Crestwood Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a safe temperature. The facility stored dairy products and eggs in a malfunctioning refrigerator for one week after a repair technician recommended the refrigerator be replaced. The refrigerator temperature was observed in the 60-degree range and the milk measured at 58.5 degrees Fahrenheit (F). Staff were observed serving the milk during a meal service. This deficient practice had the potential to affect all residents who ate at the facility. The census was 141. Review of the facility's Resident Food: Storage and Sharing policy, last reviewed 9/23/25, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Nursing Assistant (CNA) A punched the resident in the head several times and had a physical altercation with the resident. The resident fought back, and the altercation was approximately 10 seconds long. The sample size was four. The census was 146. The Administrator was notified on 06/26/26 of the past non-compliance. The facility responded appropriately when the incident occurred. The facility sent CNA A home immediately after incident and began an investigation. The facility provided training and in-services for all staff regarding abuse and neglect, de-escalation techniques, tap-out procedure, and residents' rights on 06/18/26 through 06/24/26. The deficiency was corrected on 06/24/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a Certified Nursing Assistant (CNA A) yelled and used profanity at the resident, then grabbed and pushed the resident to the ground. The sample size was four. The census was 141. The administrator was notified on 5/22/25, of the past non-compliance. The facility responded appropriately when the incident occurred. CNA A left the facility and resigned. A witness, CNA G, was terminated. The facility provided training and in-services for all staff regarding abuse and neglect, de-escalation techniques, tap-out procedure, and residents' rights. The deficiency was corrected on 5/20/26. Review of the facility's Resident's Rights policy, revised 9/21/25, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was appropriately labeled, dated, and/or sealed in an appropriate manner to prevent cross contamination and preserve food quality. The facility failed to ensure the dish machine and sanitizing sink were equipped with sufficient concentration of sanitizing solution to effectively clean and sanitize dishware. These deficient practices had the potential to affect all residents who ate at the facility. The census was 141. Review of the facility's Food Storage policy, undated, showed:-Frozen Meat/Poultry and Foods: Store items promptly at 0 degrees Fahrenheit (F). Foods shall be stored in their original containers if designed for freezing. Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil, plastic film, or special laminated papers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly statements were distributed to residents and/or their responsible parties. This deficient practice affected all 101 residents whose funds were handled by the facility. The census was 141. Review of the facility's Resident Rights policy, last review date 9/21/25, showed the facility will keep a written account of all funds and provide resident or resident's designee or guardian a quarterly accounting of all financial transactions made on behalf of the resident. Review of the resident funds records provided by the facility, showed no documentation of quarterly statements. During an interview on 4/28/26 at 11:00 A.M., the Administrator said the facility managed 101 resident accounts. The Business Office Manager was responsible for sending out the quarterly statements, but did not send out the quarterly statements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect resident funds from misappropriation by not implementing a check and balance system. During cash disbursements, the facility allowed cash and receipt books to be issued to staff for distribution without reconciliation of funds and receipts upon return. This deficient practice enabled the business manager to alter receipts and remove funds from the cash box without detection, resulting in the potential for and actual misappropriation of resident money for 33 residents (#6, #8, #11, #14, #17, #27, #35, #38, #41, #42, #47, #52, #54, #56, #60, #64, #78, #79, #86, #93, #96, #100, #112, #114, #120, #127, #129, #132, #136, #140, #150 and #151) of the 101 resident's facility managed funds. The sample size was 32. The census was 141. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision when one resident (Resident #78) eloped from the facility at approximately 6:00 A.M. and staff were not aware the resident was missing until they received notification from a hospital that the resident arrived to the hospital at 8:06 A.M. The facility failed to ensure staff responded appropriately and in accordance with facility policy when one resident (Resident #63) pulled the fire alarm. The sample was 31. The census was 141. Review of the facility's Fire Alarm Pulls and Risk for Elopement Response policy, undated, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 26 of 46 resident rooms, 17 of 46 bathrooms, and a shower room were adequately equipped with a functional call system that would allow residents to call for staff assistance. The census was 31. The census was141. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN, -CMS-10055) or a denial letter at the initiation, reduction or termination of Medicare Part A benefits. The facility identified 11 residents, who discharged from Medicare covered Part A with benefits days remaining in the past six months. Three residents were sampled, and issues were found with all three residents (Resident #41, #12 and #35). The census was 141. Review of the facility's Advance Beneficiary Notices, dated 11/5/24, showed:--To ensure that the resident, or representative, has enough time to make a decision whether ornot to receive the services in question and assume financial responsibility, the notice shall beprovided at least two days before the end of a Medicare covered Part A stay or when all of PartB therapies are ending. