Deanwood Rehabilitation and Wellness Center

Inspectors wroteBased on observation, record review, resident and staff interview, for one (1) of eight (8) sampled residents, facility staff failed to ensure that Resident #4 was provided with adequate supervision and assistance to prevent accidents. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervisions/Devices on January 30, 2026 at 6:14 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on January 30, 2026 at 8:21 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 2, 2026 at 4:30 PM. After removal of the immediacy, the deficient practice was lowered to a scope and severity level of D.

Inspectors wroteBased on observations, record review and staff interviews, facility staff failed to implement infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections as evidenced by: failure to perform hand hygiene and don required personal protective equipment (PPE) prior to entering Resident #8's room who was on contact precautions; one (1) of five (5) hand sanitizer stations on unit 2 south were not operable; and failure to have an operable hand soap dispenser and hand soap in one staff restroom.

Inspectors wroteBased on observation, record reviews and staff interviews, for two (2) of eight (8) sampled residents, facility staff failed to ensure that resident's Minimum Data Set (MDS) assessment were accurately coded for rejection of care behaviors and one wandering behaviors. Residents' #6 and #1.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of eight (8) sampled residents, facility staff failed to implement Resident #4's care plan intervention of having an escort when using the stairwell.

Inspectors wroteBased on observation, record review, resident and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to ensure that a resident who needed continuous oxygen was provided with such care. Resident #4.

Inspectors wroteBased on observations and staff interview, for one (1) out of three (3) dining observations, facility staff failed to distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on record reviews and staff interview, facility staff failed to meet the State requirement of providing a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day on 01/30/26, when an Immediate Jeopardy was identified. The census on that day was 273.

Inspectors wroteBased on record reviews, resident and staff interviews, for three (3) of eight (8) sampled residents, facility staff inaccurately documented that Residents' #5 and #6 received showers when they did not; and facility staff failed to accurately complete Resident #4's Safe Smoker Assessment.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by dust buildup in 25 of 25 residents' rooms, soiled window tracks and frames in one (1) of eight (8) dayrooms, dirty floors in 13 of 53 residents' rooms, sticky floors in nine (9) of 53 residents' rooms, a foul smell on one (1) of eight (8) resident care unit, dirty toilets in two (2) of 53 residents' rooms, dirty trash cans in three (3) of 53 residents' rooms, stained privacy curtains in three (3) of 53 residents' rooms, and dusty window blinds in five (5) of 53 residents' rooms.

Inspectors wroteBased on observations and interview, facility staff failed to maintain an efficient pest control system as evidenced by flies that were seen in three (3) of 13 resident's rooms on the third floor.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of six (6) sampled residents, facility staff failed to ensure that Resident #1 had the correct Trazadone (antidepressant medication) dose available for administration and failed to ensure that the resident received the correct dose of 50 MG (milligrams) for five (5) days.

Inspectors wroteBased on observations, record reviews and staff interviews, for one (1) of six (6) sampled residents, facility nursing staff failed to ensure that one resident received care and services according to accepted standards of clinical nursing practice as evidenced by no documented evidence that the physician was notified prior to a licensed registered nurse altering a resident's medication order label. Resident #1.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of six sampled residents, facility staff inaccurately documented that they administered Trazadone (antidepressant medication) 50 MG (milligrams), one tablet to Resident #1.

Inspectors wroteBased on observation and staff and resident interviews, the facility staff failed to provide respect to a resident when the resident spoke about a concern with her television for one (1) of 10 sampled residents (Resident # 2).

Inspectors wroteBased on observations, and resident and staff interview, the facility failed to maintain the required comfortable air temperature range of 71°F to 81°F for one for one (1) of 10 sampled residents. (Resident #2)

Inspectors wroteBased on record review and interview, the facility failed to implement their Advanced Directive (5 Wishes) policy for one (1) of three (3) sample residents. (Resident #1)

Inspectors wroteBased on record review and interview, the facility failed to have documented evidence that the resident or the resident representative was provided with a written copy of the base line care plan.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, for three (3) of 94 sampled residents, facility staff failed to provide adequate supervision for residents as evidenced by: 1. Resident #120, who uses a wheelchair for locomotion and requires medications to treat multiple diagnoses, eloped from the facility on 04/29/24; 2. Resident #64 having an unwitnessed fall from her wheelchair; and 3. Resident #79 having multiple falls with injury. The facility's census on 04/29/24 was 265. Due to this failure, an Immediate Jeopardy was identified on May 2, 2024, at 11:30 AM related to the elopement of Resident #120. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on May 3, 2024, at 12:18 AM. [...]

