Country View Nursing

Inspectors wroteBased on observation, interview and record review, the facility failed to timely repair toilets in residents' bathrooms and failed to adequately repair the door to one resident's room. The facility census was 37. Review of the undated policy, Homelike Environment, showed the following:-The facility was responsible for providing the residents with a safe, clean, comfortable and homelike environment;-Part of this responsibility is maintaining the physical structure in good repair as well as maintaining the resident areas in a clean manner. Scratched doors, missing tiles, structural damage or environmental safety issues must be corrected;-In the event a staff member identifies an environmental issue their responsibility is to notify the Maintenance Director. Any identified issue should be logged in the maintenance binder at the nurse's station. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment free of fall hazards for three residents (Residents #2, #1 and #3), in a review of six sampled residents, when the facility failed to repair a broken toilet seat and secure the toilet armrest frame for over two weeks in their shared bathroom. Residents #2 and #1 fell as a result of the broken toilet seat. The facility census was 37. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #34), in a review of 17 sampled residents, was free from abuse by staff. Certified Nursing Assistant (CNA) J slapped the resident in the face with a dirty incontinent product, was physically rough with the resident causing the resident pain and discomfort, spoke to the resident in a harsh tone and told the resident he/she could complete tasks that the resident requested help for. CNA J's actions were witnessed by Resident #34's roommate. The interaction made Resident #34 feel unsafe and angry. The facility census was 40. The administrator was notified of the past noncompliance on 01/09/26, which occurred on 01/04/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services to assist one resident (Resident #9), in a review of 17 sampled residents, to attain or maintain his/her highest level of functioning. Resident #9, who had contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and a physician order for participation in a Restorative Nursing program six days a week, had not been provided with this service since the order start date of 04/04/25. Resident #9 had a decrease in his/her range of motion abilities and required additional muscle relaxant medication to control his/her contracture pain. The facility census was 40. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy for the documentation, notification, review and monitoring of falls and implementation of interventions for two residents (Resident #6 and #5), in a review of 17 sampled residents, who experienced multiple falls. Resident #5 sustained rib fractures due to falls. The facility census was 40. Review of the facility's Fall-Clinical Protocol policy, dated September 2012, showed the following:-As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling;a. Staff will ask the resident and the caregiver or family about a history of falling;b. The staff and physician should document in the medical record a history of one or more recent falls;-In addition, the nurse shall assess and document/report the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) when the facility failed to ensure one resident (Resident #6), went to his/her follow up urology appointments as scheduled and failed to ensure his/her urinary catheter (a sterile tube inserted into the bladder to drain urine) was changed as ordered either at the urology clinic or by facility staff. The resident missed three scheduled appointments. The resident was diagnosed with a UTI which the medical director said could be a result of lack urinary catheter changes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to address weight loss for two residents, (Resident #5 and #6), in a review of 17 sampled residents. The facility failed to notify the physician of weight loss, assess for root cause, evaluate the care plan, or initiate interventions based on the evaluation to address weight loss. Review of Resident #6's weight records showed the resident lost 7.4 pounds (lbs.) between 10/01/25 and 11/01/25, a 6.32 percent (%) weight loss in one month. Review of Resident #5's record showed the resident lost 6.6.lbs. since 10/18/25 a 5.79 % weight loss in approximately 45 days and a 7 lbs. or 6% weight loss in 30 days (since 10/31/25. The resident weighed 106.0 lbs. on 11/07/25, and lost 9.2 lbs. in one week, a 7.96% weight loss. The facility census was 40. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, safe, and homelike environment by failing to maintain ceilings, walls, railings, floors, doors and toilets, in resident rooms and bathrooms, in good repair. The facility failed to maintain outside gutters and trim in good repair. The facility census was 40. Upon request, the facility did not provide a policy related to maintaining the environment. 