Country Aire Retirement Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff assisted residents, who required assistance with activities of daily living (ADLs), in a way to maintain good personal hygiene and grooming, when staff failed to provide routine bathing for seven residents (Residents #34, #29, #3, #41, #30 #8 and #36), failed to assist one resident (Resident #34) with shaving, failed to provide nailcare for one resident (Resident #30), and failed to provide incontinence care for one resident (Resident #11), in a review of 15 sampled residents. The facility census was 39. [...]

Inspectors wroteBased on interview and record review, the facility failed to have written policies and procedures in place regarding visitation rights, including restrictions placed on two residents' visitation (Resident #2 and #3), in a review of six sampled residents. The facility failed to have a system in place regarding the limitations on visitors and failed to communicate the reasons for those limitations to staff. The facility census was 34. During interview on 9/29/25 at 2:15 P.M. the Administrator said the facility did not have a policy regarding visitation rights. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff followed professional standards of practice when staff removed resident medications from packaging and placed them in medication cups prior to morning medication pass for 13 residents. Also, staff failed to ensure insulin was administered correctly for one resident (Resident#3) in a review of six sampled residents. Staff failed to follow the facility's policy to keep the dose button/plunger of the insulin pen pressed and the needle in the skin for six to ten seconds during administration. The facility census was 34. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's (Resident #1) representative when the resident was started on Rexulti (an antipsychotic medication), in a review of six sampled residents. The facility census was 34. During an email correspondence on 10/9/25 at 10:40 A.M. the Director of Nursing said she was unaware of facility policy regarding family notification for a change of condition. Review of the facility's Resident Rights form provided upon admission showed the following:-Free Choice: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #4) in a sample of six residents, remained free of a significant medication error when staff crushed and administered glipizide 24 hour extended release (used to manage blood sugars, the form of medication is gradually released throughout 24 hours) and metoprolol 24 hour extended release (used to manage high blood pressure, the form of medication is gradually released throughout 24 hours) to Resident #4. The facility census was 34. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an adequate number of licensed nurses on duty to meet resident needs. The Social Service Director (SSD)/Licensed Practical Nurse (LPN) A was pulled from his/her duties as the Social Services Director, and unable to follow up on resident concerns, to work the floor as the charge nurse on multiple occasions. SSD/LPN A worked a total of 36 consecutive hours due to having no licensed nurse coverage. SSD/LPN A slept in a recliner at the nurse's station while on duty during his/her 36 hour shift. Registered Nurse (RN) B said he/she was leaving employment 3/19/25; he/she was unable to measure wounds weekly per policy, complete routine skin assessments, or complete necessary documentation due to staffing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full-time basis. The facility census was 37. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired five full time RNs. Review of the facility's Director of Nursing Staffing policy, dated 2025, showed the following: -The facility must employ a full-time DON; -The DON must be a Licensed Registered Nurse; -The DON was responsible for overseeing operations, quality of care, staff recruitment, retention and education. Review of the facility's General Staffing policy, dated 2025, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to ensure operations including staffing and required regulatory systems necessary for the care and safety of residents were provided. The facility failed to have a full time Director of Nursing (DON), Assistant Director of Nursing (ADON), and an adequate number of licensed nurses to meet the residents' needs. The facility also failed to have an Infectionist Preventionist (IP) or antibiotic stewardship program in place,which included tracking of antibiotic use and infections. Vendors were not paid for supplies or services timely. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances and recommendations of the Resident Council concerning issues of resident care and quality of life in the facility, and failed to provide the Resident Council with responses, actions, and rationale taken regarding their concerns. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the administrator was to review resident complaints and grievances and make written reports of action taken. The administrator was to discuss such actions with residents and family as appropriate. During an email correspondence on 3/31/25 at 10:42 A.M., the Administrator said he/she was not sure if there was a written policy on council meetings. The facility followed the regulations by holding monthly meetings. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for seven residents (Resident #4, #9, #11, #13, #1, #3 and #2 ). Staff failed to follow the physician's orders for droplet precautions (measures taken to prevent the spread of infections transmitted through respiratory droplets) for four residents (Resident #4, #9, #11 and #13). The facility also failed to ensure staff followed physician's orders for medications for three residents (Resident #1, #3 and #2) in a review of 13 sampled residents. The facility census was 37. Review of the facility's policy and procedure, Physician's Orders, dated 2025, showed the following: -It is the policy of the facility to ensure that all physician orders are obtained, documented, and implemented in accordance with federal and state regulations, professional standards, and facility protocols. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating, consisting of chest compressions and artificial respirations) certified staff were scheduled 24 hours a day seven days a week, failed to develop and implement a policy addressing CPR requirements for staff, and failed to maintain documentation of CPR certifications for staff members. The facility had 13 residents with full code status (residents requested to have full resuscitation efforts/CPR in the event of cardiac arrest). The facility census was 37. During an email correspondence on [DATE] at 12:56 P.M., the Administrator said the facility did not have a policy specific to CPR training or certification. The facility would follow the regulatory requirements. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use was in place. The facility also failed to have a designated Infection Preventionist (IP). The facility census was 37. Review of the facility's Infection Control Policy and Procedure, dated 2025, showed the following: -The facility implements evidence-based infection prevention practices to protect residents, staff, and visitors; -The facility maintains an Infection Prevention and Control Program (IPCP) overseen by a designated Infection Preventionist (IP) who was trained in infection control; -The IPCP includes: -Surveillance of infections; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #2), who had three Stage IV pressure ulcers (Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location) and was identified at risk for pressure ulcers in a review of 13 sampled residents. The facility census was 37. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 44. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired two full time RNs. Review of the facility's undated Director of Nursing Services policy showed the following: -The nursing services department is under the direct supervision of a registered nurse; -The nursing services department is managed by the Director of Nursing Services. The director is a registered nurse; -The DON is employed full time ( 40 hours per week); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents, (Resident #1 and Resident #2), in a review of eight sampled residents, were free from misappropriation of property, when Registered Nurse (RN) A/Former Assistant Director of Nursing (ADON) misappropriated the residents' narcotics. RN A/Former ADON signed as receiving the residents' narcotic medications from the pharmacy. There was no documentation the narcotic medications were administered or destroyed. The narcotic medications were not found in the facility after RN A/Former ADON received the narcotic medications from the pharmacy. The facility census was 39. On 09/09/24 at 4:05 P.M., the administrator was notified of the past noncompliance which began on 07/06/24. On 08/31/24, the Director of Nursing became aware of the violation of misappropriation of resident's narcotic medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the range hood free of a buildup of grease and debris; failed to maintain the air conditioner and microwave free of a buildup of debris; failed to ensure food items were labeled, dated, covered and discarded when expired; failed to ensure a water dispenser and a water dispensing unit was free of a buildup of debris; failed to ensure staff utilized safe food handling practices when preparing ready to eat food items; failed to ensure staff handled ready to eat foods safely; failed to ensure staff wore hair restraints properly; and failed to ensure the ice machine was equipped with an appropriate air gap to prevent back siphonage. The facility census was 43. 1. Review of the undated facility policy, Cleaning Instructions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #40 and #293), in a review of 16 sampled residents, and one additional resident (Resident #35), were treated in a manner to promote dignity and respect, when the facility failed to cover a urinary catheter (a tub inserted into the bladder that drains urine from the bladder into a collection bag outside of the body) collection bag. The facility census was 43. Review of the facility policy, Quality of Life-Dignity, dated August 2009, showed the following: -Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 25 residents. The census was 43. Request for a facility policy regarding the reconciliation of the resident funds account was made and none provided. 1. Record review of the reconciliation of resident funds, provided by the Business Office Manager (BOM), showed no reconciliation for the full resident trust account. 2. Record review of the Corporate Accountant's attempted reconciliation of the resident trust account, for accounts ending in #370665 and #342130, for the period 06/2023 through 06/2024, showed no reconciliations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete comprehensive assessments for three residents (#25, #2, #18) in a review of 16 sampled residents. The facility census was 43. Review of the undated facility policy titled, Minimum Data Set (MDS), Completion and Submission Timeframes, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy did not address accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.18.11, October 2023, showed the following: -The Omnibus Budget Reconciliation Act (OBRA) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infectious causing contaminates for one sampled resident (Resident #18) and one additional resident (Resident #35); failed to ensure urinary catheter (tube inserted into the bladder to drain urine) drainage bags did not touch the floor for three residents (Residents #35, #40, and #293); [...]

