Country Club Center I

Inspectors wroteBased on closed record review, policy review and interviews the facility failed to ensure residents were appropriately prepared for discharge when Resident #47 was discharged home without access to prescribed medications. This affected one (Resident #47) of four residents reviewed for discharge.

Inspectors wroteBased on medical record review, review of hospital records, review of medical education provided by The University of Pittsburgh Medical Center, facility policy review, and interview, the facility failed to timely and accurately assess Resident #24 and failed to respond to an acute change in condition. This resulted in Immediate Jeopardy and Actual Harm beginning on [DATE] at 7:30 A.M. when Resident #24 was noted to have an oxygen saturation (SpO2) of 83% (normal SpO2 95-100%), a heart rate of 138 ((tachycardic) normal heart rate 60-100), was febrile (elevated body temperature) with a temperature of 102.1 degrees Fahrenheit (normal temperature 97.5 to 98.9 degree Fahrenheit) and rhonchus lung sounds bilaterally (abnormal lung sounds in both lungs occurring when air moves through partially obstructed or narrowed airways due to fluid, mucus, or thick secretions). [...]

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure residents were free from physical abuse. Actual harm occurred on 03/20/26 when the facility failed to implement appropriate interventions to prevent a resident-to-resident physical altercation despite staff knowledge of Resident #52's known history of aggression and verbal threats to kill his roommate, Resident #15. Resident #15 sustained bruising and psychosocial harm of fear and self-isolation because of the altercation. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on observation, record review, interview, national library of medicine review, drug manufacturer review, and policy review, the facility failed to ensure effective pain management interventions were implemented to adequately control resident pain. This affected three (Residents #1, #10 and #30) of three residents reviewed for pain. Actual Harm occurred to Resident #10 on 03/28/26 at 9:30 A.M. when the facility failed to administer the ordered dosage of Lyrica (an anticonvulsant medication and gabapentin used to treat neuropathic pain, fibromyalgia, and partial-onset seizures) and failed to provide any pharmacological or non-pharmacological interventions. This resulted in Resident #10 suffering excruciating pain and extreme nausea. Resident #10 was crying and restless, lying in bed while grabbing her legs due to complaints of severe leg pain.

Inspectors wroteBased on observation, interview, review of the facility assessment, and review of facility grievances the facility failed to timely to resident concerns regarding dietary, housekeeping, and staffing services. This affected all 52 residents residing in the facility. The facility census was 52.

Inspectors wroteBased on observation, resident interview, staff interview, resident council minute review, grievance review, review of call light audits, record review, facility assessment review and facility policy review the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all residents residing in the facility. The census was 52.

Inspectors wroteBased on observation, interview, and sampled test tray the facility failed to ensure food was served at appropriate and palatable temperatures and was appetizing. This affected three residents (Resident #3, #11 and #39) of three residents. The facility census was 52.

Inspectors wroteBased on observation, interview, and policy review the facility failed to store food in a manner to prevent contamination and spoilage. The facility also failed to ensure staff wore appropriate hair restraints while in the kitchen. This had the potential to affect all residents in the facility. The census was 52.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain the privacy of residents. This affected four residents (#27, #49, #45, and #65) of 52 residents reviewed for privacy. The facility census was 52 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior which was neat and well kept. This affected six residents (#4, #7, #44, #54, #55, and #57) of 52 residents reviewed for a safe, clean, comfortable homelike environment. The facility census was 52.

Inspectors wroteBased on record review, observation, policy review and interview, the facility failed to provide activities of daily living (ADLs) for residents who needed assistance. This affected seven residents (#65, #55, #30, #7, #18, #51 and #1) of seven residents reviewed for ADLs. The facility census was 52.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered parameters were followed related to medication administration. This affected five residents (Resident #9, Resident #42, Resident #55, Resident #7, and Resident #5) of six reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on observation, review of the facility diet list, interview, and review of facility policy the facility failed to ensure food was prepared in accordance with the physician ordered diet consistency. This had the potential to affect six residents (Resident #11, #14, #30, #43, #53 and #55) who had physician ordered pureed diets. The census was 52.

