported incident, review of resident concern log, review of resident council minutes, policy review, resident interview, ombudsman interview and staff interviews, the facility failed to timely and fully address residents expressed concerns with care and treatment and environmental issues. This directly affected eighteen Residents (#9, #10, #11, #19, #27, #30, #31, #32, #40, #47, #48, #49, #52, #54, #55, #56, #58, and #62), with the potential to affect all resident residing on the 300 hall. The census was 59.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure potentially hazardous chemicals and medicated treatments were kept in a secured area where residents residing in the Memory Care Unit did not have access. This had the potential to affect 14 (#1, #7, #12, #15, #16, #35, #37, #43, #44, #50, #52, #57, #59, and #60) who were identified by the facility as being independently mobile of the 17 residents residing in the Memory Care Unit. In addition, the facility failed to ensure a resident at risk for choking was supervised and monitored during meals. This affected one (#50) of ten residents observed for dining in the memory care unit. The facility census was 59.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure medications were stored in a secure manner. This affected six (#4, #25, #27, #40, #41, and #60) and had the potential to affect 19 additional residents (#1, #3, #7, #12, #15, #16, #17, #21, #26, #29, #35, #37, #43, #44, #49, #50, #52, #57, and #59) identified by the facility as being cognitively impaired and independently mobile. The facility census was 40.

Inspectors wroteBased on observations, resident interviews, staff interviews, review of resident diet order list and policy review, the facility did not ensure food was held at appropriate temperatures while on the steam table and served at palatable temperatures. This affected seven residents on pureed (#13, #36 #52) and/or mechanical soft (#4, #15, #19, #50) diets respectively. Additionally, interviews with four residents (#11, #19, #33, #40) voiced concerns that the food was served cold. The facility census was 59.

Inspectors wroteBased on observations, resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure physician orders were followed and implemented. This affected two (#46 and #62) of six residents reviewed for physician orders. The facility census was 59.

Inspectors wroteBased on observations, resident record review, and staff interviews, the facility failed to ensure physician ordered pressure relieving devices were in place to prevent pressure ulcers. This affected one (#21) of two residents reviewed for pressure sores. The facility census was 59.

Inspectors wroteBased on medical record review, observation, staff interview, and review of policy, the facility failed to ensure foot care was provided as needed. This affected two (#15 and #41) of two residents reviewed for non-pressure wounds. The facility census was 59.

Inspectors wroteBased on observations, resident record review, and staff interviews, the facility failed to ensure a resident with limited range of motion from a fractured hip was provided with positioning device to prevent dislocation of hip. This affected one (#21) of six residents reviewed for accidents. The facility census was 59.

Inspectors wroteBased on observation, staff interview, medical record review, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had three medication errors of 25 opportunities for an error rate of 12%. This affected two (#31 and #32) of four residents reviewed for medication administration. The facility census was 59 residents.

Inspectors wroteBased on observations, medical record review, policy review, resident interview and staff interview, the facility failed to arrange an Maxillary Oral Surgeon consult as ordered. This affected one (#2) of one resident reviewed for dental services. The facility census was 59.

Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of policy, the facility failed to ensure accurate documentation reflecting care and treatment provided. This affected two (#15 and #62) of three residents reviewed for wound care. The facility census was 59.

Inspectors wroteBased on observation, staff interview, record review, and review of policies, the facility failed to ensure infection control practices were maintained during a sterile peripherally inserted central catheter (PICC) line dressing change. This affected one (#62) of one resident reviewed for infection control with intravenous access care. The facility census was 59.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure call lights were answered in a timely manner and failed to promptly address resident needs. This affected one resident (#14) of three residents reviewed for call light response and had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to employ a full-time licensed social worker (LSW) as required. This had the potential to affect all 68 residents in the facility.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure residents and/or their representatives were invited to participate in care conferences as required. This affected three residents (#7, #36, and #43) of three residents reviewed for participation in care planning. The facility census was 68.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure care conferences were completed as required. This finding affected three residents (#7, #36 and #43) of three residents reviewed for care planning. The facility census was 68.

Inspectors wroteBased on observation and interview the facility failed to ensure posted nursing staff information was posted daily as required. This had the potential to affect all 68 residents residing in the facility.