Inspectors wroteBased on observation and interview, the facility to maintain essential kitchen equipment in good working order. The facility census was 43. 1. Observation on 7/8/24 at 1:50 P.M. of the three-compartment sink in the facility kitchen showed the drain pipe for the third sink well (used for sanitizer solution) leaked below the sink into a plastic tub on the floor. The tub was full of water and slowly ran over the edge of the tub into the floor drain. Observation 7/9/24 at 7:49 A.M. of the three-compartment sink showed the sanitizer well sink drain leaked below the sink and water dripped directly on the floor. The tub that had previously caught the dripping water (the day before) had been removed. During interviews on 7/8/24 at 1:53 P.M. and on 7/9/24 at 8:20 A.M., the Dietary Manager said the pipes under the three-compartment sink leaked and the seals were broken. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattress, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Residents #24, #25 and #40), in a review of 16 sampled residents. The facility census was 43. Review of the facility policy, Bed Safety, dated December 2007, showed the following: -The resident's sleeping environment shall be assessed for the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the telephone number and contact information for the state survey agency and the elder abuse hotline were posted in the facility. The facility census was 43. Review of the undated facility policy titled, Resident Rights, showed the following: -Employees shall treat all residents with kindness, respect, and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter. 1. Observation on 7/8/24 at 11:35 A.M. throughout the facility showed no posted state survey agency or elder abuse hotline contact information. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely serve a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing, at least two days before the Medicare days were exhausted, to three residents (Residents #344, #343 and #34), in a review of three sampled residents. The facility census was 43. Request for a facility policy regarding the issuing of NOMNCs was made and none provided. Record review of the undated, Form Instructions for the NOMNC, showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Record review of the CMS Survey and Certification memo, dated 1/9/09, showed the following: -The NOMNC is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post required nurse staffing information, which included the facility name, resident census and total actual hours worked by both licensed and unlicensed nursing staff, directly responsible for resident care, per shift, daily. The facility census was 43. Review of the facility policy, titled Posting Direct Care Daily Staffing Numbers, dated 7/2016, showed the following: -The facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge with required information to the resident and/or resident representative for one additional resident (Resident #2), in a review of four sampled residents, when the facility initiated a transfer to the hospital and denied the resident re-admission to the facility. The facility census was 38. Review of the facility's undated policy, Transfer or Discharge Notice, showed the following: -Our facility shall provide a resident and/or the resident's representative with a 30-day written notice of impending transfer or discharge; -A resident, and/or his/her representative, will be given a 30-day advance notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each certified nurse assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified eight CNAs employed by the facility for more than a year. Five of five CNAs (CNA D, CNA V, CNA F, CNA W and CNA E) sampled did not have the required 12 hours of in-service education. The facility census was 37. Review of the Facility Assessment, dated 1/2/23, showed the the following: -Staff training, education, and competencies: Attach or describe your facility's training program; -Include information on what training frequency of trainings (e.g. before hire and/or ongoing, which individuals or departments conducting and tracking training's, and how the process is monitored or audited; -The facility's plan is: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary practices in the kitchen. The facility census was 37. Review of the facility policy, Floors, revised December 2009, showed floors shall be maintained in a clean, safe, and sanitary manner. 1. Observation on 1/9/23 at 10:28 A.M. showed the range hood baffle filters had a heavy buildup of dark yellow grease and dark-colored fuzzy debris. A sticker on the exterior of the range hood showed the hood had previously been cleaned on 7/20/22 and was due for professional cleaning in January 2023. During an interview on 1/9/23 at 1:30 P.M., Dietary Staff K said dietary staff was supposed to clean the range hood filters every two weeks but no one was responsible for ensuring this was done and it was not documented. A professional company came and cleaned the hood twice a year. [...]