Inspectors wroteBased on record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to ensure that Resident #463 received timely treatment and care after an unwitnessed fall with documented pain and swelling in her left arm. Subsequently, 23 hours lapsed before an order for x-ray was obtained that determined that the resident sustained a fracture to her left arm; and she was sent to the hospital 2 days later. These failures resulted in actual harm to Resident #463 who had unresolved pain for a minimum of 23 hours post fall.

Inspectors wroteBased on observations, residents and staff interviews, facility staff failed to make information on how to file grievances available to the residents. The census on the first day of the survey was 265.

Inspectors wroteBased on record reviews and staff interviews, for four (4) of 94 sampled residents, facility staff failed to maintain accurate medical records. (Residents' #365, #417, #464, and #467).

Inspectors wroteBased on observations, record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to treat Resident #68 with dignity and respect.

Inspectors wroteBased on record review and staff interviews, for one (1) of 94 sampled residents, the physician failed to follow the resident's/resident representatives (RP) Advanced Directives wishes. Resident #109.

Inspectors wroteBased on record review and staff interview, for one (1) of 94 sampled residents, facility staff failed to have documented evidence that they provided Resident #216 or their representative with Notice of Medicare Non-Coverage (NOMNC).

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, orderly environment as evidenced by two (2) of two (2) storage rooms that were filled with miscellaneous items that were scattered throughout.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 94 sampled residents, facility staff failed to report Resident #120's incident of elopement to the State Agency in a timely manner (within 2 hours); and failed to have documented evidence that they reported an unusual incident in which Resident #127 had a psychiatric emergency and broke her bedroom window to the State Agency.

Inspectors wroteBased on observation, record reviews and staff interviews, for three (3) of 94 sampled residents, facility staff failed to: follow their corrective actions of ensuring a resident's safety after Resident #313's allegation of abuse by a male caregiver; follow their corrective actions of ensuring Resident #43's safety from further potential abuse and retaliation by staff after an allegation of abuse; and have documented evidence that Resident #466's injury of unknown origin was thoroughly investigated. Residents' #313, #43 and #466.

Inspectors wroteBased on record reviews and staff interviews, for four (4) of 94 sampled residents, facility staff failed to provide documented evidence that the resident or resident's representative was provided with written notification that specified the duration of the state bed hold policy to include notification of when the resident is permitted to return to the facility and resume residence in the nursing home. Resident's #3, #79, #414, and #419.

Inspectors wroteBased on record review and staff interview, for one (1) of 94 sampled residents, facility staff failed to accurately code Resident #79's falls history on the Quarterly Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, for two (2) of 94 sampled residents, facility staff failed to implement care plan interventions as indicated in the resident's comprehensive care plan. Residents' #79 and #189.

Inspectors wroteBased on record review, resident, and staff interviews, for one (1) of 94 sampled residents, facility staff failed to provide Resident #189 with the necessary restorative nursing treatment, care, and services to maintain or improve ability to carry out the activities of daily living (mobility and ambulation) based on the comprehensive assessment of the resident and consistent with the resident's care plan.

Inspectors wroteBased on observation, record review and staff interviews, for two (2) of 94 sampled residents, facility staff failed to ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Residents' #68 and #107.

Inspectors wroteBased on record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to have documented evidence of any skin changes on Resident #466's sacrum prior a deep tissue injury being found that measured 5 centimeters (cm) by 5 cm.

Inspectors wroteBased on observations, record reviews and staff interviews, for two (2) of 94 sampled residents, the facility staff failed to provide pain management services that were consistent with professional standards and in accordance with the resident's care plan. Residents' #463 and #68.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 94 sampled residents, the nurse practitioner failed to timely address a resident's known subtherapeutic Valporic Acid (anitconvulsant medication) level. Resident #120.

Inspectors wroteBased on record review and staff Interview of one (1) of 94 sampled resident, the physician staff failed to review Resident #177's total program of care to include documented reports of critical lab values.