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment when the facility failed to ensure one toilet in a [NAME] and [NAME] bathroom (bathroom situated and directly accessible from two separate rooms) was functional (Resident #12). In addition, the facility failed to ensure one resident's bed had clean linen (Resident#114). The sample was 31. The census was 141. Review of the facility's Safe and Homelike Environment Policy, dated 6/5/2024, showed:-Housekeeping and maintenance services will be provided as necessary to maintain a sanitaryand comfortable environment;-The facility will provide and maintain bed and bath linens that are clean and in good condition;- Minimize odors by disposing of soiled linens promptly and reporting lingering odorsand bathrooms needing cleaning to housekeeping department. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff. This deficiency affected two of 31 sampled residents (Resident #9 and Resident #28). The census was 141. Review of the MDS care assessment summary policy, revised 11/6/23, showed: -Purpose: To understand the changes presented by Centers for Medicare and Medicaid Services (CMS) 3.0, to define the intent of each section of the MDS 3.0 and to ensure that MDS sections are completed accurately and in a timely manner by the assigned responsible parties. -Procedure: -Section J is to be completed by nursing staff. This section addresses any condition that impacts the resident's quality of life and functional status; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update a resident's comprehensive care plan following admission into hospice services (Resident #9). The sample size was 31. The census was 141. Review of the facility's Comprehensive Care plan policy, reviewed 10/31/24, showed:-Purpose: To develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Person centered care: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice by not following physician's orders when staff administered the wrong medication to one resident (resident #92). The sample size was 31. The census was 141. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed assistance with nail care, received timely nail care services. The delay in services resulted in long, jagged and unkempt toenails (Resident #107 and Resident #12). The sample was 31. The census was 141. Review of the nail care policy, revised 6/26/24, showed:-Purpose: To provide guidelines for the provision of care to a resident's nails for good grooming and health;-Policy: -Assessments of nails will be conducted on admission and readmission to determine the nail condition, needs, and preferences for nail care: -Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changes, separation from the nail bed, redness, bleeding, pain, odor, and infection); -Obtain history and preferences regarding podiatry; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Nurse Aide (NA) registry verifications were checked before allowing four employees to work and provide care to residents (Employees AAA, CCC, DDD, and EEE). The census was 141. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent or greater. Five errors were observed out of 25 opportunities, with a 20 percent error rate (Residents #5, #16, #23, and #102). The sample was 38. The census was 141. Review of the facility's Medication Administration policy, revised 6/26/24, showed:-Purpose: Medications are administered by licensed staff and as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of the facility to ensure the safe and effective administration of all medications by utilizing practice guidelines;-Policy:-Ensure that the six rights of medication administration are followed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post nurse staffing information that included the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift, on a daily basis. The census was 141. Review of the facility's Nurse Staffing Posting Information policy, revised on 6/26/24, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide on-going monitoring and close supervision of Resident #11, who had a history of being non-compliant with facility rules and policies by obtaining unauthorized and/or illegal drugs for both his/her own use as well as distribution to other residents. On [DATE], cardiopulmonary resuscitation (CPR, an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until spontaneous breathing and heartbeat can be restored) was initiated on Resident #11, Resident #1, and Resident #2 after an overdose. All three residents were sent to the hospital, and all three had drug screens that were positive for unauthorized and/or illegal substances. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff notified one resident's physician regarding the resident's low blood pressure. In addition, the resident had two antihypertensive medications ordered, and one of those two medications was administered while the resident was hypotensive (blood pressure below 90/60) (Resident #7). The sample was 33. The census was 133. Review of the facility Notification Of Changes Policy, dated [DATE], showed:-Purpose: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents (Residents #1 and #2) were involved in a resident-to-resident altercation. Resident #1 suffered a bloody lip as a result of Resident #2 hitting him/her in the mouth. The sample was 12. The census was 137. The Administrator was notified on 9/23/25 at 4:55 P.M., of the past non-compliance, which occurred on 9/16/25. The facility provided 1:1 for the residents and updated their care plans. The deficiency was corrected on 9/16/25. [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 6/13/25. See the deficiency cited at F584 in Event ID Z3RV-H2.