Inspectors wroteBased on interview and record review the facility failed to have quarterly Quality Assessment and Assurance (QAA) committee meetings, or have the required members present for the meeting that occurred. The facility also failed to provide evidence that the facility consistently implemented a Quality Assurance and Process Improvement (QAPI) program with measurable data, actions, and evaluations. The facility census was 37. During an interview on 1/11/23, at 4:30 P.M., administrator A said she would provide the QAA policy. The policy was not received. Emailed request on 1/23/23 to administrator B for the QAA policy. The policy was not received. Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program, revised April 2014, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that an effective training program for all new and existing staff was in place. The facility failed to identify specific training needs in the facility assessment, and did not have a plan or schedule of how or when required training would be completed. The facility census was 37. Review of the Facility Assessment, dated 1/2/23, showed the the following: -The facility cared for 19 residents with mental, behavioral and neurodevelopmental disorders; -The facility provided care for behavior and mental health that includes identifying and implementing interventions with issues such as anxiety, care of cognitive impairment, trauma/Post Traumatic Stress Disorder (PTSD), other psychiatric, intellectual or developmental disabilities; -Staff training, education, and competencies: Attach or describe your facility's training program; [...]

Inspectors wroteBased on interview and record review the facility failed to provide annual staff training to include abuse, neglect, exploitation, and misappropriation of resident property and the reporting and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property to five facility staff (Certified Nurse Assistant (CNA) D, CNA E, CNA V, CNA F and CNA W) out of five employee records reviewed. The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each certified nurse aide (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified eight CNA's employed by the facility for more than a year. Five CNAs were sampled and five out of five did not have the required 12 hours of in-service education, or training for abuse. Four of the five sampled did attend an in-service that included the topic of dementia, but there was no agenda provided, depth or scope of the training. Two of the five sampled CNA's attended an in-service for behaviors, but there was no agenda, depth, or scope of the training. Five out of five did not have documented attendance for an in-service regarding care of the cognitively impaired. The facility census was 37. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment by failing to maintain walls, floors, ventilation fans, and wheelchairs in good repair. The facility census was 37. Review of the facility policy, Quality of Life - Homelike Environment, last revised May 2017, showed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. 1. Observation on 01/09/23 between 9:50 A.M. and 3:45 P.M., showed the following: -In resident room [ROOM NUMBER], several brown stains on the floor in the bedroom, and the independently motorized bathroom ventilation fan did not work; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required pre-employment screenings for two employees in a review of nine newly hired employees. The facility failed to review the Nurse Aide (NA) Registry for a Federal indicator (which would disqualify an individual from working in the facility) for Transport Aide T, and failed to request a criminal background check and complete an Employee Disqualification List (EDL) check prior to hire for Licensed Practical Nurse (LPN) U. The facility also failed to develop a policy and procedure to address reviewing the Nurse Aide Registry for a Federal indicator and for requesting a criminal background check prior to hire. The facility census was 37. Review of the facility policy, Registry of Nurse Aides, revised January 2008, showed the following: -Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks to provide effective person-centered care for three residents (Resident's #13, #21 and #28), in a review of 14 sampled residents. The facility census was 37. Review of the facility Care Plans, Comprehensive Person-Centered policy dated December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for labs, nutritional supplements and daily and weekly weights for five residents (Resident #4, #13, #24, #29, and #37) in a review of 14 sampled residents. The facility census is 37. During an interview on 1/18/23, at 11:00 A.M., the Director of Nursing said the facility may not have a policy for following physician orders for tests and procedures but it was like the one the facility had for medications. The staff are expected to follow all physician's orders and if there is an issue call the physician or the medical director for concerns or further direction. 1. Review of Resident #4's care plan, dated 7/25/21, showed the following: -Risk for dehydration; -Monitor labs as ordered; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete activities of daily living (ADL) for dependent residents to ensure six residents (Residents #10, #21, #14 #18, #27, and #37), in a review of 14 sampled residents, were clean and groomed. The census was 37. Review of the facility policy, Showers, last revised December 2010, showed the purposes of the procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded on the resident's ADL record and/or in the resident's medical record. 