Divine Rehabilitation and Nursing at Sylvania

Inspectors wroteBased on medical record review, observation, resident, staff, and family interview, review of the facility policy, review of the facility assessment, and review of staffing schedules, the facility failed to have sufficient staffing to meet the care needs of all residents. This directly affected three residents (#41, #34, and #30) and had the potential to affect all residents residing in the facility. The facility census was 67. Findings Include:1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, hypertension, depression, respiratory failure, chronic kidney disease, difficulty in walking, and muscle weakness. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #41 was cognitively intact. [...]

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure the pre-planned menu was followed. This affected all 67 residents who received food from the facility kitchen. The facility census was 67.

Inspectors wroteBased on observation, staff interview, and review of the facility policy for environment, the facility failed to maintain a clean, safe, and homelike environment. This directly affected Resident #55 and had the potential to affect 18 residents who resided on the memory care unit (#60, #61, #62, #63, #64, #65, #66, #67, #68, #69. #70, #71, #72, #73, #74, #75, #76, and #77). The facility also failed to ensure cleanliness of shower chairs. This had the potential to affect all but 13 residents (#13, #16, #17, #19, #22, #29, #31, #40, #53, #58, #63, #66, and #69) in the facility who were identified to not utilized shower chairs. The facility census was 67.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure infection control measures were followed. This affected two residents (#46 and #48) of three residents observed during medication administration, two residents (#32 and #46) of two residents observed while obtaining vital signs, one resident (#46) of three residents observed during medication preparation, and one resident (#55) of one resident observed during incontinence care. The facility census was 67.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure protected health information was secured. This affected one resident (#50) of six residents reviewed for secured health information. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, observation, and facility policy review, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received assistance with eating. This affected one (#23) of one resident reviewed for assistance with eating. The facility census was 67. Findings Include:Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, dementia, hyponatremia, hypertension, Alzheimer's disease, and dysphagia. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. The resident was dependent on staff for eating. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to answer call lights in a timely manner. This affected two (#34 and #38) of two residents reviewed for call light response. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to timely implement wound care orders. This affected one resident (#14) of three residents reviewed for wound care. The facility census was 67.

Inspectors wroteBased on medical record review, observations, staff interviews, and review of facility policies, the facility failed to ensure fall interventions were in place for one (#28) out of two residents reviewed for falls. The facility also failed to ensure hazardous items were secure. This had the potential to affect 21 residents (#15, #20, #23, #24, #27, #31, #35, #37, #42, #43, #48, #61, #63, #64, #65, #66, #68, #69, #72, and #77) identified by the facility as cognitively impaired and independently mobile. The facility census was 67.

Inspectors wroteBased on medical record review, observation, interview, and review of facility policy, the facility failed to ensure urinary catheter securement devices were utilized. This affected two residents (#14 and #59) of two residents reviewed for urinary catheters. Additionally, the facility failed to ensure urinary catheter care was completed each shift. This affected one resident (#59) of two residents with urinary catheters. Finally, the facility failed to ensure residents received assistance with incontinence care in a timely manner. This affected one resident (#41) out of three residents reviewed for incontinence care. The facility census was 67.

Inspectors wroteBased on medical record review, observations, staff interview, and review of the facility policy, the facility failed to ensure all safety injury prevention interventions were in place as care planned for residents identified at risk for falls. This affected one (#35) of three residents reviewed for falls. The facility census was 60.

Inspectors wroteBased on observation, interviews with facility staff and the wound physician, review of the medical record, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure a resident's skin impairment was identified timely and a treatment initiated. This resulted in Actual Harm to Resident #68 on 01/30/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #68 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) requiring debridement. This affected one (#68) of two residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 75.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure care plan conferences were conducted quarterly for the resident and/or resident representative. This affected six (#14, #18, #43, #49, #58 and #60) of seven residents reviewed for care plan conferences. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident and staff interview and facility policy review, the facility failed to monitor effectiveness of medications utilized to manage the resident's mood and behavior. This affected five of five residents (#10, #15, #26, #34, and #45) reviewed for unnecessary medications in a facility census of 75.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staff hand sanitized between serving resident's meals. This affected four (#1, #33, #44, and #45) of 26 residents reviewed for dining services. The facility census was 75.