1. Observation on 01/06/26 through 01/09/26, during the survey process, showed the following in occupied resident room [ROOM NUMBER]: [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified dietary manager with appropriate competencies and skills set to carry out the function of the food and nutrition services program. This practice affected all residents at the facility. The facility census was 40. Review of the facility's Facility Assessment, dated 02/11/25, showed the following:-Average daily census 45;-Services and care offered are based on our resident needs: Nutrition - individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis;-Facility resources needed to provide competent support and care for our resident population every day and during emergencies: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature and taste. The facility census was 40. Review of the facility policy, Meal Service Temperatures, revised January 2016, showed the following: -Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees;-The [NAME] shall take temperatures of food (as appropriate) during meal preparation to ensure food is cooked or chilled to the appropriate temperature. Staff shall also take the temperatures once the food is on the steamtable prior to the start of meal service.-Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable temperatures. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not practice proper hand and glove hygiene or hair restraint usage. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris. Staff failed to ensure an air gap was present at the ice machine drains to prevent possible backflow from the drain back into the ice machine. The facility census was 40. 1. Review of the facility policy, Sanitation, revised January 2016, showed employees shall wash their hands: after touching bare human body parts (face, nose, etc.); after using the restroom; after coughing, sneezing, using a handkerchief or tissue; after eating or drinking; after handling soiled equipment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to follow infection control practices when staff failed to utilize proper Transmission Based Precautions (TBP) when caring for one resident (Resident #34), who was positive for COVID (coronavirus disease 2019 - a contagious respiratory disease) infection and in isolation. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure resident trust accounts were not allowed to go into a negative balance for four residents (Resident #29, #9, #44 and #10) and one additional resident (Resident #103) in a review of 17 sampled residents. Further review showed the facility failed to obtain a signature from the resident when funds were removed from the Resident Trust Fund account, failed to send quarterly statements to the residents or the resident representatives for those with transactions in the Resident Trust Fund Account, and failed to reimburse the Resident Trust Fund account after charges for check printing fees were taken out of the Resident Trust Fund account. The facility held funds in the Resident Trust Fund account for 31 residents. The facility census was 40. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure ten additional residents (Resident #108, #109, #110, #112, #106, #107, #111, #113, #114 and #115), who were discharged from the facility and held money in the Resident Trust Fund account, had their funds reimbursed to the appropriate entity within the required timeframe of their discharge. The facility census was 40. Review of the facility policy, Facility Resident Trust Fund, revised [DATE], showed the following:-Policy: It will be the policy of the management company that the Resident Trust Fund is managed and accounted for in accordance with state and federal regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to two residents (Residents #1 and #37), or their representatives, in a review of 17 sampled residents and to one resident (Resident #42), in a closed record review, when the residents were transferred to the hospital. The facility failed to provide a recapitulation of the resident's stay that included a summary of the resident's stay, a summary of the resident's status at the time of discharge and a reconciliation of all pre-discharge medications with the resident's post-discharge medications for Resident #42. The facility census was 40. Review of the facility policy, Transfer or Discharge Notice, revised December 2018, showed the following: -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received sufficient nourishing bedtime snacks. The facility census was 40. Upon request, the facility did not provide a policy for bedtime snacks. 1. Review of the facility provided, mealtime service schedule, showed the following:-Supper to be served at 5:30 P.M.;-Breakfast to be served at 7:45 A.M.;(14.25 hours between meals). 2. During the group interview on 01/07/26 at 2:42 P.M., residents said the following:-Resident #17 said staff used to pass snacks every night, but now the residents must ask for snacks; snacks most generally are cookies and snack cakes, sometimes graham crackers; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain documentation to show the staff notified the resident's physician and the resident's representative following a significant weight loss and falls for one resident (Resident #5), in a sample of 17 residents. The facility census was 40. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #6 and #2), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 40. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition of a resident who has mental illness for one resident (Resident #4) in a review of 17 sampled residents. The facility census was 40. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident's (Resident #2) of 17 sampled resident's, comprehensive care plan included direction to the staff for the resident with a diagnosis of Post Traumatic Stress Disorder (PTSD, (a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, accidents, or disasters.) to ensure trauma-informed care was provided. The facility did not communicate triggers or interventions to eliminate or mitigate the resident's triggers that may cause re-traumatization. The facility census was 40. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #29), received the prescribed insulin dosage when staff failed to prime the insulin pen prior to administration per the manufacturer's guidelines, in a review of 17 sampled residents. The facility census was 40. Review of the facility's policy, Specific Medication Administration Procedures, dated June 1, 2018, showed the following:-Purpose: To ensure safe, accurate, and consistent administration of insulin using insulin pens or syringes;-Policy statement: All licensed nursing staff must follow proper priming and administration procedures when giving insulin to prevent dosing errors and ensure resident safety;- Priming the Insulin Pen: -Dial two units (or per manufacturer instructions); -Hold pen upright with needle pointing up; -Tap gently to move air bubbles to the top; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment by not maintaining the indoor air temperatures in resident use areas including the end of the 300 hall resident hallway, dining room and nurses' station between 71.0 F. (degrees Fahrenheit) and 81.0 F. The facility census was 39. Review of email communication dated 07/28/25 AT 4:18 p.m., showed the administrator said the facility did not have a policy related to heating and cooling or an emergency heating and cooling policy.1. Observation on 07/20/25 at 1:10 P.M. showed the following:-The nurses station thermostat read 78 degrees F;-The area felt warm if moving or doing any tasks; the air temperature with a thermometer was 84 degrees Fahrenheit;-Staff carried portable battery operated fans. 2. Observation of the dining room on 07/20/25 at 2:08 P.M. and 2:13 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), who utilized a wheelchair for mobility and required assistance of one staff member during a facility van transport, was appropriately secured in the facility van when two of the four straps in the van were not functional. At the time of the transport on 5/23/25 at about 8:00 A.M., Transport Staff A said he/she could only attach two of the four straps in the van to the resident's wheelchair (front left and back right), because the other two straps were stuck. During the return transport to the facility, Transport Staff A attached the same two straps to secure the wheelchair in the van and a seat belt to secure the resident. [...]

Inspectors wroteBased on observation and interview, the facility failed to comply with state laws and designate a person as an administrator who was employed in the facility and served in that capacity on a full-time basis. This had the potential to affect all facility residents. The facility census was 42. The facility did not have a policy regarding the administrator or their duties. 1. During an interview on [DATE] at 8:30 A.M. and 11:00 A.M., Administrator L said the following: -She introduced herself as the facility administrator; -She started as the administrator on [DATE] and fulfilled the duties as acting administrator for the facility; -She had not applied for a temporary emergency license; -Administrator K had her license hanging in the facility. During an interview on [DATE] at 12:00 P.M., Licensed Practical Nurse (LPN) H said the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice when physician orders for wound care for two residents (Resident #2 and Resident #9) in a review of 12 sampled residents, were not completed as ordered. The facility failed to follow all orders from the outside Wound Care Clinic or add orders to the resident physician order sheets (POS). Additionally, the facility failed to ensure Resident #9 had transportation to the Wound Care Clinic for scheduled appointments. The facility census was 42. Review of the facility policy, following physician's orders, undated, showed the following: -The facility was committed to ensuring physician orders were carried out properly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of fourteen sampled residents, was free from abuse when resident (Resident #2) hit Resident #1 on the head with his/her walker, causing an injury to Resident #1's head. Resident #1 was tearful and expressed fear of Resident #2 after the incident. The facility census was 38. Review of the facility policy, Abuse, Prevention and Prohibition Policy, reviewed 2021, showed the following: - Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of 14 sampled residents. Staff failed to remove a 100 microgram (mcg) fentanyl patch (topical narcotic pain patch) as ordered before applying another 100 mcg fentanyl patch. Staff who applied the patch failed to follow facility policy and did not label the new 100 mcg fentanyl patch with the date of application and staff initials. The facility census was 38. Review of the facility policy, Specific Medication Administration Procedures, dated June 1, 2018, showed the following: -Transdermal drug delivery system (patch) application; -To administer medication through the skin through proper placement of the patch and care of the applications site(s); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food to one resident (Resident #4), in a review of 14 sampled residents, that accommodated the resident's preferences. The facility census was 38. 