1. Date and time of the shower; 2. The name and title of the individual(s) who assisted the resident with the shower; 3. All assessment data (e.g. reddened areas, sore etc., on the resident's skin) obtained during the shower; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an on-going activities program for three resident (Residents #21, #25, and #37), in a review of 14 sampled residents, to ensure the residents had meaningful activities or activity material available to meet their interests and support their psychosocial needs. The facility also failed to provide meaningful activities program in the evenings and on the weekends as directed by facility policy, and failed to provide residents with a schedule of activities that readily available to encourage involvement in scheduled activities. The facility census was 37. Review of facility policy, Activity Programs, revised August 2006, showed the following: -Policy Statement: Activity programs designed to meet the needs of each resident are available on a daily basis; -1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor a resident's weight, ensure interventions to address weight loss, including supplements and snacks, were consistently implemented, or re-evaluate interventions for effectiveness for two residents (Residents #13 and #21) with weight loss. The facility also failed to ensure meals were set up for two residents (Resident #21 and #27) of 14 sampled residents. The facility census was 37. Review of the facility's policy, Hydration, revised September 2012, showed the following: -The staff, with the physician's input, will identify individuals with signs and symptoms (for example, delirium, lethargy, increased thirst, etc.) or lab test results (for example, hypernatremia, azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, and failed to obtain informed consent with risks prior to installing and using a bed rail for three residents with bed rails (Residents #13, #21 and #37), in a review of 14 sampled residents. The facility census was 37. Review of the facility policy, Bed Safety, dated December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; -1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were clean and free of body odors or had their nails trimmed for four residents (Resident #10, #21, #27 and #37) in a review of 14 sampled residents. The facility also failed to provide adequate staffing to ensure the right to self determination for one sampled resident (Resident #10) when there were not staff available to take the resident outside to supervise his/her smoking. The facility failed to provide adequate staffing to complete weekly weights for three resident (Resident #37, #29 and #21), two of which had weight loss. The facility failed to provide enough staff to ensure one resident (Resident #37), who had pressure injuries, was turned or repositioned every two hours to prevent further injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician response to a pharmacist recommendation for two residents (Resident #13 and #21) and failed to ensure one resident (Resident #37) had a pharmacy review for one month, in a review of five sampled residents. The facility census was 37. Review of the facilities Medication Regimen Reviews policy, dated April 2007, showed the following: -The Consultant Pharmacist shall review the medication regimen of each resident at least monthly; -1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility; -2. Routine reviews will be done monthly; -3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and secured in a medication cart for two residents (Residents #13 and #87), in a review of 14 sampled residents, and for two additional residents (Residents #31 and #16). The facility staff also failed to label multi-use insulin vials and pens when opened to ensure they were used within 28 days of opening for two additional resident's (Residents #5 and #12). The facility census was 37. 1. Review of Resident #13's facility face sheet showed his/her diagnoses included keratoconjunctivitis sicca (dry eye that occurs when tears aren't able to provide adequate moisture) and primary biliary cirrhosis (an autoimmune disease that causes progressive destruction of the bile ducts). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the spreadsheet menu and recipes to prepare and serve the pureed entree for the lunch meal on 3/28/23. The facility identified five residents on a pureed diet. The facility census was 37. Review of the undated facility policy Standardized Recipes showed the following: -Standardized recipes shall be developed and used in the preparation of foods; -Only tested, standardized recipes will be used to prepare foods; -Standardized recipes will be adjusted to the number of portions required for a meal; -The Food Services Manager will maintain the recipe file and make it available to Food Services staff as necessary. Review of the spreadsheet lunch menu for 3/28/23, provided by the facility, showed residents on a pureed diet were to receive a pureed breaded fish sandwich with cheese on a hamburger bun. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to failed to serve food at a safe and appetizing temperature. The facility census was 37. Review of the facility's policy Food Preparation and Handling, revised July 2014, showed the following: -The danger zone for food temperatures is between 41 degrees Fahrenheit (F) and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness; -Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese; -The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. During an interview on 1/11/23, at 11:44 A.M., Resident # 28 said the hot food is cold sometimes and the cold food is warm. The food is not great. Observation on 1/11/23, at 12:12 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bedtime snacks for all residents and failed to ensure snacks that were provided were in accordance with the resident's diet orders. The facility census was 37. Review of facility policy, Resident Nutrition Services, revised November 2015, showed the following: -Meal hours shall be scheduled at regular times to assure that each resident receives at least three meals per day; -Snacks are available to the residents 24 hours a day; -The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. 