Inspectors wroteBased on observation and interview, the facility failed to follow its cleaning policy when staff did not provide residents with a clean, sanitary, and homelike environment. Facility staff failed to thoroughly clean two residents' rooms (Resident #30 and Resident #29). The facility also failed to use proper precautions when handling soiled towels and/or linen, affecting all residents residing at the facility. In addition, the facility also failed to thoroughly clean shower rooms on the 100 and 200 halls after resident use. This had the potential to affect all residents who utilized those shower rooms. The sample was 32. The census was 139. Review of the facility's Housekeeping Deep Cleaning policy, revised 6/29/23, showed: -Purpose: To ensure all rooms are clean; -Policy: Deep cleaning is to be completed as scheduled. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse and Neglect policy when they failed to notify the Department of Health and Senior Services (DHSS) after Certified Medication Technician (CMT) F threw Kool-Aid in Resident #25's face on the morning of 5/28/25. The census was 139. Review of the facility Abuse and Neglect Policy revise on 6/12/25, showed: -Purpose: It is the policy of this facility to report all allegations of abuse/neglect/mistreatment immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Definitions: -Mental Abuse: Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight. On 5/14/25, Resident #16 was left unsupervised in the courtyard during a smoking break. The resident used a chair in the courtyard to climb over the fence and was noticed in the road close to the facility by an off duty staff member. On 5/24/25, the resident once again used a chair in the courtyard to climb over the fence. The resident was not noticed missing for three to four hours and was found approximately 3.7 to 4.7 miles from the facility, depending on the route the resident walked. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff documented accurate information in Resident #16's electronic medical record (EMR). On 5/24/25 at 9:15 A.M., Registered Nurse (RN) C documented the resident eloped from the facility and was found on the facility parking lot, despite having knowledge staff were actively searching for the resident. The resident was found approximately 3.7 to 4.7 miles from the facility. The census was 139. Review of the facility Documentation in Medical Record policy, revised on 5/30/25, showed: -Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the residents and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation; -Policy Explanation and Compliance Guidelines; [...]

Inspectors wroteBased on observation and interview, the facility failed to follow their Bloodborne Pathogens/Exposure Control Plan policy by failing to immediately clean and disinfect a potentially infectious blood spill left overnight on one resident's floor (Resident #34). In addition, the facility failed to follow its Handling Clean and Dirty Linen policy when staff failed to place plastic liners inside the designated soiled linen receptacle located in the 100, 200, and 400 shower rooms and did not place the lid back on top of the soiled linen barrel in the 200 and 400 hall shower rooms. The shower room was a community shower. Twenty-five residents were sampled. The census was 145. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's (Resident #2's) right to be free from physical abuse was not violated when Resident #1 hit Resident #2 in the head and face with a dismantled towel rack, which caused bruises to Resident #2. The facility also failed to ensure two other residents' rights to be free from abuse were not violated when the residents got into a fight (Resident #3 and #4) and Resident #4 sustained a swollen eye. The sample was eight. The census was 140. The Administrator was notified on 3/25/25, of the past non-compliance. The facility responded appropriately when the incident occurred. The residents were separated and received medical assessment and attention. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to supervise residents while smoking in the designated smoke room (Resident #3, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). In addition, the facility failed to conduct a thorough investigation in a timely manner on how the residents were able to light the cigarette and smoke unsupervised. The sample was 10. The census was 145. Review of the facility's Smoking Safety Regulations, dated 6/29/23, showed the following: -Purpose: The purpose of this policy is to ensure that all staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protection Association and State and Federal Regulations; -Procedure: -The facility will follow all smoking regulations; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident (Resident #4) and another resident (Resident #5) were in a physical altercation. Resident #4 sold a cellular phone to Resident #5. Resident #5 said the cellular phone did not work and Resident #5 tried to attack Resident #4. Resident #4 hit Resident #5 and gave him/her bruising to the right eye and a laceration to the right eyebrow. The sample was five. The census was 144. The Administrator was notified on 2/19/25 at 10:07 A.M., of the past non-compliance, which occurred on 2/1/25. The facility provided training and in-servicing for all staff regarding the facility's Abuse and Neglect Policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in a black eye and the need for sutures (Residents #1 and #2). The census was 138. The sample was 20. The administrator was notified on 1/9/25, of the past non-compliance. The facility responded appropriately when the incident occurred. The residents were separated and were sent to the hospital for evaluation. Care was provided to injuries and the rooms were changed so the residents no longer resided on the same hall. Continued education on abuse and neglect provided to staff. The deficiency was corrected on 1/2/25. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when three residents (Residents #1, #2, and #3) were involved in two physical resident to resident altercations (Resident #1 and #2) and (Resident #1 and #3). Resident #1 was involved in a resident to resident altercations two days in a row and suffered a nose bleed as a result of Resident #3 hitting him/her in the nose. The sample was seven. The census was 139. The facility was notified of the past non-compliance on 12/20/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. The deficiency was corrected 12/14/24. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents were involved in physical resident to resident altercation, in which one resident placed their hands around another resident's neck (Residents #3 and #2). The sample was 7. The census was 137. The facility was notified of past non-compliance on 11/6/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 10/28/24. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when staff failed to effectively intervene while two residents (Resident #1 and Resident #2) were involved in a verbal argument which escalated to a physical altercation, resulting in Resident #1 to be struck in the face by Resident #2. The facility census was 139. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -Definitions: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have Registered Nurses (RNs) on each shift daily. Review of the Payroll Based Journal (PBJ) Staffing Report CASPER Report from CMS dated FY Quarter 1 2024 (October 1 - December 31, 2023) revealed a One Star Staffing Rating for excessively low weekend staffing. An interview with the Staffing Coordinator and the Human Resources Manager for the facility on 6/19/24 at 1:00 p.m. in the conference room revealed there was no RN coverage on the night shift (11 p.m. until 7 a.m.) documented on the daily staffing forms provided for Saturday, 6/15/24, Sunday, 6/16/24, and upcoming shifts for evening or night shifts for 6/20/24. The Staffing Coordinator stated the Licensed Practical Nurses (LPNs) take charge and notify the Physicians, call families and emergency personnel in the event of emergencies.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure foods were stored, prepared and distributed under sanitary conditions as evidenced by: 1.) Failure to ensure food preparation areas and distribution equipment were stored under clean and sanitary conditions, 2.) Failure to ensure foods temperature logs were maintained to ensure the appropriate cooking temperatures were reached, and 3.) Monitor temperature and sanitizer concentration for the dish machine. Failure to meet these requirements could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and maintain complete and accurate accounting records, regarding the reconciliation of petty cash kept on hand, for the resident trust account. The census was 144. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Resident Trust Petty Cash: -The facility will maintain a Resident petty cash fund for resident trust transactions only. The Petty Cash Clerk will be a facility employee designated by the Administrator at each facility. The Petty Cash Clerk will be someone other than the Resident Trust Clerk and the Administrator and will not be authorized to sign checks. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 11 months. The census was 144. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -General Information Regarding Responsibilities of Holding Resident Funds: -The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. A copy of the current bond shall be kept in a file in the facility by the Resident Trust Clerk. [...]

Inspectors wroteBased on observations of the residents' rooms and bathrooms and interviews with Residents #93 and #130, Houskeeper A and the Housekeeping Supervisor, the facility failed to provide a safe, clean, comfortable and homelike environment. An observation and interview with Resident #93 in his/her room on 6/20/24 at 10 a.m. revealed that his/her room (room [ROOM NUMBER]) and bathroom had not been cleaned thoroughly. Observation of the bathroom and his/her bedroom revealed the walls had brown stains, the floors were dirty, the commode in the bathroom had a brown substance around it's base and had stains on the floor and the walls and baseboard behind the commode. There was a dark brown substance on the vents of the exhaust fan above the commode. An observation of room [ROOM NUMBER], Resident #130's room on 6/21/24 at 10:03 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the preplanned menus and Diet Spreadsheets (which identified which foods and portion serving sizes should be served to each diet). Failure to ensure the preplanned menu was followed could place residents at risk for weight loss.

Inspectors wroteBased on observation, interview and record review, facility staff failed to sanitize their hands before they entered the room, during medication administration, and after they exited the room to prevent the spread of infection. This action affected two (2) residents (Resident #89 and Resident #83). Additionally, facility staff failed to remove their gloves and sanitize or wash their hands after they placed plastic liners into trash cans to be delivered to resident rooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure one (1) of six (6) medication carts was locked and all drugs and biologicals were in secured and locked compartments, on one (1) of six (6) floors outside of the nurse's station. This action did not ensure that these drugs and biologicals were not accessible to cognitively impaired residents.

Inspectors wrotePlease refer to Event ID 7FZ113. This deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. Certified Nurse's Aide (CNA) C was in the doorway to the smoking room and yelled out Code [NAME] (behavioral emergency to notify additional staff). [...]