1. Review of the facility provided, resident diet type report, dated 02/27/25, showed the following: -Resident #4 was listed on the report; -He/She had allergies listed that included milk. 2. Review of Resident #4's Face Sheet showed the following: -His/Her allergies included milk; -He/She had diagnoses that included lactose intolerance (the inability to digest lactose, the sugar in milk; causes digestive symptoms such as diarrhea, gas and bloating after eating or drinking dairy products). Review of the resident's clinical allergies, listed in the resident's electronic medical record (EMR), showed the resident had milk listed as an allergy (noted 06/04/20). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a dignified and respectful manner for two residents (Residents #3 and #4), in a review of eight sampled residents, when staff failed to answer call lights timely, resulting in incontinence and residents waiting in soiled briefs for staff to respond. The facility census was 41. Review of the facility's undated policy, Call Lights, showed the following: -All nursing personnel must be aware of call lights at all times; -Answer ALL call lights promptly whether you are assigned to the resident; -Answer all call lights in a prompt, calm, courteous manner, turn off the call light as soon as you enter the room; -Never make the resident feel you are too busy to give assistance, offer further assistance before you leave the room. 1. Review of Resident #3's Care Plan, updated 6/13/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident's representative with a copy of the resident's medical records upon written request within 24 hours of the resident's representative request for one resident (Resident #8), in a review of 8 sampled residents. The facility census was 41. 1. Review of Resident #8's face sheet showed the following: -The resident was admitted to the facility from the hospital on 7/30/24; -He/She was discharged on 9/7/24. During an interview on 9/20/24 at 8:06 A.M., the resident's power of attorney (POA) said the following: -He/She asked Licensed Practical Nurse (LPN) A to view the resident's medical records. LPN A said he/she was unable because the records were on the computer; -LPN A provided the POA a copy of the resident's physician orders from the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy to notify the resident's power of attorney for two residents (Residents #1 and #2), in a review of eight sampled residents, following a resident-to-resident altercation. The facility census was 41. Review of the facility's undated policy, Significant Condition Change and Notification, showed the following: -To ensure the resident's family and/or representative and medical practitioner are notified of resident changes; -A significant change in the resident's physical, mental, or psychosocial status, including resident-to-resident altercation, which require notification for both residents. 1. Review of Resident #1's undated face sheet, showed the following: -The resident had a power of attorney; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow hospital discharge orders for post operative appointments and administer anticoagulant medication (medicine that helps prevent blood clots) as ordered for one resident (Resident #8), in a review of eight sampled residents. The facility census was 41. Review of the facility's undated policy, Following Physician Orders, showed the following: -admission orders are received from the discharging physician and communicated to the primary care physician at the time of admission; -Medical records will conduct chart audits on a monthly basis to help monitor correct documentation. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents, (Resident #1, #2, and #5), in a sample of 14 residents, were treated with dignity and respect when Nursing Assistant (NA) H told Resident #1 don't cry, I didn't hurt you that much and when Certified Nurse Assistant (CNA) K turned off Resident #1's call light because he/she could not understand Resident #1. CNA I and CNA J made statements to Resident #2 about his/her smoking and medical diagnosis that upset and made Resident #2 mad. Additionally, Resident #5 said NA H was,very rude to him/her in the resident's room. The facility census was 42. Review of the facility's policy, Quality of Life -Dignity, dated 2/2020, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide/designate a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 44. Review of the facility's staffing policy, dated October 2017, showed the following: -Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; -The policy did not contain information regarding registered nurse coverage for at least eight hours daily. 