Inspectors wroteBased on observations record reviews and staff interviews for, two (2) of 94 sampled residents, the facility staff failed to have nursing staff with the appropriate skill sets to care for residents needs as identified in the residents plan of care as evidenced by a Licensed Practical Nurse documenting Resident #417's blood glucose reading as 1 in the medical record on multiple dates, and a Licensed Practical Nurse who was observed administering pain medication for Resident #68 without doing a pain assessment and after Resident #68 complained of pain and for also failing to reposition Resident #68 who asked repeatedly to be repositioned for comfort. Residents' #417 and #68.

Inspectors wroteBased on observations, record reviews, and staff interviews for three (3) of 94 sampled residents, the facility staff failed to ensure that the residents' medications were labeled and stored in accordance with currently accepted professional principles. As evidenced by multiple loose and unwrapped pills noted in two (2) residents' sections in the medication cart. Also, noted was a resident's expired Acetaminophen-Codeine 300-30 mg tablets in a locked narcotic box which contained other residents' current medications.

Inspectors wroteBased on record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to provide services in compliance with all applicable Federal and State regulations in the facility as evidenced by failing to conduct quarterly care plan meetings for Resident #107.

Inspectors wroteBased on observation, record review, resident and staff interviews, for seven (7) of 105 sampled residents, facility staff failed to ensure residents were free from abuse (willful infliction of injury) and neglect as evidenced by: failure to prevent the willful infliction of serious injury of Resident #404 by Resident #82; failure to implement person center care measures for Resident #151 who had incidences of aggressive behavior towards Resident #71 and willful infliction of injury to Resident #67; failure to ensure staff received training to provide person-centered care to Resident #409 post hip replacement, subsequently the resident sustained a dislocated hip; failure to ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, the resident to be transferred to the emergency room (ER) for dislodgment; [...]

Inspectors wroteBased on observation, record review, resident, family and staff interviews, for 11 of 105 sampled residents, the facility's staff failed to ensure that residents received adequate supervision as evidenced by failure to 1. ensure that Resident #404 received adequate supervision to prevent an altercation with Resident #82, resulting in serious injury, 2. provide adequate supervision for Resident #56 who sustained a fall outside in front of the facility resulting in serious injury, 3. provide Resident #409 who was status post hip surgery with adequate supervision to prevent an injury of unknown origin (dislocated hip), 4. provide adequate supervision of Resident #151 to prevent altercations with Residents #71 and #67, 5. properly secure Resident #183's wheelchair during a van transport, resulting in a fall with injury, 6. [...]

Inspectors wroteBased on observation, record review and staff and family interviews, for two (2) of two (2) sampled residents with laryngectomies, the facility's staff failed to: 1. ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, the resident to be transferred to the emergency room (ER) for dislodgment, 2. keep a supply of respiratory medical equipment in the facility that was necessary to care for and treat Resident #3's laryngectomy and stoma, resulting in the resident being transferred to the ER for a replacement 3. obtain/provide Resident #3 with HMEs, 4. change and clean respiratory equipment in accordance with the physician's orders for Resident #304, and 4. obtain an order for the use of a button (HME) for Resident #304 with a Tracheostomy. These failures resulted in actual harm for Resident #3, example #1.

Inspectors wroteBased on staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 255.

Inspectors wroteBased on observation and staff interview, facility staff failed to: (1) ensure Resident #132's urine collection bag was not resting on the floor and (2) maintain infection control and prevention practices to help prevent the development and transmission of communicable diseases and infections. The census on the first day of survey was 255.

Inspectors wroteBased on observations and staff interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by damaged privacy curtains in six (6) of 76 resident's rooms, soiled bathroom vents in five (5) of 76 resident's rooms, a foul, offensive odor in (5) of 76 resident's rooms and malfunctioning packaged terminal air conditioner (PTAC) units in three (3) of 76 resident rooms.

Inspectors wroteBased on record review and staff interview, for eight (8) of 105 sampled residents, facility staff failed to implement its policies and procedures for investigating allegations of abuse, neglect and injuries of unknown source. Residents' #11, #50, #67, #71, #151, #221, #408 and #409.

Inspectors wroteBased on record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) conduct investigations for unusual occurrences for Residents' #3 and #409; (2) conduct investigations of resident-to-resident altercations with Residents' #67, #71 and #151; and (3) conduct a thorough investigation of Resident #221's threat of violence against his roommate.