Inspectors wrotePlease refer to Event ID 7FZ113. Based on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when one resident (Resident #4) was involved in a physical altercation with another resident (Resident #3). In two separate incidents, Resident #3 hit Resident #4 in the mouth when Resident #4 wandered into Resident #3's room. The sample size was 5. The census was 139. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. [...]

Inspectors wrotePlease refer to Event ID 7FZ113. Based on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to report to the Department of Health and Senior Services (DHSS) and investigate physical abuse between two residents which occurred when one resident wandered into another resident's room. The first altercation was not reported to DHSS and investigated. A second altercation occurred the next day, when the resident again wandered into the other resident's room. Both times, the resident hit the other resident in the mouth (Residents #3 and #4). The sample size was 5. The census was 139. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. [...]

Inspectors wroteSee F760 cited at 7FZ112. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on [DATE] and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. [...]

Inspectors wroteSee F689 cited at 7FZ112. Based on observation, interview and record review, the facility failed to provide protective oversight to one resident (Resident #30) with a known history of wandering and elopement, who resided on a locked unit. The resident eloped from the facility on 1/17/24, out of an alarmed door. Staff did not realize the resident had left until the resident was found at a gas station and brought back by the police over an hour after he/she was last seen by staff . In addition, the facility failed to complete elopement assessments per protocol, to include interventions to be implemented. The sample size was 22. The census was 140. Review of the facility's Elopement Protocol policy, last revised 1/19/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were abused by other residents (Resident #1, #2, #3, and #4) for four of five sampled residents. The facility census was 136 residents. The Administrator was notified on 1/10/24 of the past non-compliance. The facility immediately began investigations of the incidents, separated and assessed the residents, as well as contacted all responsible parties and physicians, and sent the residents out for evaluations following the altercations. Upon the residents' return to the facility, the facility had interventions in place to ensure no further altercations would take place, which included: Medication adjustments (while at the hospital), room changes, frequent meetings, and social services follow up. [...]

Inspectors wroteThis deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. Certified Nurse's Aide (CNA) C was in the doorway to the smoking room and yelled out Code [NAME] (behavioral emergency to notify additional staff). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on [DATE] and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraint when, in an attempt to keep a resident from wandering (Resident #20), Certified Nurse Aide (CNA) E picked the resident up, placed the resident over his/her shoulder and carried the resident to a chair. CNA E then tied a sheet to the chair, around the resident, to prevent the resident from getting up. The sample was 20. The facility census was 135. Review of the facility Abuse and Neglect Policy, dated 4/7/2017, revised on 1/19/2022, showed: -PURPOSE: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/ property, and to define terms of types of abuse/neglect and misappropriation of funds and property. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy when staff observed a staff member (Certified Nurse Aide (CNA) E) use a sheet to restrain a resident (Resident #20) to a chair because the resident wandered. The facility also failed to ensure staff were aware of their Abuse and Neglect Policy when Nurse Aide (NA) D observed the resident restrained and did not immediately report it because he/she was unsure if restraints were allowed. In addition, Certified Medication Technician (CMT) C observed CNA E pick up the resident and carry him/her to a different area. CNA E asked CMT C for medication to make the resident stop wandering. CMT C failed to immediately report this. Upon being made aware of the allegations, staff failed to immediately send CNA E home. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight to one resident (Resident #30) with a known history of wandering and elopement, who resided on a locked unit. The resident eloped from the facility on 1/17/24, out of an alarmed door. Staff did not realize the resident had left until the resident was found at a gas station and brought back by the police over an hour after he/she was last seen by staff . In addition, the facility failed to complete elopement assessments per protocol, to include interventions to be implemented. The sample size was 22. The census was 140. Review of the facility's Elopement Protocol policy, last revised 1/19/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient skilled and competent staff worked effectively with behavioral health residents when a staff person, who was assigned to provide one on one (1:1) intensive supervision to a resident (Resident #12) left the hall, leaving the hall insufficiently staffed. Soon after, a resident to resident altercation occurred between two residents (Resident's #11 and #12). The sample was 20. The facility census was 135. Review of the facility Abuse and Neglect Policy, dated 4/7/2017, revised on revised on 1/19/2022, showed: -PURPOSE: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/ property, and to define terms of types of abuse/neglect and misappropriation of funds and property. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice by not following physician's order and documenting the administration of orders for insulin (a naturally occurring hormone made by your pancreas that helps your body use sugar for energy) for one resident (Resident #1). The sample was five. The census was 139. Review of the facility's Blood Glucose Monitoring and Insulin Administration policy, last revised on 6/29/23, included: -Affected Personnel: Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Insulin Certified Medication Technicians (CMTs); -Purpose: To define accurate procedures to be followed when checking a blood sugar (measures the level of glucose (sugar) in your blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate, in accordance with their policies and procedures, a staff-to-resident incident which resulted in an allegation of abuse from Resident #506. Per facility policy, nursing staff also failed to thoroughly assess the resident, who experienced difficulty breathing, after two staff members witnessed Administrator-in-training (AIT) X lying on top of the resident (who was supine/lying face up on the floor) while holding the resident's arms on the floor. The resident's face was covered by the resident's shirt. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the overall cleanliness of the kitchen's floor, walk-in refrigerator and freezer, and label and date opened food items in the walk-in freezer. The facility staff also failed to wear hair restraints while in the kitchen and practice adequate infection control while handling food items. Additionally, the facility failed to maintain the cleanliness of the dining room. This deficient practice affected all residents who ate at the facility. The census was 132. 1. Observations on 7/7/21 at 8:29 A.M., 7/8/21 at 6:52 A.M., 7/13/21 at 5:21 P.M., 7/14/21 at 11:11 A.M. and 7/15/21 at 8:04 A.M., showed dried food debris, white speckles and grime near the food preparation area, outside of the walk-in refrigerator, and in the dry storage area throughout the kitchen floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide reasonable accommodations of individual needs and preferences by failing to ensure an acceptable table tray to encourage meal independence for seven residents (Residents #23, #90, #81, #62, #21, #75 and #142). The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed the resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health and safety of the individual or other residents would be endangered. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/3/21, showed: -admitted : 6/1/07; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties received quarterly statements to show the residents' activity regarding their trust fund. This affected 124 residents whose funds were handled by the facility. The census was 132. Review of the facility's Resident Trust policy regarding resident statements, revised on April 2018, showed: -A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis; -The Resident Trust Clerk is responsible for sending out quarterly statements; -Make copies of all statements and date stamp them with the date they were mailed. Retain the copies for your files; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 social security (SSI) limit or when the resident's account was over the SSI limit ($5,000). The facility also failed to update their policy to include the increase in the Medicaid limit. This affected 11 residents who received Medicaid benefits (Residents #606, #603, #610, #604, #605, #608, #609, #601, #600, #607 and #602). The census was 132. Review of the facility's Resident Trust Policy regarding monitoring resident trust balances, revised on 4/2018, showed: -The Resident Trust Clerk must monitor account balances. Medicaid residents are allowed to keep 999.99 in non-exempt resources. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents. The sample was 26. The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed the resident has the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility and readily accessible to residents and the facility must post a notice of their availability. Observation on 7/7/21 at 8:58 P.M., 7/8/21 at 7:20 A.M., 7/9/21 at 8:00 A.M., 7/13/21 at 11:00 A.M. and 7/15/21 at 8:00 A.M., showed a sign behind the receptionist's desk that read, survey binder upon request. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment by not ensuring walls, floors, furniture, exhaust vents and equipment were clean and in good repair in resident rooms and common areas for 7 out of 26 sampled residents (Residents #81, #28, #74, #118, #42, #110 and #39). The census was 132. 1. Review of Resident #81's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/21, showed the following: -admission date 2/18/21; -Cognitively intact; -Diagnoses included anemia, schizophrenia (a mental disorder leading to faulty perception, inappropriate actions and feelings and withdrawal from reality) and chronic obstructive lung disease. Observations on 7/7/21 at 9:15 A.M., 7/9/21 9:25 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely checks were completed for criminal backgrounds, the employment disqualification list, and federal indicator checks and follow their policy for seven of ten employee records reviewed. In addition, the facility failed to implement abuse and neglect policies and procedures, in accordance with federal requirements, that addressed resident to resident sexual activity. The facility failed to ensure the resident's capacity to consent forms were signed all required parties for three residents (Residents #503, #39, and #58). The census was 132. 