Inspectors wroteBased on observation, staff and resident interview, review of a job description, and facility policy review, the facility failed to maintain a clean and functional environment for the residents. This affected seven (#2, #9, #12, #29, #39, #70, and #72) of thirteen residents reviewed for physical environment.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure residents were treated in a dignified manner. This affected one (#31) of three residents reviewed for dignity. The facility census was 75.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure call lights were accessible to residents. This affected two (#49 and #70) of two residents reviewed for call lights. The facility census was 75.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policy, the facility failed to provide timely access to medical records as requested. This affected one (#26) of 24 residents reviewed for medical record access in a facility census of 75.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) were provided with adequate assistance with grooming and hygiene. This affected three (#14, #42 and #60) of 24 residents reviewed for ADL. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident interview, and physician and staff interview, the facility failed to ensure wound treatments and edema management equipment were implemented in accordance with physician orders. This affected two (Residents #42 and #44) of two residents reviewed with skin conditions in a facility census of 75.

Inspectors wroteBased on observations, medical record review, and resident and staff interview, the facility failed to ensure range of motion exercises were provided as ordered by the physician. This affected one (#44) of one resident reviewed for contracture management in a facility census of 75.

Inspectors wrote0Based on medical record review, observation, staff interview, review of hospital report, and review of the facility policy, the facility failed to timely report a fall and monitor a resident status post fall and failed to ensure a resident's fall interventions were in place for a resident at risk for falls. This affected two (#18 and #68) of three residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure water was readily available for proper hydration. This affected one (#20) of two residents reviewed for hydration. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure oxygen equipment was maintained and applied as ordered by the physician. This affected one (#42) of two residents reviewed for respiratory services in a facility census of 75.

Inspectors wroteBased on record review, staff interview, and review of a contract, the facility failed to document communication and assessments before and after dialysis, failed to monitor fluid intake and output, and monitor the resident's dialysis access port. This affected one (#75) of one resident reviewed for dialysis. The facility identified one resident as receiving dialysis services. The facility census was 75.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the resident's prescribed pain medication was available to administer as physician ordered. This affected one (#60) of three residents reviewed for pain. The facility census was 75.

Inspectors wroteBased on review of the medical record, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure a physician responded timely to pharmacy recommendations. This affected three (#10, #15, #34) of five residents reviewed for unnecessary medications. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician's orders resulting in a medication error rate exceeding five percent. 25 opportunities were observed with five medication errors, resulting in a medication error rate of 20 percent. This affected two (#37 and #64) of three residents reviewed for medications. The facility census was 75.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure medications were dated when opened and the safe disposal of medications. This affected two of three medication carts inspected and had the potential to affect two residents (#19 and #48) the facility identified as cognitively impaired and independently mobile. The facility census was 75.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure a resident received his food preference of double portions. This affected one (#30) of three residents reviewed for meals. The facility census was 75.

Inspectors wroteBased on observation, staff interview, record review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore personal protective equipment (PPE) when providing care to residents in Enhanced Barrier Precautions (EBP). This affected one resident (#11). The facility identified 16 residents on EBP. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the manufacturer guidelines, the facility failed to ensure a mattress was compatible with a bed. This affected one (#70) of seven resident reviewed for accident hazards. The facility census was 75.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided with the notice of transfer/discharge. This affected four (#78, #79, #180, and #181) of four residents reviewed for transfer/discharge. The facility identified 12 residents sent to the hospital in the past 90 days. The facility census was 75.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided a bed hold notice at the time of transfer. This affected four (#78, #79, #180, and #181) of four residents reviewed for transfer/discharge. The facility identified 12 residents sent to the hospital in the past 90 days. The facility census was 75.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to timely notify a resident before a roommate change. This affected one (#85) of three residents reviewed for room changes. The facility census was 80.

Inspectors wroteBased on observations, medical record review, review of hospital medical records, review of the emergency department record, review of the Abuse/Neglect policy and procedure, review of the Wound Treatment Management policy, review of the Skin Assessment policy, resident interview, Medical Director interview and staff interviews, the facility failed to ensure Resident #59, who was admitted to the facility on hospice care, was free from a situation of neglect when facility staff failed to provide ongoing wound assessments, care and services to prevent a significant decline in a wound, and notification to the physician when there was a decline in the wound. [...]