Inspectors wroteBased on record review and staff interview, for six (6) of 105 sampled residents, the facility staff failed to: (1) notify Resident #3's, #132's and #406's representative(s) in writing the reason for the resident's transfer to a hospital and (2) provide written notification to Resident #82's, #233's and #404's representatives of room relocation.

Inspectors wroteBased on record review and staff interview, for five (5) of 105 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS). Residents' #50, #155, #160, #183 and #502.

Inspectors wroteBased on record review and staff interview, for eight (8) of 105 sampled residents, facility staff failed to develop and/or comprehensive care plans with measurable goals, timeframes and approaches to address resident care concerns (Stoma Site Care, 2 CNAs for ADL care, assistance with dentures, indwelling urinary catheter, speech deficit, new diagnosis of chest pain, behavior of urinating on the bathroom floor, refusal of care and complaints of chest pain. Residents' #3, #50, #204, #126, #132, #155, #180 and #403.

Inspectors wroteBased on record review and staff interview for 11 of 105 sampled residents, the facility staff failed to update the comprehensive care plan with goals and approaches that address one (1) resident's visit to the dentist for actual tooth extractions, one (1) resident with a right upper arm fistula access site post-dialysis care, three (3) residents with a PermaCath; and three (3) resident exhibiting behaviors and failed to update one (1) residents care plan to address their need to have two (2) person physical assist. Residents' #27, #61, #82, #95, #126, #151,#71, #67, #182, #404 and #502.

Inspectors wroteBased on record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) have a discharge plan for one resident; (2) record/document information related to the resident's discharge plan to the community in the clinical record;(3) ensure the residents discharge needs were adequately identified and the results developed into a discharge plan. Residents' #155, #170, #227, #237, #406 and #412.

Inspectors wroteBased on observation, record review, family interview and staff interview, for four (4) of 105 sampled residents, the facility's staff failed to ensure that residents received treatment and care in accordance to the physicians' order and the comprehensive person-centered care plan as evidenced by: failed to provide stoma site for one (1) resident; failed to schedule one (1) resident for an audiology consult appointment; failed to implement the care plan intervention of having two (2) certified nurse aides (CNAs) for activities of daily living (ADLs) for one (1) resident; and failed to administer nebulizer inhaler as ordered the physician's order for one (1) resident. (Residents' #3, #50, #82 and #181).

Inspectors wroteBased on observation, record review and staff interview for five (5) of 105 sampled residents, facility staff failed to: (1) ensure the dialysis communication form (used to reflect ongoing collaboration between the facility and dialysis staff contained pertinent information that reflected the resident care) was completed and included in the medical record as part of the record and (2) have an emergency kit (pressure bandage) at bedside of a resident who had an arteriovenous graft dialysis access site. Residents' #61, #95, #181, #182 and #502.

Inspectors wroteBased on record review and staff interviews, facility staff failed to ensure that the system used for the reconciliation of controlled medications was followed; and failed to accurately reconcile controlled medications for three (3) of 16 records reviewed.

Inspectors wroteBased on record review and staff interview, for six (6) of 105 sampled residents, facility staff failed to: (1) show documented evidence that the attending physician or designee reviewed the monthly medication regimen review and that they acted upon the pharmacists' recommendations. Residents' #16, #22, #61, #167, #190, #238

Inspectors wroteBased on observation and staff interview, facility staff failed to serve and distribute foods in accordance with professional standards of practice for food services safety as evidenced by hot food temperatures that tested at less than 135° Fahrenheit (F) during a food tray assessment on April 12, 2022.

Inspectors wroteBased on observation, record review and staff interview, Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by failure to ensure that: staff implemented measures to prevent resident-to-resident abuse and altercations for six (6) residents; adequate supervision was provided to one (1) resident who sustain a dislocated hip of unknown origin; to adequately supervise one (1) resident who sustained a fall with injury; ensure the appropriate respiratory medical supplies were on hand for care and treatment, and to ensure staff were trained on how to care for two (2) residents with a laryngectomies. The census on the first day of survey was 255.