1. Review of the facility's Screening-Applicant employee, volunteer staff and Vendor policy revised on 4/29/21, under pre-employment screening, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for 7 residents (Residents #1, #92, #30, #20, #111, #142 and #9). The sample was 26. The census was 132. Review of the facility's Abuse and Neglect Policy, dated as last reviewed and approved 7/18/20, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 12 of 26 sampled residents (Residents #503, #502, #92, #1, #493, #4, #28, #30, #20, #110, #62 and #34) who were involved in resident altercations. Appropriate witnesses and resident interviews were not documented or provided. This failure resulted in the facility not determining what actions are necessary for the protection of residents. The census was 132. Review of the facility's Abuse and Neglect Policy, dated last reviewed and approved 7/18/20, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided according to acceptable standards of clinical practice. The facility failed to provide a low bed and administer medications as ordered by the physician, document a fall, notify the physician and responsible party (RP) of the fall, and complete post fall follow ups (Resident #23). The facility failed to complete post fall follow ups, daily weights and notify the physician that daily weights were not being completed (Residents #64 and #28). The facility failed to ensure physician orders were followed by not administering medication as ordered (Residents #6, #75, #116, #142, #69 and #33). The facility also failed to complete daily weights (Resident #101) and provide nutritional supplements as ordered (Resident #51). [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three narcotic books reviewed. The census was 132. 1 Review of the controlled substance logs, dated 5/1/21 through 7/6/21, for the 500/600 halls, showed the following: -No signature recorded by the on-coming nurse, a total of 18 shifts; -No signature recorded by the off-going nurse, a total of 28 shifts; -Out of 201 shifts, narcotic count not recorded as completed a total of 57 times. 2 .Review of the controlled substance logs, dated 5/1/21 through 7/6/21, for the 100/400 halls, showed the following: -No signature recorded by the on-coming nurse, a total of 30 times; -No signature recorded by the off-going nurse, a total of 39 times; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident is offered an influenza immunization between October 1st through March 31st annually, unless contraindicated and failed to ensure the resident's medical record includes documentation that indicates at a minimum the resident or resident representative was provided education and either received or refused the immunization. This affected four of five residents sampled for immunizations (Residents #28, #81, #62 and #37). The census was 132. Review of the facility's Influenza and Pneumococcal immunization policy, last revised on 2/24/21, showed: -The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent gnats in resident common areas and resident rooms for 9 out of 26 sampled residents (Residents #23, #37, #51, #39, #118, #74, #110, #92 and #42). The census was 132. 1. Review of the facility's pest control logs from April through July 2021, showed: -On 4/12/21, inspected and treated interior and exterior. Paid special attention to kitchen area; -On 4/16/21, 4/23/21, and 4/30/21, service call backs. No further information regarding treatment or observations; -On 5/10/21, inspected fly light on normal pest service ticket; -On 6/4/21, inspected and treated interior and exterior. Additional treatment applied in kitchen; -On 6/9/21, 6/15/21, and 7/1/21, service call backs; -On 7/12/21, inspected and treated areas of concern. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer their own medications for one resident with a history of drug seeking when staff left medications at the bedside (Resident #69). The sample was 26. The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed an individual resident may self-administer drugs if the interdisciplinary team, as defined by Section of Regulations of the Health Care Financing Administration, has determined this practice is safe. Review of Resident #69's medical record, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and facilitate residents' right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone for three residents (Residents # 115, #59 and #507) out of a sample of 26 residents. The census was 132. 1. Review of Resident #115's 5 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/21, showed the following: -Wheelchair mobility; -Diagnoses included medically complex conditions, dementia, Parkinson's disease, asthma and chronic obstructive pulmonary disease (COPD, a lung disease which makes it difficult to breathe); -Required set up and supervision with bed mobility and eating; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident of the facility bed hold policy at the time of transfer to the hospital for one resident (Resident #135) hospitalized three times in June 2021. The sample was 26. The census was 132. Review of the facility's Resident Transfer/Discharge, Immediate Discharge policy, approved 4/29/21, showed: -When a resident is transferred to the hospital or other location or when a resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy; -This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of the transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a preadmission screening for individuals with a mental disorder and individuals with intellectual disability by failing to ensure a resident had a DA-124 Level I screening (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screening is required) as required, for one of one sampled resident reviewed for PASARR (Resident #75). The census was 132. Review of Resident #75's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/21, showed the following: -Date of admission on [DATE]; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement person-centered comprehensive care plans for one resident with a history of depression and self-harm (Resident #118) and one resident with behaviors of acting out (Resident #34). The sample size was 26. The census was 132. 