Inspectors wroteBased on record review and interview, the facility failed to provide and implement a comprehensive influenza and pneumonia vaccination program including education, assessment and documentation related to the immunizations. This affected five residents (Resident #5, #30, #65, #18 and #1) of five reviewed for immunizations. The facility census was 52.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure a comprehensive COVID-19 vaccination program was implemented related to education and documentation of administration /refusal for four residents (Resident #5, #18, #30, and #65) of five residents reviewed for vaccination status and failed to ensure evidence of staff vaccination and education related to COVID-19 vaccination status was maintained. The facility census was 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity of a resident by leaving her pants pulled down while she was in bed. This affected one resident (#30) of three residents reviewed for dignity. The facility census was 52.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to notify residents of a change in Medical Director or provide residents with a choice of physician and failed to ensure a resident had the right to choose how their diabetes mellitus was managed. This affected two residents (#3, #9) . The census was 52.

Inspectors wroteBased on record review, interview, policy review, and review of electronic communication, the facility failed to provide residents, families, and/or resident representatives with an explanation in advance, in writing, describing why a room or roommate reassignment took place. This affected two residents (#65, #52) of two residents reviewed for room change. The facility census was 52.

Inspectors wroteBased on closed medical record review, policy review, and interview, the facility failed to ensure advanced directives were accurately documented per resident wishes. This affected one resident (#28) of three residents reviewed for death.

Inspectors wroteBased on medical record review, beneficiary notice review, and interview, the facility failed to issue beneficiary notices as required. This affected one resident (#43) of three residents reviewed for liability notices. The census was 52.

Inspectors wroteBased on medical record review, review of manufacturer guideline review, policy review, and interview, the facility failed to ensure psychoactive medications administered had adequate indications for use. This affected one resident (#1) of five residents reviewed for unnecessary medications. The census was 52.

Inspectors wroteBased on interview, record review, self-reported incident dash board review, and policy review the facility failed to ensure an allegation of resident to resident physical abuse were reported to the Administrator and State Survey Agency (SSA) as required. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on observation, record review, interview, investigation review and policy review the facility failed to ensure allegations of abuse were thoroughly investigated. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure a comprehensive discharge process and receipt of a bed hold notice upon transfer. This affected two residents (#24 and #63) of six residents reviewed for discharges. The census was 52.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive assessments were completed timely as required. This affected one resident (#43) of 26 residents reviewed for assessments. The census was 52.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive assessments were accurately completed. This affected three residents (#1, #2 and #55) of 26 residents reviewed for accuracy of assessments. The census was 52.

Inspectors wroteBased on medical record review, pre-admission screening and resident review (PASARR), and interview, the facility failed to notify the appropriate state agency of a newly diagnosed mental illness for evaluation. This affected one resident (#10) of one resident reviewed for PASARR. The census was 52.

Inspectors wroteBased on medical record review and interview, the facility failed to provide baseline care plans within the required timeframe to residents. This affected one resident (#50) of 18 residents reviewed for development of care plans. The census was 52.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plans were reviewed after each assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Further the facility failed to appropriately revise discharge plans of care. The affected two residents (#51 and #63) reviewed for care plan accuracy. The facility census was 52.

Inspectors wroteBased on staff and resident interview, record review, call light audits, and policy review the facility failed to ensure residents were provided care and services to support their activities of daily living. This affected two residents (#24, #63) of twelve residents reviewed for activities of daily living. The census was 52.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents were provided an on-going, comprehensive activity program to meet their preferences. This affected two residents (#2 and #28) of two residents sampled for activities. The census was 52.1. Closed medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including encephalopathy, heart failure, anemia, diabetes and a fractured hip. The resident expired on [DATE]. Review of the Activities assessment dated [DATE] revealed activities were to be offered one to three times a week. The resident's activity pursuit and preferences included current the following interests: [...]

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to develop and implement a comprehensive, individualized and effective pressure ulcer prevention program to prevent the development of a pressure ulcer. This affected one resident (#2) of four residents reviewed for pressure ulcers. The census was 52.

Inspectors wroteBased on record review, observation, review of manufacturer's guideline, policy review, and interview, the facility failed to safely transfer residents while using a mechanical lift, failed to provide staff training on the use of all mechanical lifts, and failed to ensure resident call lights were within reach for a resident at risk for falls. This affected three residents (#30, #55, #11) of three residents reviewed for accidents. The facility census was 52.