Inspectors wroteBased on observation, record review and staff interview, Governing body failed to ensure that established and implemented policies regarding the management and operation of the facility were followed and action plans were developed and implemented to: prevent resident-to-resident abuse and altercations for six (6) residents; ensure adequate supervision was provided to one (1) resident who sustain a dislocated hip of unknown origin; adequately supervise one (1) resident who sustained a fall with injury; ensure the appropriate respiratory medical supplies were on hand for care and treatment; ensure staff were trained on how to care for two (2) residents with a laryngectomies; and to ensure the administrative staff maintained the integrity of an Incident/Accident Report (investigative report) for one (1) resident. The census on the first day of survey was 255.

Inspectors wroteBased on record review and staff interview, for five (5) of 105 sampled residents, the facility's staff failed to ensure a resident's record contained accurate information as evidenced by failure to: accurately record information on a Treatment administration record for one (1) resident; maintain the integrity of an Incident/Accident Report related to a resident-to-resident altercation resulting in serious injury to the resident; and ensure resident's medical record were accurately documented for three (3) residents. Residents' #3, #126, #164, #404, and #408.

Inspectors wroteBased on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to ensure that there was documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization, the administration or the refusal of or medical contraindications to the vaccine(s). Residents' #182 and #603.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 105 sampled residents, facility staff failed to ensure that Resident #64 was treated with respect and dignity evidenced by failure to provide an environment that enhances the resident's quality of life, was based on his individuality and medical condition.

Inspectors wroteBased on observation and resident and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to provide Resident #113 access to the bathroom and an elevated toilet seat causing the resident to be dependent on staff to use the bathroom.

Inspectors wroteBased on observation, record review, and interviews for one (1) out of 105 sampled residents, facility staff failed to offer a resident who had been moved due to a COVID-19 outbreak, the opportunity to move back to her previous room or previous unit once COVID-19 precautions were lifted. Resident #233.

Inspectors wroteBased on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to ensure that two (2) residents or their representative was provided the NOMNC form no later than noon of the day before the effective date indicated/date listed as discontinuance of skilled services. Residents' #209 and #553.

Inspectors wroteBased on record review and staff interview, for three (3) of 105 sampled residents, facility staff failed to: (1) report the unusual occurrences for Resident #3 and Resident #409 and (2) report the results of the investigation for Resident #408's injury of unknown origin.

Inspectors wroteBased on record review and staff interview for three (3) of 105 sampled residents, the facility's staff failed to ensure: (1) Resident #3's discharge, transfer, or relocation form dated 12/03/21 included accurate information and (2) Resident #126's and #155's care plan goals were sent to the receiving hospital.

Inspectors wroteBased on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to provide Resident #132 and Resident #151 or their representative(s) with written information that specified the bed-hold policy.

Inspectors wroteBased on record review and staff interview, for 2 (two) of 105 sampled residents, the facility's staff failed to ensure that Resident #181's Quarterly Minimum Data Set (MDS) dated [DATE] and Resident #188's Quarterly Minimum Data Set (MDS) dated [DATE] were completed 14 days after the assessment reference date.

Inspectors wroteBased on record review, family interview, and staff interview, for one (1) of 105 sampled residents, facility staff failed to provide Resident #3's representative with a summary of the baseline care plan.

Inspectors wroteBased on observation, record review, resident and staff interview, for two (2) of 105 sampled residents, facility staff failed to: 1) assist a resident with applying her dentures before meals; and 2) failed to ensure one (1) resident was seen by audiology to address his ability to hear when communicating with others. Residents' #204 and #82.

Inspectors wroteBased on record review, resident interview, and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to provide Resident #113 showers.

Inspectors wroteBased on observation, record review, resident and staff interviews, for one (1) of 105 sampled residents, facility staff failed to ensure that Resident #82 received assistive devices to maintain hearing ability.

Inspectors wroteBased on record review and staff interview, for two (2) of 105 sampled residents, facility staff failed to administer pain medication to Resident #118 in accordance with the physician's order; and failed to assess Resident #236's pain before administering Tylenol (pain reliever).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility staff failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety as evidence by failure to: (1) follow facility policy to make changes in Resident #56's active clinical record; (2) ensure the facility's nurse was competent on how to administer Tiotropium Bromide Aerosol Inhaler for Resident #181; and (3) address Resident #404's intrusive behavior which led to a resident-to resident altercation resulting in serious injury to Resident #404. The resident census on the first day of survey was 255.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 105 sampled residents, facility staff failed to: monitor and provide ongoing assessment of the effectiveness of interventions for a resident with a mental or psychosocial disorder; and demonstrate reasonable attempts were made to implement approaches to help meet the behavioral health needs to assure resident safety. Resident #404.