1. Review of the daily staffing sheets, dated 11/12/23-11/18/23, showed no RN coverage on 11/16/23. Review of the daily staffing sheets, dated 11/19/23-11/25/23, showed no RN coverage on 11/25/23. Review of the daily staffing sheets, dated 11/26/23-12/2/23, showed no RN coverage on 11/26/23, 11/27/23, 11/29/23, 11/30/23, and 12/1/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sanitary practices in accordance with professional standards for food service regarding the storage, preparation, and serving of residents' food and beverages. Staff failed to employ proper equipment cleaning and maintenance, dish handling and storage, and handwashing and gloving techniques to prevent potential contamination to residents' food and beverages. Staff failed to ensure food items were labeled, dated, sealed, and stored appropriately, including in dent-free cans, not in single-use containers, and within the manufacturer's best by date. Staff failed to ensure the kitchen dishwashing machine utilized the appropriate water temperature and sanitizer chemical level to clean and sanitize dishes and that staff were knowledgeable of the machine's acceptable temperature and chemical parameters. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center of Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment to identify potential sources of Legionella growth (discussed but not started). The facility's water management team had not had a meeting and the facility's water flow map was not completed. The facility failed to store respiratory and oxygen equipment in a manner to protect it from contamination when not in use for four residents (Residents #6, #29, #32 and #43), in a review of 15 sampled residents. The facility census was 44. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 11 residents (Resident #9, #12, #15, #26, #30, #502, #503, #504, #505, #506 and #507). The facility census was 44. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 12/06/23, showed the following residents with personal funds held in the facility operating account. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written statement of the individual resident's trust fund balance and activity in the account (deposits and withdrawals) to the resident and/or his/her responsible party quarterly and upon request. The facility managed funds for 24 residents. The facility census was 44. Review of the facility policy, Deposit of Resident Funds, last revised April 2017, showed resident personal funds that are held and managed by the facility will be safeguarded. The resident is provided a confidential quarterly statement of funds on deposit with the facility, including activity since the previous statement. During the group interview on 12/4/23 at 2:22 P.M., the residents in attendance said the following: -Resident #14 said he/she had asked for a statement several times and never received one; [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for four residents (Resident #18, #33, #41 and #200) in a sample of 15 residents. The facility census was 44. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised on October 2018, showed the following: -A comprehensive, person-centered care plan that includes measurable objective 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; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided four residents (Resident #3, #18, #36 and #41), who were unable to perform their own activities of daily living (ADLs), in a review of 15 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 44. Review of the facility's policy, Quality of Life - Dignity, revised August 2009, showed the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow resident's care plan interventions to prevent the development of pressure ulcers for four residents (Residents #3, #18, #20, and #35), in a review of 15 sampled residents, who were dependent on staff and were at risk for developing pressure ulcers. The facility failed to float Resident #20's heel and apply a heel protector to the heel as directed in his/her plan of care, and failed to reposition Residents #3, #18, and #35 at least every two hours according to their plan of care. The census was 44. Review of the facility's policy for prevention of pressure ulcers/injuries, last revised October 2018, showed the following: -The purpose was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature and taste. The facility census was 44. Review of the facility policy, Food and Nutrition Services, revised October 2017, showed the following: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature; -Meals will be provided within 45 minutes of either resident request or scheduled meal time; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and provide a copy of a baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility, for two residents (Resident #41 and #200), in a review of 15 sampled residents. The facility census was 44. Review of the facility's policy, Care Plans - Baseline, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Residents #1), in a review of 15 sampled residents, and for one additional resident (Resident #200). The facility failed to administer and monitor Resident #1's oxygen therapy as ordered, failed to ensure Resident #1 had geri-sleeves (a sleeve of breathable material worn to protect against skin tears) in place on his/her bilateral upper extremities as directed in his/her care plan, and failed to administer Resident #198's medications at the prescribed time or within one hour of the prescribed time. The facility census was 44. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner and as prescribed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two nurse aides completed a State-approved training and competency evaluation program within four months of their date of hire. The facility census was 44. Review of the facility's nurse aide qualifications and training requirements, dated October 2017, showed the following: -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: a. That individual is competent to provide designated nursing care and nursing related services; b. That individual has completed a training program and competency evaluation program, or a competency evaluation program provided by the state; c. That individual has been deemed competent as provided in 483.150(a) and (b) of the Requirements of Participation; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, three errors occurred, resulting in a 10% error rate which affected three additionally sampled residents (Resident #24, #42 and #200). The facility census was 44. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one additional sampled resident (Resident #24) and one closed record resident (Resident #500), in a sample of 15 residents, was free from a significant medication error. The facility census was 44. Review of the facility's policy, Medication Orders, effective January 2017, showed the purpose of his procedure is to establish uniform guidelines in the receiving and recording of medication orders. Review of the facility's policy, Administering Medications, revised December 2012, showed the following: -Medications shall be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify five residents (Residents #6, #18, #29, #33, and #41) in a review of 15 sampled residents, or their representatives in writing of the reason for transfer to the hospital as directed in facility policy. The facility census was 44. Review of the facility's transfer or discharge notice policy, revised December 2018, showed the resident and/or the representative would be notified in writing of the following information: -The reason for the transfer or discharge; -The effective date of the transfer or discharge; -The location to which the resident was being transferred or discharged ; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information of the facility's bed hold policy to the resident representative prior to transfer of a resident to the hospital for four residents (Residents #6, #18, #29 and #41), in a review of 15 sampled residents. The facility census was 44. Review of the facility's Bed Hold Policy and Agreement form, revised February 2014, showed the following: -Purpose: To establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement to Pay Charges for Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his/her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one discharged resident (Resident #46), who was discharged to his/her home with a discharge summary that contained a recapitulation of the residents' nursing home stay. The facility census was 44. Review of the facility's policy for discharge summaries, last revised in December 2016, showed the following: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan would be developed which will assist the resident to adjust to his/her new living environment; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility transporter, who transported three sampled residents (Residents #1, #12 and #29) and one closed record resident (Resident #5) in the facility van, all of which had elected a full code status, was trained and certified to provide cardiopulmonary resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood). Additionally, the facility to obtain physicians' orders for three residents' (Resident #1, #12 and #29) requested code status and failed to maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment and to monitor to ensure CPR certified staff were scheduled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quarterly statements of the resident trust funds account to the resident or their representative for all residents who maintained a balance in the resident trust fund, including petty cash; failed to ensure residents did not carry a negative balance in the resident trust fund; and failed to establish and maintain an effective bookkeeping system and follow the facility's policy for ensuring the resident trust fund account was accurately monitored and reconciled. The facility managed funds for 31 residents. The facility census 32. Review of the facility's Resident Trust Policy, dated May 2012, showed the following: -Resident Trust Fund would be managed and accounted for in accordance with state and federal regulations; [...]

Inspectors wroteBased on interview and record review, the facility failed to purchase a surety bond in an amount of at least one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. The facility census was 32. Review of the facility's Resident Trust Fund policy, dated May 2012, showed the following: -Resident trust account would be managed and accounted for in accordance to State and Federal regulations; -The facility must purchase and maintain a surety bond that would protect resident personal funds against loss, theft, and insolvency. The surety bond must be greater than all resident funds managed by the facility and adheres to State and Federal guidelines. 1. Review of the resident trust fund account for November 2020 through October 2021, showed an average monthly balance of $43,009.37, which required a surety bond of $64,500.00. [...]