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure ordered respiratory care was provided. This affected one resident (#1) of three residents observed for respiratory care. The census was 52.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure medications were administered without significant error. This affected one resident (#1) of five residents sampled for unnecessary medications. The census was 52.

Inspectors wroteBased on record review, text message communication review, incident log review, time punch review, interview, and facility policy review the facility failed to maintain comprehensive and accurate medical records. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse and one resident (Resident #30) of four residents reviewed for accidents. The census was 52.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure infection control procedures were followed during a dressing change. This affected one resident (Resident #4) of one residents reviewed for dialysis.

Inspectors wroteBased on observation, survey result review and interview, the facility failed to ensure completed survey results were readily available for review. This affected all 52 residents residing within the facility. The facility census was 52.

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure a pressure ulcer was comprehensively assessed and treatment orders were obtained timely for Resident #28 to prevent the further decline of an identified in-house obtained pressure ulcer. Actual Harm occurred on 12/12/25 when Resident #28, who had moderately impaired cognition, and was at risk for pressure ulcer development, developed a new, in-house acquired left buttock pressure ulcer. The ulcer was first assessed as an open area without proper prevention, treatment, and interventions implemented. This affected one resident (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 56. Findings Include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of medical records, interview, review of facility Self-Reported Incidents (SRI) and associated investigations, and review of the facility's Abuse policy, the facility failed to prevent the verbal abuse of Resident #10 by a facility staff member. This affected one resident (Resident #10) of three reviewed for abuse however this had the potential to affect all 56 residents in the facility. Findings Include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included traumatic subdural hemorrhage, chronic obstructive pulmonary disease, asthma, respiratory failure, diabetes, blindness, heart failure, end stage renal disease with renal dialysis, major depressive disorder, generalized anxiety disorder, cannabis use, hypertension, hypothyroidism and traumatic brain injury. [...]

Inspectors wroteBased on observation, review of the medical record, interview, and review of the facility policy, the facility failed to knock prior to entering the room of Resident #16. This affected one resident (Resident #16) of three reviewed for privacy. Findings Include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease, peripheral vascular disease, diabetes, chronic kidney disease, bipolar disorder, generalized anxiety disorder, lymphedema, and gout. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #16 had intact cognition. Observation and interview on 01/17/26 at 10:12 A.M. revealed Maintenance #106 opened the door of Resident #16's room without knocking prior to entering. [...]

Inspectors wroteBased on review of facility in-service records, review of the resident concerns/grievances log, review of the resident council minutes, interviews with residents and staff, and review of facility policy, the facility failed to ensure resident grievances were resolved in an appropriate manner and time frame regarding the answering of call llights. This affected nine residents (#30, #33, #34, #35, #39, #41, #44, #47, and #53) of nine residents reviewed for resident rights. The facility census was 54.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure infection control standards were implemented during resident care. This affected two residents (Resident #35 and Resident #25) out of three residents observed for infection control. The census was 54.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of the test tray, review of facility policy, and review of United States Department of Agriculture (USDA) guidelines, the facility failed to maintain palatable and appetizing food temperatures. This had the potential to affect all residents in the facility. The census was 56.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure an orthopedic consultation was set up as ordered for Resident #57. This affected one resident (Resident #57) of three reviewed for quality of care.

Inspectors wroteBased on observation and interview, the facility failed to maintain a resident room in a clean, organized, and sanitary manner. This affected one resident (#15). The facility census was 62.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized during a dressing change. This affected one resident (#15) of one resident observed for a dressing change. The facility census was 62.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure meals were served at a palatable temperature. This had the potential to affect all 55 residents who received meals from the kitchen, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 55.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 55 residents who received a meal from the kitchen, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 55.

Inspectors wroteBased on observation, interviews, review of the facility kitchen sanitation audits and facility policy review, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 55.

Inspectors wroteBased on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure residents requiring a mechanically altered diet were served the appropriate diet consistency. This affected four residents (#12, #42, #153, and #202) of four residents reviewed for mechanically altered diets. The facility identified eight residents (#12, #16, #22, #25, #42, #152, #153, #202) as receiving mechanically altered diets. The facility census was 55.