Inspectors wroteBased on record review, observation, staff interview and review of policy, the facility failed to provide appropriate care, assessments, and ongoing monitoring of a pressure ulcer. This affected one (#9) of three residents reviewed for wounds. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, admission packet review, review of facility documents and review of facility policy, the facility failed to ensure a written discharge notice was provided to residents and their representatives for a facility-initiated discharge. This affected one (#1) of three residents reviewed for discharge. The facility census was 80. Findings Include: Review of Resident #1's medical record revealed an admission date of 07/18/23 and a discharge date of 02/24/24. Diagnoses included pleural effusion (fluid around his lungs), Alzheimer's disease, dementia, cough, edema, shortness of breath and altered mental status. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating Resident #1 was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review, staff interviews, review of the facility investigation, review of a personnel file, review of an emergency medical services (EMS) run report, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPNs), and review of the cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR for one resident (Resident #05) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or death when Resident #05 did not receive timely CPR after she was discovered with no pulse or blood pressure. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide privacy during personal care and failed to ensure residents in a semi-private room had a means to maintain privacy. This affected three residents (#33, #69, and #83) of three residents observed for privacy. The facility census was 79.

Inspectors wroteBased on self-reported incident review, medical record review, staff interview, and review of a facility policy, the facility failed to submit the results of an investigation to the State Survey Agency in a timely manner. This affected one (#27) of one residents reviewed for neglect. The facility census is 79.

Inspectors wroteBased on staff interview, review of staffing schedules and payroll information, the facility failed to ensure staffing included Registered Nurse in-house coverage was provided daily for eight consecutive hours during a 24-hour period. This affected all 85 residents residing in the facility. The facility census in 85.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies, the facility failed to ensure the kitchen and food storage areas were maintained in a clean and sanitary manner. In addition, the facility failed to ensure staff sanitized their hands prior to and during meal service and did not sanitize the hands of the 17 residents in the memory care (#2, #5, #10, #13, #18, #22, #25, #27, #28, #43, #44, #45, #46, #60, #65, #82, and #84; Resident #62 did not eat lunch.) prior to their lunch meal. This had the potential to affect all residents except one resident (#11) who the facility identified as not accepting food by mouth. The facility census was 85.

Inspectors wroteBased on medical record reviews, review of the Certification And Survey Provider Enhanced Reports (CASPER) Report, staff interviews, review of staff schedules, and review of the administrator's job description, the facility failed to implement resources to ensure identified concerns were sufficiently corrected and resident needs were adequately met. This affected five residents (#9, #39, #63, #64, and #288) and had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observations, record review, resident interviews, staff interviews, and policy review, the facility failed to ensure residents had daily access to their resident fund accounts. This had the potential to affect 54 (#1, #2, #3, #4, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #28, #29, #30, #31, #36, #37, #38, #40, #43, #44, #45, #46, #48, #50, #51, #53, #55, #56, #60, #61, #62, #65, #66, #69, #71, #72, #73, #74, #77, #78, #81, #82, and #388) of 54 residents with an open resident fund accounts. The facility census was 85.

Inspectors wroteBased on medical record review, resident and resident representative interview, staff interview, and facility policy, the facility failed to ensure care plan conferences were offered timely. This affected four (#13, #22, #24, and #47) of four residents reviewed for care plan conferences. The facility census was 85.

Inspectors wroteBased on resident interviews, staff interviews, review of the facility policy, and record review, the facility failed to ensure the facility's arbitration agreement was thoroughly explained for complete understanding of the agreement upon the residents' admission to the facility. The facility also failed to ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This affected five (#8, #11, #52, #69, and #78) of five residents reviewed for binding arbitration. This had the potential to affect the 59 residents who resided in the facility that entered into the binding arbitration agreement. [...]

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility failed to maintain a clean and sanitary environment. This affected seven (Residents #13, #21, #47, #48, #63, #79, and #80) of 30 residents reviewed for clean and sanitary environment. The facility census was 85.

Inspectors wroteBased on observation, resident interview, staff interview, record review and review of policy, the facility failed to ensure residents were treated in a dignified manner. This affected two residents (#14 and #79) of four residents reviewed for dignity. The facility identified 18 resident smokers. The facility census was 85.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to ensure call lights were within reach and accessible. This affected two (#9 and #39) of 25 residents reviewed for call light placement. The facility census was 85.

Inspectors wroteBased on observation, medical record review, resident interview and staff interview, the facility failed to ensure residents were provided with opportunities and assistive devices for out of bed activity. This affected one (#73) of 24 residents reviewed for the provision of choices. The facility census was 85.

Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to ensure they received approval in writing to access personal funds and keep the Medicaid regulated $50 each month for a Medicaid resident. This affected one (#22) of five residents reviewed for resident funds. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure resident's advanced directives were clearly described and contained in medical records. This affected three (#33, #68, #81) of 24 residents reviewed for advanced directives and code status choices. The facility census was 85.

Inspectors wroteBased on record review, Power of Attorney (POA) interview, staff interview, and policy review, the facility failed to ensure the physician and family were contacted after a change in condition with acute pain was identified. This affected one (#47) of two residents reviewed for a change in condition. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure beneficiary notices were completed. This affected two (#22 and #82) of four residents reviewed for beneficiary notices. The facility census was 85.

Inspectors wroteBased of medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's personal privacy was honored. This affected one (#80) of two residents reviewed for personal privacy. The facility census was 85.

Inspectors wroteBased on observations, resident interview and staff interviews, the facility failed to ensure a resident's bed linens were changed when the linens became soiled and torn. This affected one (#47) of three residents reviewed for linens. The facility census was 85.

Inspectors wroteBased on medical record review, review of self-reported incidents (SRI), staff interview, and policy review, the facility failed to thoroughly investigate an allegation of injury of unknown origin and abuse. This affected one (#61) of three residents reviewed for abuse. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure the resident, or their representative, received written transfer information. This affected one (#86) of one resident reviewed for hospitalization. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure bed hold information was provided to resident upon hospitalization. This affected one (#86) of one resident reviewed for hospitalization. The facility census was 85.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure an accurate Minimum Data Set Assessment (MDS) was completed. This affected one (#81) of 25 residents reviewed for accurate MDS assessments. The facility census was 85.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate and updated Pre-admission Screening and Resident Review (PASARR) was completed. This affected one (#21) of two residents reviewed for PASARR. The facility census was 85.

Inspectors wroteBased on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure an oxygen care plan was developed for Resident #52 and a vision care plan was developed for Resident #81. This affected two (#52 and #81) of 25 resident care plans reviewed. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, manufacturer's instruction review, and facility policy, the facility failed to ensure nursing staff worked within their scope of practice. This affected two (#288 and #78) of five resident reviewed for medication administration. The facility census was 85.

Inspectors wrote2. Review of the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses included complete traumatic amputation at knee level, vascular disease, diabetes, and chronic viral hepatitis c. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired and required extensive assistance of one to two staff members for mobility and activities of daily living. Review of the plan of care dated 10/26/23 revealed Resident #52 had an ADL self-care deficit related to amputation with interventions for one to two staff to assist with bathing and provide a bed bath if not able to shower. Review of the shower sheets revealed dated 09/01/23 to 11/13/23 revealed resident last had his hair washed on 10/12/23. Resident #52 was noted to not need nails trimmed on 11/13/23 according to the shower sheets. [...]

Inspectors wroteBased on medical record review, resident and staff interview, physician interview, and policy reviews, the facility failed to ensure clear physician instructions for blood sugars above or below parameters, physician and nursing staff had no barriers to communication, and a resident with a change in condition was treated and monitored appropriately. This affected one (#288) of one residents reviewed for insulin. In addition, the facility failed to properly assess and monitor change in condition for Resident #47 related to acute pain. The facility census was 85.

Inspectors wroteBased on review of the medical record, observation, staff interview and facility policy the facility failed to ensure fall interventions were in place. This affected one (#22) of three residents reviewed for falls. The facility census was 85.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure an indwelling urinary catheter was appropriately secured and maintained to prevent infections. This affected one (#77) of one resident reviewed for indwelling catheter maintenance and care. Facility census 85.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to ensure physician ordered weights were obtained and accurate, and failed to ensure significant changes in weight were evaluated and addressed. This affected one (#63) of two residents reviewed for nutritional status. The facility census was 85.

Inspectors wroteBased on observation, resident interview, staff interviews, record review and policy review, the facility failed to ensure oxygen had an active order, the tubing had been changed timely, and had proper humidification of oxygen. This affected two (#52 and #14) of three residents reviewed for respiratory care. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, physician interview and policy review, the facility failed to ensure residents care was supervised by a physician when the physician was unable to have effective communication with the nursing staff to provide direct orders for residents. This affected two (#9 and #288) of two residents for a change in condition. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and review of policy, the facility failed to ensure newly admitted residents were seen and evaluated by a physician within the first 30 days of admission. This affected three (#39, #63 and #64) of 25 residents reviewed for physician services. The facility census was 85.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications to address psychiatric diagnosis were monitored for effectiveness and specific treatment outcome for specified condition. This affected one (#16) of five resident sampled residents reviewed for unnecessary medications. The facility census was 85.