Inspectors wroteBased on observations and staff interviews, facility staff failed to ensure that medications and biologicals were properly labeled and stored for three (3) of 16 medication carts.

Inspectors wroteBased on observation, record review and staff interviews, the facility staff failed to record the total number of staff worked and the hours per patient day for one day on the Report of Nursing Staff Directly Responsible for Resident Care form; and failed to maintain 18 months of the posted daily nurse staffing data. The resident census on 04/14/22 was 245.

Inspectors wroteBased on record review and staff interview, facility staff failed to update the Facility Assessment to reflect the facility's current operations. The resident census on the first day of survey was 255.

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare foods under sanitary conditions as evidenced by missing ceiling tiles in the main kitchen, a dusty electric fan in use in the food preparation area, two (2) of four (4) dietary staff members who failed to wear gloves while clearing off breakfast food trays, and erroneous documentation of dishwashing machine final rinse temperatures.

Inspectors wroteBased on observations and staff interview, facility staff failed to have adequate trash receptacles to dispose of used personal protective equipment (PPE) on the Person Under Investigation (PUI) and COVID-19 Unit; follow acceptable infection control standards to prevent the spread of infection in one (1) of two (2) dressing change observations; and follow acceptable standards to prevent the spread of infection between residents while using a glucose meter.

Inspectors wroteBased on observations and staff interview, the facility failed to protect the resident's dignity during one (1) of two (2) dressing change observations.

Inspectors wroteBased on record review and staff interview for one (1) of 66 sampled residents, the facility staff failed to ensure the physician's order for the resident's code status was reflective of Resident #196 wishes to be a DNR (do not resuscitate).

Inspectors wroteBased on record review and interview, facility staff failed to code accurately the Minimum Data Set (MDS) for one (1) of 66 sampled residents (Resident #231).

Inspectors wroteBased on record review and staff interview for one (1) of 66 sampled residents the facility staff failed to develop a care plan to address Resident #196's code status.

Inspectors wroteBased on record review and staff interview the facility failed to update two residents care plans to include the actions and interventions related to preparing one (1) resident for discharge and the code status for one (1) resident in two of 66 sampled residents. Residents' #43 and #159.

Inspectors wroteBased on observations made on July 22, 2020, at approximately 1:20 PM, and on July 23, 2020, at approximately 1:20 PM, facility staff failed to provide housekeeping services necessary to maintain a clean area evidenced by several surgical masks, plastic bottles, and debris that were observed in the staff parking lot area and in areas surrounding the emergency generator and the chiller, and a plastic container full of water and other debris that was stored in the loading dock area.

Inspectors wroteBased on observations and staff interview, facility staff failed to store, prepare, distribute and serve foods under sanitary conditions as evidenced by fifteen of nineteen nine-inch sheet pans that were stored wet and ready for use, one (1) of one (1) case of evaporated milk with a Best By date of February 2017, stored for use as emergency food, and three (3) of four (4) puree food dishes that tested at less than 135 degrees Fahrenheit (F) from the test tray.

Inspectors wroteBased on observation, medical record review and staff interview for one (1) of 68 sampled residents facility staff failed to maintain infection control standard of practicice by failing to use approriate personnel protective equipment (PPE) when providing Foley catheter care for Resident # 591 with Vancomycin-Resistant Enterococcus (VRE) in the urine and to ensure that laundry items are handled, stored, and processed in a sanitary manner as evidenced by two (2) of two (2) soiled electrical fans, in use in the clean laundry area, four (4) of four (4) soiled exhaust vents, and fifteen of nineteen nine-inch sheet pans that were stored wet and ready for use.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by torn and worn door gaskets from two (2) of two (2) steamers in Dietary Services.

Inspectors wroteBased on an observation, record review, resident and staff interview for one (1) of 68 sampled residents, facility staff failed to ensure that one resident who was observed with medications at her bedside was cleared by the Interdisciplinary Team (IDT) to self-administer her medications.