1. Review of Resident #118's medical record, showed: -admitted [DATE]; -Diagnoses included schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), suicidal ideations, depressive episodes, insomnia and nightmare disorder (disturbing or scary dreams that awaken you, causing distress or preventing adequate sleep). Review of the resident's psychiatrist visit note, dated 1/20/21, showed: -Chief complaint: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary for one of three discharged residents (Resident #99). The census was 132. Review of Resident #99's closed medical record, showed he/she discharged to another facility on 6/27/21. Review of the resident's Interdisciplinary Discharge summary, dated [DATE], showed no information regarding the final summary of the resident's status, no reconciliation of all pre and post-discharge medication and no post discharge plan of care, including discharge instructions. During an interview on 7/15/21 at 10:24 A.M., the Social Services Director said he completed the social services portion of the discharge summary. Nursing should have completed their part regarding the medication and post-discharge instructions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received proper assistance with showers and nail care for two of 26 sampled residents. The census was 132. 1. Review of the facility's Shower and Bath Policy, revised 5/15/20, showed: -Purpose: To ensure all residents receive scheduled showers and baths and as needed/requested. Each resident must be scheduled for at least two showers or baths per week. Review of Resident #127's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/11/21, showed: -Cognitively intact; -Independent with personal hygiene; -Diagnoses that included high blood pressure, seizures, anxiety, manic depression (mental disorder that causes extreme mood swings) and psychotic disorder (mental disorder). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (Resident #505) out of 26 sampled residents received treatment and care in accordance with professional standards of practice by not providing adequate supervision to prevent falls and not implementing restorative nursing programs in a timely manner which would enable the resident to maintain progress made in physical therapy. The resident's care plan showed that most of his/her falls were attributed to seizure activity, yet the facility failed to consistently document administration of his/her medications, in order to ensure the resident was receiving his/her seizure medications per his/her physician's orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a dialysis contract for one of one residents receiving dialysis (the process of filtering the blood for individuals with kidney failure) services (Resident #37). The facility also failed to notify the physician timely when the facility scale malfunctioned and staff were unable to obtain daily weights as ordered. The facility also failed to monitor the resident's bruit and thrill (the sound heard and vibration felt as the blood pumps through the dialysis access site) every shift, per the facility's policy. The sample was 26. The census was 132. Review of the facility's Dialysis Policy, approved date 12/1/19, showed: -Purpose: Ensure that residents who require dialysis receive such services as ordered by physicians; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the drug use of a resident with a known history of drug dependence (Resident #69). The resident was hospitalized after taking an unknown drug substance and was placed on 1:1 monitoring after returning to the facility. The facility also failed to ensure necessary care services were person-centered and reflected the resident's need for safety, personal well-being, and to address drug addiction. The sample was 26. The census was 132. Review of the Facility's Assessment, showed the facility identified no residents with active or current substance use disorders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have ongoing monitoring of the effectiveness of the psychotropic medications for one out of seven residents investigated for unnecessary medications (Resident #6). The census was 132. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/15/21, showed: -Cognitively intact; -Diagnoses include anxiety and schizophrenia (serious mental illness that affects how a person thinks, feels and behaves). Review of the resident's care plan, dated 6/3/21, showed: -Focus: The resident has impaired cognitive function/dementia or impaired thought processes related to the diagnosis of moderate intellectual disabilities; -Goal: The resident will maintain current level of cognitive function; -Interventions: Administer medications as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 33 opportunities observed, there were five errors, resulting in a 15.15% medication error rate (Residents #4 and #116). The census was 132. Review of the facility's Medication Administration and Monitoring Policy, last revised on 4/6/17, showed the following: -Procedure: Medications are to be given per doctor's orders. All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. (The nurse/Certified Medication Technician (CMT) has ensured that the medications were swallowed by the resident). The nurse/CMT will check each medication to the MAR noting correct name of the medication, correct name of the resident and correct time, dose and route of administration. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in shared rooms were provided with curtains which fully extended around the bed in order to provide total visual privacy, affecting four residents (Residents #39, #97, #110 and #74). The sample size was 26. The census was 132. 1. Observation on 7/7/21 at 11:52 A.M., 7/8/21 at 7:22 A.M., 7/9/21 at 6:31 A.M., 7/13/21 at 4:55 P.M. and 7/14/21 at 7:11 A.M., showed a room shared by Resident #39 and Resident #97, with Resident #39's bed next to the window. A privacy curtain hung from the ceiling and extended to the foot of the resident's bed, leaving the left side of the bed exposed and facing Resident #97's bed. No privacy curtain hung on Resident #97's side of the room. During an interview on 7/15/21 at 7:53 A.M., Resident #39 said the curtains in his/her room have been broken for a while. [...]