Inspectors wroteBased on observation, medical record review, staff interview, and review of policy, the facility failed to ensure medications were appropriately stored and secured. This affected one (#68) of one resident observed with medications unattended at the bedside. The facility census was 85.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the resident council minutes, the facility failed to ensure residents were provided with all reasonable ingredients during meal service. This affected one Resident (#32) of six reviewed for food and had the potential to affect all residents except one resident (#11) the facility identified as not receiving food by mouth (NPO). The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure newly admitted residents were seen and evaluated by a physician within the first 30 days of admission. This affected three (Residents #10, #19, and #23) of 17 residents reviewed for physician services. The facility census was 83.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's transportation was arranged and provided for a scheduled medical appointment. This affected one (Resident #10) of four residents reviewed for transportation services. The facility census was 83.

Inspectors wroteBased on medical record review, Self-Reported Incident review, hospital record review, staff interview, and policy review, the facility failed to prevent an incident of resident-to-resident abuse with injury. This resulted in actual harm when Resident #23 was found on top of Resident #12, punching him and bit the tip of Resident #12's finger off. Subsequently, requiring Resident #12 to have surgical interventions to reattach the fingertip, pain medication and antibiotic therapy. This affected one (Resident #12) of three resident reviewed for potential abuse. The facility census was 92.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with nail care. This affected two (#54 and #55) of three residents reviewed for activities of daily living. The facility census was 92.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to label and date open foods. This had the potential to affect all residents, except for one (#52), identified by the facility as having nothing by mouth. The facility census was 79.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of an example of a menu food choice document, the facility failed to allow residents to make choices related to their breakfast foods. This affected a total of seven residents, one (#32) resident reviewed for choices and affected five (#6, #19, #28, #44, and #60) additional residents interviewed for food choices. The census was 79.

Inspectors wroteBased on observation, medical record review, resident interview, resident representative interview, staff interview, review of monthly activity calendar, and facility policy review, the facility failed offer appropriate and scheduled activities to residents. This affected six residents, one resident (Resident #4) reviewed for activities and five additional residents (#6, #28, #60, #44, and #19) interviewed. The facility census was 79.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure semi-private resident rooms were equipped with full visual privacy. This affected six (#2, #14, #43, #45, #73, and #78) residents observed on the secured neighborhood. The census was 79.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents had a sanitary and homelike environment. This affected 21 residents, Resident #283 and 20 (#2, #3, #5, #14, #17, #21, #35, #36, #38, #42, #43, #45, #58, #63, #73, #75, #76, #78, #80, and #81) residents who resided on the secured neighborhood. The census was 79.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure a resident's call light was positioned in a manner to allow for freedom of use. This affected one (#42) of four residents observed for call light placement on the secured neighborhood. The census was 79.

Inspectors wroteBased on medical record review, review of resident trust accounts, staff interview, and review of facility policy, the facility failed to convey personal funds to the resident within 30 days of discharge. This affected one (#284) resident reviewed for conveyance of personal funds. The facility census was 79.

Inspectors wroteBased on medical record review, resident interview, resident representative interview, staff interview, and review of the facility policy, the facility failed to offer resident and/or representative participation in care plan conferences. This affected two (#39 and #71) of two residents reviewed for comprehensive care plan conferences. The facility census was 79.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure resident safety while smoking. This affected one (Resident #37) of six residents who smoke. The facility census was 79.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to change oxygen supplies for one (#51) of three residents reviewed for respiratory care. The facility census was 79.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to complete side rail assessments prior to installation on the bed for two (#34 and #64) of two residents reviewed for side rails. The facility census was 79.

Inspectors wroteBased on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered by the physician which resulted in a medication error rate of 11.11%. The deficient practice affected two (#52 and #62) of five residents observed during medication administration with four errors occurring out of 36 opportunities. The census was 79.

Inspectors wroteBased on observation and staff interview, the facility failed to post daily nurse staffing. This had the potential to affect 79 residents in the facility.