Inspectors wroteBased on resident and staff interviews and facility document review for one (1) of 68 sampled residents, the facility staff failed to provide Resident #7 with quarterly statements within 30 days after the end of the quarter and/or upon request.

Inspectors wroteBased on an observation, record review and staff and resident interview for one (1) of 68 sampled resident's, the facility staff failed to respect Resident #96's privacy by failing to knock on the resident's door and entering the resident's room without receiving permission to enter.

Inspectors wroteBased on observation, medical record review and staff interview for one (1) of 68 sampled resident facility staff failed to ensure Resident #186 was free from neglect by failing to assess the resident's care needs after the resident repeatedly called a Certified Nursing Assistants (CNA) for assistance. Resident #186.

Inspectors wroteBased on observation, investigative documents, medical record review and staff interview of one (1) of 68 sampled residents facility staff failed to conduct a thorough investigation involving an incident of neglect. Resident# 186.

Inspectors wroteBased on record review and staff interview for three (3) of 68 sampled residents, the facility staff failed to document the information communicated to the receiving health care institution for Residents' #126, # 215 and #247.

Inspectors wroteBased on record review and staff interview, the facility failed to notify one (1) of 68 residents of the reason for transfer from the facility to the hospital. Resident #215.

Inspectors wroteBased on record review and staff interviews of three (3) of 68 sampled residents, the facility staff failed to accurately code the Minimum Data Set (MDS) for one (1) Resident's Discharge to home, for one (1) Resident's use of psychotropic medications and for one (1) resident with a behavioral indicator for psychosis. Residents' #70, #198 and #258.

Inspectors wroteBased on record review and staff interview for one (1) of 68 sampled residents, it was determined that facility staff failed to ensure that the Level II Pre-admission Screen/Resident Review for Mental Illness and or Mental Retardation screening was completed for Resident #262.

Inspectors wroteBased on medical record review and staff interview for one (1) of 68 sampled residents, the facility staff failed to provide the resident and or the resident's representative with a written summary of the baseline care plan within 48 hours after the resident's admission to the facility. Resident #591.

Inspectors wroteBased on record review and staff interview for one (1) of 68 sampled residents facility staff failed to revise/update the care plan after Resident #215's hospitalization.

Inspectors wroteBased on observation, record review, resident and staff interviews for one (1) of 68 sampled residents, facility staff failed to provide necessary services to maintain good grooming (Removal of facial hair from chin) and Activities of Daily Living for Resident #223.

Inspectors wroteBased on observation, medical record review, family and staff interviews for one (1) of 68 sampled residents facility staff failed to honor the resident's preferences and choice of activities to support her psychosocial well-being. Resident # 201.

Inspectors wroteBased on observation, record review and interview, the facility staff failed to administer oxygen in accordance with the physician's order for one (1) of 68 sampled residents. Resident #53.

Inspectors wroteBased on observations and interview, facility staff failed to provide an environment free from accident hazards as evidenced by privacy curtains that were attached to an electrical power cord in one (1) of 56 resident's rooms.

Inspectors wroteBased on observation, record review and staff interview,the facility staff failed to ensure the filter of an oxygen concentrator was free of dust for one (1) of 68 sampled residents. Resident #53.

Inspectors wroteBased on medical record review and staff interview for one (1) of 68 sampled residents, facility staff failed to monitor and consistently document Resident# 258's aggressive/delusional behavior and to obtain necessary services to address the resident's behavioral health care needs.

Inspectors wroteBased on observation, record review, staff and resident interview for one (1) of 68 sampled residents, facility staff failed to have Resident #166's routine medication available for her use when she requested it.

Inspectors wroteBased on record review and staff interview for two (2) of 68 sampled residents, facility staff failed to respond to a request from the pharmacist to evaluate one (1) resident's Trazadone and Seroquel and one (1) resident's Zoloft medication for a gradual dose reduction (GDR). Residents' #105 and #173.

Inspectors wroteBased on observation, and interview the facility's staff failed to ensure metered dose inhalers Pulmicort (treatment of lung disease) and Spiriva Respimat (treatment of lung disease) were safely stored for one (1) of 68 sampled residents Resident #53.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by torn privacy curtains in one (1) of 56 resident's rooms, four (4) of four (4) soiled exhaust vents in the Laundry area, and a stained ceiling tile in one (1) of 56 resident's rooms.