Inspectors wroteBased on observations, review of the medical record, interviews with staff, and review of facility policy, the facility failed to ensure proper hand hygiene was maintained while distributing meal tray on the unit, failed to ensure proper handling of linens in the laundry room, failed to ensure the nasal cannula was stored in a protective barrier when not in use for Resident #7, failed to utilize Enhanced Barrier Precautions (EBP) for Resident #253 while receiving an intravenous medication through a peripherally inserted central catheter, and failed to maintain proper infection control measures during wound care for resident Resident #21. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe environment in good repair. This affected three residents (#7, #48 and #160) of 55 residents observed for physical environment. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record and interview with staff the facility failed to ensure call lights were within reach of Resident #7 and #8. This affected two residents (#7 and #8) of three residents reviewed for physical environment. The facility census was 55.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure there was a signed Do Not Resuscitate (DNR) form in Resident #1's medical record. This affected one resident (#1) out of 17 residents reviewed for advance directives. The facility census was 55.

Inspectors wroteBased on observation, record review, interview and review of facility policy the facility did not ensure Resident #1's preference to wear undersized clothing was added to her care plan. This affected one resident (#1) of 17 residents reviewed for care plans. The facility census was 55.

Inspectors wroteBased on medical record review, facility policy review, and interview, the facility failed to ensure discharge summaries were completed as required for Resident #47 and #51. This affected two Residents (#47 and #51) of three residents reviewed for discharge. The facility census was 55.

Inspectors wroteBased on observation, review of the medical record, interview with staff and review of facility policy the facility failed to ensure fall interventions were implemented as ordered for Resident #31. This affected one resident (Resident #31) of two residents reviewed for falls. The facility census was 55.

Inspectors wroteBased on record review, interview and review of facility policy the facility failed to ensure reweights were obtained in a timely manner for Residents #15 and #31 and meal intakes were adequately monitored for Resident #31. This affected two residents (#15 and #31) of five residents reviewed for nutrition. The facility census was 55.

Inspectors wroteBased on observation, interview and record review the facility failed to administer oxygen at the prescribed dose, failed to ensure oxygen in use signage was posted and oxygen tubing was dated and not lying on the floor. This affected one resident (#153) of four residents reviewed for respiratory care. The facility census was 55.

Inspectors wroteBased on medical record review, facility policy review, and interview, the facility failed to ensure residents on dialysis were assessed and monitored routinely. This affected one Resident (#154) of one reviewed for dialysis. The facility census was 55.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure pharmacy recommendations were fully addressed in an acceptable manner. This affected one (Resident #32) of five residents reviewed for medication use. The facility census was 55.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a resident receiving medications to treat diabetes mellitus had blood glucose levels monitored in accordance with orders to monitor effectiveness of medications. This affected one (Resident #1) of five residents reviewed for medications. The facility census was 55.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure anti-anxiety medications ordered on an as necessary basis had time limits for use and failed to address why gradual dose reductions (GDR) of psychotropic medications were contraindicated. This affected one (Resident #32) of five residents reviewed for medication use. The facility census was 55.

Inspectors wroteBased on observations, interview, record review, and review of manufacturer information, the facility failed to ensure medications were administered in accordance with physician orders. Three errors were identified out of 30 opportunities for error resulting in a 10% medication error rate. This affected three (Residents #10, #20, and #152) of four residents observed for medication administration. The facility census was 55.

Inspectors wroteBased on observation, review of medication manufacturer information, review of physician orders, policy review and interview, the facility failed to ensure multi-dose medication vials and pens were dated when opened, disposed of when expired, and stored at the appropriate temperature. This involved one of two medication carts observed for medication storage and affected Residents #33 and #252.

Inspectors wroteBased on interview and review of the facility arbitration agreement, the facility failed to ensure the arbitration agreement allowed for a mutually agreeable arbitrator and venue. This affected all residents residing in the facility. The facility was census was 55.

Inspectors wroteBased on review of the medical record, interview with staff, information from the Pneumonia (Pneumo) Recommendations (Rec) Vaccinations (Vax) Advisor application, and policy review, the facility failed to ensure pneumonia vaccine were up-to-date for Resident #7 and #30. This affected two residents (Resident #7 and #30) of five reviewed for vaccination status. The facility census was 55.