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. The facility census was 32. 1. During entrance conference on 11/15/21 at 10:30 A.M., the administrator said RN A was providing DON coverage. 2. Review of the October 2021 nursing schedule showed RN A worked as the day shift charge nurse from 7:00 A.M. to 7:00 P.M. on 10/16, 10/17, 10/18, 10/21, 10/22, 10/25, 10/26, 10/30 and 10/31. Review of the November 2021 nursing schedule showed RN A worked as the day shift charge nurse from 7:00 A.M. to 7:00 P.M. on 11/1, 11/2, 11/5, 11/8, 11/9, 11/12, 11/13, 11/14, 11/17 and 11/18. During interview on 11/18/21 at 5:00 P.M., RN A said the following: -She became a RN in May 2021; -She had not been functioning as the DON for the facility. She has been working full time as a charge nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify five residents (Residents #28, #15, #30, #12, and #23) or his/her legal representative, who received Medicaid benefits, when the resident's trust fund balance reached $200 less than the Supplemental Security Income (SSI; Federal income supplement program designed to help aged, blind, and disabled people who have little to no income) resource limit ($5,000). The facility census was 32. Review of the facility's Resident Trust Fund policy, dated May 2012, showed the following: -Resident trust fund would be managed and accounted for in accordance with State and Federal regulations; -Any individual resident trust account that was nearing the state specified maximum balance would require the following action: A) Notification to resident/responsible party as to balance. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 32. Record review of facility's admission Packet Policy - Resident's Rights State and Federal, dated 5/13/10, showed the resident has the right to send and promptly receive mail that is unopened, as well as have access to stationary, postage, and writing implements at the resident's own expense. During group interview on 11/16/21 at 9:30 A.M., Resident #12 said he/she gets a big pile of mail on Monday and doesn't get mail brought to him/her on Saturday. During an interview on 11/18/21 at 9:48 A.M., the activity director said he/she was responsible for obtaining mail from the post office and delivering it to the residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable and homelike environment free from the presence of urine odors by not ensuring one resident's (Resident #29's) wheelchair cushion was cleaned after an episode of urinary incontinence that left the cushion soiled. The facility also failed to ensure floors and walls were clean and in good repair, and failed to ensure ceiling vents were clean and free from a buildup of dust and debris. The facility census was 32. 1. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/12/21, showed he/she was always incontinent of bowel and bladder. Observation on 11/16/21 at 11:20 A.M. showed the following: -The resident sat in his/her wheelchair. He/She was incontinent and his/her pants were visibly soiled with urine; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to implement an ongoing activities program designed to meet individual interests for three residents (Residents #12, #22 and #29), in a review of 12 sampled residents. The facility also failed to provide activities on the weekends and after 2:00 P.M., conduct scheduled activities that were on the calendar, and assess activity preferences. The facility census was 32. 1. During an interview on 11/18/21 at 2:30 P.M., the regional director of operations said there were no facility policies related to activities. 2. Review of facility's activity calendar, dated 9/1/21 to 9/30/21, showed the following: -There were no scheduled activities after 2:00 P.M. Monday through Friday; -There were no scheduled activities on the weekends. Review of facility's activity calendar, dated 10/1/21 to 10/31/21, showed the following: [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the activity program was directed by a qualified professional. The facility census was 32. 1. Review of the activity director's employee file showed no documentation she was eligible for certification as a therapeutic recreation specialist, or as an activities professional by a recognized accrediting body on or after October 1, 1990, or had two years of experience in a social or recreational program with the last five years, one of which was full-time in a therapeutic activities program or was a qualified occupational therapist or occupational therapy assistant or had completed a training course approved by the state. During an interview on 11/16/21 at 8:10 A.M. the activity director said she assumed the role as activity director in the middle of September/first of October 2021. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional standards when facility staff failed to keep medications in a medication cart secured and locked. Staff left a medication cart unlocked and unattended in a hallway and in an open, unattended area that residents passed by. The medication cart was not locked or attended, and the cart was not behind a locked door. The facility census was 32. Review of the facility policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/2016, showed the following: -It is the policy of this facility to ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. [...]