1. Review of Resident #37's face sheet showed the resident's diagnoses included type 2 diabetes mellitus and morbid obesity. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program and a system to monitor appropriate antibiotic use. The facility failed to fully complete the antibiotic tracking done from 6/1/22 through 12/31/22. The facility census was 37. Review of the facility's Surveillance for Infections, last revised August 2014, showed the following: -The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer to vaccinate eligible residents the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease, which is any type of infection caused by streptococcus pneumoniae bacteria) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for five residents (Residents #13, #21, #24, #29 and #37) in a review of 14 sampled residents. The facility census was 37. Review of the facility policy titled Influenza/Pneumococcal Vaccine, last revised 11/27/16, showed the following: -The facility will provide pneumococcal vaccine to residents upon request; -All residents admitted to the facility will receive a screening as to the date of their last pneumococcal vaccine; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light in one resident's (Resident #4's) room functioned properly so he/she could alert staff if needed. A sample of 14 residents was selected for review. The facility census was 37. Review of facility answering the call light policy updated 1/12/21 showed the following: -The purpose of this procedure is to respond to the resident's requests and needs; -Be sure that the call light is plugged in at all times; -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident; -Report defective call lights to the nurse supervisor and/or maintenance department, director of nursing and administrator promptly. Other means for the resident to alert staff, such as bells, should be provided for resident use while call light is being repaired/replaced. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure one resident (Resident #10), in a review of 14 sampled residents, was provided with the opportunity to smoke after the resident made multiple requests. The facility identified Resident #10 was the only resident who smoked in the facility. The facility census was 37. Review of the facility's Resident Smoking Policy, revised December 2016, showed the following: -The facility shall establish and maintain safe resident smoking practices; -Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of changes in condition for one resident (Resident #27), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy, Change in a Resident's Condition or Status, revised May 2017, showed the following: -Our facility shall promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. Accident or incident involving the resident; b. Discovery of injuries of an unknown source; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents know how to file grievances for two anonymous residents of 14 sampled residents. Facility census was 37. Review of the facility's policy, Grievance -Voicing and Resolution, effective date May 2019, showed the following: -It is the policy of this home that staff will promptly attempt to resolve grievances the resident may have, including those, which involve the behavior of others. They will be able to voice grievances without fear of reprisal or discrimination. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #27) in a review of 14 sampled residents, was free from physical restraint. The facility census was 37. Review of the facility's policy, Use of Restraints, revised April 2017, showed the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse when one resident (Resident #25), in a review of 14 sampled residents, reported someone who staff believed was another resident had hurt him/her. The resident presented with a large bruise on his/her right upper chest area (rib cage to right breast). The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Physical abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation when a large bruise was found in the right upper chest area (rib cage to right breast) of one resident (Resident #25) which staff believed could have been the result of physical or sexual abuse. The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -Physical abuse: Physical action within the definition of abuse including but not limited to, hitting, slapping, pinching, and kicking; -Sexual abuse: The non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intend to inflict injury or harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission to the facility for one resident (Resident #87), in a review of 14 sampled residents. The census was 37. Review of the Long-Term Care Facility RAI User's Manual, version 3.0 showed the admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of the fourteenth day, counting the date of admission to the nursing home as day one if this is the resident's first time in this facility. 1. Review of Resident #87's face sheet showed he/she was admitted the facility from the hospital on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Residents #21 and #37), in a review of 14 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 37. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate comprehensive assessments to reflect the resident's status for two residents (Residents #28, and #21), in a review of 14 sampled residents. The inaccuracy had the potential to negatively affect the person-center care plan and services the facility provided to the resident. The inaccuracies included coding of pressure wounds, activities of daily living (ADL's), pneumococcal vaccines, and indwelling urinary catheter and ostomies ( is a stoma created surgically that allows bodily waste to pass through the abdomen into a prosthetic). The facility census was 37. Review of the Resident Assessment Instrument (RAI) manual, a manual with guidance on how to complete MDS assessments, dated 10/1/19, showed the following: [...]