Inspectors wroteBased on review of the facility Payroll Based Journal (PBJ) submission data, Staffing Data Report and staff interview, the facility failed to ensure submission of the Payroll Based Journal data as required. This had the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure infection control standards were followed regarding sanitary pericare technique. This affected one resident (#14) of three residents reviewed for infection control.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were treated with dignity and respect. This affected one (Resident #9) of three residents reviewed for dignity. The facility census was 55.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of the Self-Reported Incident (SRI), review of facility investigation, review of the facility policy, and interview with staff the facility failed to prevent misappropriation of medication for Resident #40 by a staff member. This affected one resident (#40) of three residents reviewed for medication.

Inspectors wroteBased on medical record review and staff interview the facility failed to complete routine respiratory assessments for residents requiring continuous supplement oxygen and aerosolized respiratory medications. This affected two (Residents #61 and #47) of three residents reviewed for oxygen use. The facility identified 14 residents (Residents #3, #5, #6, #9, #22, #25, #28, #40, #43, #46, #47, #51, #54 and #58) currently on continuous supplemental oxygen therapy.

Inspectors wroteBased on record review, review of video camera footage, ambulance report, and hospital records, and interviews with residents, power of attorney, and staff, the facility failed to provide adequate assistance to prevent a fall for Resident #9 and failed to provide timely assistance following a fall for Resident #1. This resulted in Actual Harm on 09/28/23 when Resident #9, who required maximum assistance from two staff for bed mobility, fell from the bed while a staff member was providing incontinence care resulting in Resident #9 sustaining bilateral femur fractures. At the time of the incident, the facility failed to ensure staff had adequate training on the use of a low air loss and alternating pressure mattress to provide adequate assistance with incontinence care to the resident to prevent the fall with injury. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure food was discarded and the kitchen was clean and sanitary. This had the potential to affect all 54 residents who received food from the kitchen. The facility census was 54.

Inspectors wroteBased on record review, interview with the resident's responsible party, and interview with staff, the facility failed to accommodate a resident's responsible parties request for a WanderGuard/elopement bracelet. This affected one (Resident #2) of three residents reviewed for accomodation of needs. The facility census was 54.

Inspectors wroteBased on record review, interview with resident's representative, and interview with staff, the facility failed to notify the responsible party when Resident #2 eloped from the facility and for the new physician order for a WanderGuard bracelet for Resident #2. This affected one (Resident #2) out of three residents reviewed for notification of change. The facility censes was 54.

Inspectors wroteBased on record review and interview, the facility failed to safely store the resident's medications. This affected one (Resident #2) of three residents reviewed for medications. The facility census was 54.

Inspectors wroteBased on record review, review of video camera footage, and staff interview, the facility failed to ensure Resident #1's medical record had accurate documentation of times of resident fall, medication administration, and when Resident #1 was sent to the hospital. This affected one (Resident #1) of nine residents reviewed for medical records. The facility census was 54.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Residents #12, #38, #43, #47, #51 and #53. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to complete comprehensive and ongoing respiratory assessments for residents who had a diagnosis of COVID-19 to ensure the residents were monitored for complications and/or respiratory problems. This affected seven residents (#47, #51, #60, #39, #27, #33 and #36) of 18 residents currently identified to be positive for COVID-19 in the facility.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents who required staff assistance with activities of daily living received timely and adequate assistance with dining and/or showers. This affected four residents (#38, #51, #63 and #224) of six residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure a timely fall risk assessment was completed for Resident #60 following an unwitnessed fall to ensure individualized and appropriate fall risk interventions and monitoring were initiated. This affected one resident (#60) of three residents reviewed for falls.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a comprehensive bowel and bladder assessment was completed for Resident #50 to implement an individualized program to restore normal bowel and bladder function. This affected one resident (#50) of one resident reviewed for bowel and bladder function.

Inspectors wroteBased on record review and interview the facility failed to ensure nutritional interventions were initiated timely for Resident #45 and failed to ensure weekly weight monitoring was completed as recommended for Resident #45 and #59 to ensure the resident's nutritional needs were being met. This affected two residents (#45 and #59) of three residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure adequate and proper tracheostomy care was provided for Resident #28 to decrease the risk of infection. This affected one resident (#28) of one resident reviewed for tracheostomy care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure adaptive equipment for meals were provided as ordered/planned for Resident #45 and Resident #59. This affected two residents (#45 and #59) of three residents reviewed for nutrition.