Inspectors wroteBased on interview and record review, the facility failed to practice acceptable infection control practices when nursing staff failed to record annual tuberculin skin test (TST) screenings for four sampled residents (Residents #4, #8, #30, and #33), in a review of 12 sampled residents. The facility census was 32. Review of the facility's Tuberculosis (TB) Control Plan, dated 2019, showed the following: -Residents in long-term care facilities have been identified as a high-risk group for re-activation of latent TB infection, acquisition of TB infection and potential spread of TB within the facility; -Some states may have different requirements for annual screening. Follow state and local guidelines. (The facility's policy did not direct staff to conduct an annual evaluation to rule out signs and symptoms of TB disease as directed in state regulation.) 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 32. Review of the facility's Antibiotic Stewardship Policy, dated 2019, showed the following: -It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease (an infection caused by bacteria) as required for six residents (Resident #29, #4, #17, #21, #22, and #26) in a review of 12 sampled residents, six additional residents (Resident #505, #23, #1, #11, #16, and #20) and one closed record (Resident #36). The facility failed to document if residents received the pneumococcal vaccine or did not receive the vaccine due to medical contraindications, previous vaccination or refusal, and failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 32. Review of the facility policy Pneumococcal Vaccine Program dated 2019 showed the following: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident's (Resident #14) representative was notified when the resident had a change in condition in a review of 12 sampled residents. The facility census was 32. Review of the facility's policy, Significant Condition Change and Notification, not dated, showed the following: Purpose: To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: - An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention; - A significant change in the resident's physical, mental or psychosocial status. (see below for examples); sudden onset of shortness of breath,symptoms of an infectious process, abnormal lab values, other abnormal assessment findings; - A need to significantly alter treatment; [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Certified Nurse Assistant (CNA) Registry for any Federal Indicators of abuse, neglect, or misappropriation of property prior to hiring one employee, in a review of six employees hired since the previous annual survey. The facility census was 32. Review of the facility's Abuse, Prevention and Prohibition Policy, dated November 2018, showed the facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation. The facility will make reasonable efforts to uncover information about any past criminal prosecutions. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for daily weights for one sampled resident (Resident #12), in a review of 12 sampled residents. The facility census was 32. 1. Record review of Resident #12's January 2021 physician's orders showed an order for weekly weights. Record review of the resident's progress notes showed a new physician's order was issued for daily weights on 1/18/21. Record review of the resident's January 2021 Treatment Administration Record (TAR) showed the following: -Daily weights (ordered 1/18/21); -No documentation staff obtained the resident's weight on 1/18/21 through 1/27/21; -Staff documented obtaining the resident's weight on 1/28/21. Staff did not document the resident's weight; -No documentation staff obtained the resident's weight from 1/29/21 through 1/31/21. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three residents' (Residents #4, #26, and #30), in a review of 12 sampled residents, representatives in writing of the reason for transfer to hospital in a language they understood and provide a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. The facility census was 32. 1. During interview on 12/01/21 at 1:27 P.M., the administrator said she was unable to find a policy for transfer, discharge, and Ombudsman notification. 2. Review of Resident #4's medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of a medical condition on 10/4/21; -No documentation to show the facility notified the resident's representative of the transfer; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or legal representatives of their bed hold policy at the time of transfer for three residents (Residents #4, #26, and #30), in a review of 12 sampled residents. The facility census was 32. Review of the facility's Bed Hold Policy and Agreement form, revised February 2014, showed the following: -Purpose: To establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement to Pay Charges for Bed Hold. The facility is to execute an acknowledgement stating whether or not such Resident desires to exercise his or her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines; -Policy-The Bed Hold Policy is to be obtained for each occurrence-hospital or therapeutic home leave; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had a minimum of 12 hours of in-service education (which should include abuse, neglect, and dementia care) per year. This had the potential to affect all of the residents. The facility census was 32. 1. The facility did not provide a policy for required annual CNA training upon request. 2. Review of the facility assessment, dated 9/10/21, showed the following: Required in-service training for nurse aides. In-service training must: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and resident abuse prevention training; [...]