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive care plan within 21 days for one resident (Residents #87) of 14 sampled residents, after admission to the facility. The census was 37. Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last revised 12/2016 showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The Care plan interventions are gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition one resident (Resident #37), who had a pressure ulcer (an injury to skin and underlying tissue resulting from prolonged pressure on the skin, most often on bony areas of the body), and failed to report and treat a reddened coccyx (small, triangular bone at the base of the spine) for one resident (Resident #18), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy titled Repositioning, revised May 2013, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff assisted one resident (Resident #18) to reposition and be propelled in a wheelchair safely in a review of 14 sampled residents. The facility failed to ensure wheelchair footrests were in place when propelling Resident #18 in a wheelchair and improperly repositioned him/her in the chair. The facility census was 37. The facility did not provide a policy that addressed transfers, proper lifting techniques, gait belt use or wheelchair safety. 1. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/6/22, showed the following: -Memory problem; -Required extensive assistance from one staff for transfers and locomotion; -Used a wheelchair for mobility. Review of the resident's January 2023 Physician Order Sheet (POS) showed the following: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure gradual dose reductions were conducted for one resident (Resident #4), in a review of five sampled residents, who were ordered and received pyschotropic medications. The census was 37. Review of the facility policy, titled Medication Regimen Review, last revised 4/2007 showed the consultant pharmacist shall review the medication regimen of each resident at least monthly. The consultant will perform a medication regimen review (mrr) for every resident in the facility. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure administration of insulin pens according to manufacturers' recommendations for one additionally sampled resident (Resident #12) out of 14 sampled, and 16 additionally sampled residents to ensure the prescribed insulin dose was administered. The facility census is 37. Review of the facility's policy Medication Administration, dated revised December 2012, showed medications must be administered in accordance with the physicians orders. Review of the manufacturer's instructions at www.mynovoinsulin.com showed the following for administration with an insulin flexpen: 1. Check your insulin type. Make sure the insulin is clear and colorless do not use if it looks cloudy or colored. 2. Attach a new needle: Pull off the paper tab. Push and twist the needle on until it is tight. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the facility name, total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 37. Review of the facility's policy Posting Direct Care Daily Staffing Numbers, dated July 2016, showed the following: -Facility will post, on a daily basis for each shift the number of nursing personnel responsible for providing direct care to residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or resident representative when three residents (Residents #10, #29 and #37), in a review of 14 sampled residents, were transferred to the hospital. The facility did not provide any other written documentation to the resident or resident representative of the reason and date for transfer/discharge, where the resident was transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, or how to contact the mental health advocacy group for resident with intellectual disabilities or mental illness. The facility census was 37. During an interview on 1/12/23, at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a written policy for providing written notice upon transfer/discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy to the resident and/or resident representative for three residents (Resident #10, #29 and #37 ), in a review of 14 sampled residents, when they were transferred to the hospital. The facility census was 37. Review of the facility Bed-Holds and Returns policy dated March 2017, showed the following: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy -1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy; -2. The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility; -3. [...]