Divine Rehabilitation and Nursing at Toledo

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a dependent resident received assistance with eating. This affected one (#01) of three residents reviewed for mealtime assistance. The facility census was 61.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, review of a facility policy, and review of a glucometer manufacturer instructions, the facility failed to ensure glucometers were properly disinfected after use and failed to ensure bedpans were properly stored for residents with urinary infections. This affected three (#35, #49, and #54) of four residents observed for infection control practices with the potential to affected two additional residents (#22 and #42) who have their blood glucose level checked using the same glucometer as Resident #35 and #49. The facility census was 60.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a resident's urinary catheter bag was covered and placed in a manner to ensure dignity was maintained. This affected one (#5) of one residents reviewed with an indwelling catheter in place. The facility identified six current residents with indwelling urinary catheters in place in a facility census of 60.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents prescribed psychotropic medications were monitored for behaviors and medication side effects. This affected three (#1, #48, and #66) of five residents reviewed for psychotropic medications. The facility census was 60.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure dependent residents received adequate oral care as ordered. This affected one (#23) of one residents reviewed for oral care. The facility census was 60.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure residents compression stockings were applied as ordered. This affected one (#6) of one residents reviewed for application of compression stockings. The facility census was 60.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure pressure ulcers were assessed thoroughly and accurately, failed to ensure wound care orders were implemented, and failed to ensure devices used to prevent pressure ulcer development were implemented as ordered. This affected two (#48 and #6) of three residents reviewed for pressure ulcers. The facility census was 60.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure smoking materials were stored in a safe manner, failed to ensure resident smoking assessments were accurate, and failed to ensure fall interventions were in place as care planned. This affected two (#58 and #11) of three residents reviewed for accidents and hazards. The facility census was 60.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure residents received diets as ordered. This affected one (#1) of three residents reviewed for diet. The facility census was 60.

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure residents received tube feeding nutrition as ordered by the physician. This affected one (#23) of two residents reviewed for tube feeding. The facility census was 60.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to safely store medications. This affected one (#43) out of five residents reviewed for medication storage. The facility census was 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure laboratory tests were completed per physician orders. This affected one (#23) of five residents reviewed for laboratory tests. The facility census was 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure skin assessments were completed accurately. This affected one (#48) of two people reviewed for skin assessments. The facility census was 60.

Inspectors wroteBased on medical record review, review of hospital records, staff, pharmacist, and physician interview, and review of the facility policy, the facility failed to ensure residents were administered medications indicated for their medical diagnosis and free from unnecessary medications. This affected one (#39) of three residents reviewed for unnecessary medications. The facility census was 65.

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure staff honored the rights of residents. This resulted in actual harm on 11/12/25 at 2:50 P.M. when Resident #145 expressed fear of a nurse and a concern for her health status after a nurse unexpectedly approached her and administered a second dose of the influenza vaccination in error, despite Resident #145 declining the shot and informing the nurse that she had already received the 2025 influenza vaccination. This affected one resident (#145) of three residents reviewed for resident rights. The facility census was 67. Review of Resident #145's medical record revealed an admission date of 10/14/25. Diagnoses included cellulitis of the chest wall, type II diabetes mellitus, chronic pulmonary edema, obesity, and post-traumatic stress disorder. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, staff interviews, review of the facility incident investigation, review of video surveillance, review of employee personnel files, review of the facility self-reported incident (SRI), and review of facility policy, the facility failed to ensure residents were free from abuse. Actual harm occurred on 11/15/25 at 8:42 P.M. when Resident #169 was subjected to excessive physical force by a facility staff member, after which Resident #169 verbalized a fear for his safety, and being depressed at times with positive thoughts of self-harm. This affected one (#169) of three residents reviewed for abuse. The facility census was 67. [...]

Inspectors wroteBased on observation, review of pest control records, staff and resident interview, and review of the facility policy, the facility failed to ensure effective pest control in the facility. This affected two (#14 and #19) of three residents reviewed for pest control, and had the potential to affect all 71 residents residing in the facility. The facility census was 71.

Inspectors wroteBased on medical record review and facility and oncology staff interview, the facility failed to follow pre-procedure physician orders to ensure the completion of a procedure. This affected one (#56) of three residents reviewed for completion of medical appointments. The facility census was 71.

Inspectors wroteBased on closed record review, review of hospital documentation, staff interview, and review of facility policy, the facility failed to ensure timely assessment, measurement, and documentation of wound descriptions were completed and further failed to ensure physician ordered treatments and skin impairment interventions for a right heel pressure ulcer were initiated timely and completed as ordered. This affected one (#71) of three residents reviewed for pressure ulcers. The facility census was 71.

Inspectors wroteBased on medical record review, personnel file review, family interview, staff interview, and policy review, the facility failed to ensure a resident who was dependent on tube feeding and ordered nothing by mouth (NPO) was not served food to eat by a staff member. This resulted in actual harm when Resident #34 who was found choking on food after being served a dish of watermelon at the bedside and left alone to consume the watermelon. Subsequently, Resident #34 was sent to the hospital for invasive procedure to dislodge the food from the esophagus. Resident #34 was admitted to the hospital with aspiration pneumonia from choking and aspirating (breathing food into the lungs) on food. This affected one (Resident #34) of three residents reviewed for altered needs for dietary. The facility census was 78.

Inspectors wroteBased on observed, review of facility's temperature log, review of facility policy, and staff interview, the facility failed to ensure all food was stored at appropriate temperatures. This has the potential to affect all residents with the exception of Resident #34 and Resident #19 (two residents identified as not receiving any food from the kitchen). The current census is 78.

Inspectors wroteBased on record review, review of hospital documentation, and staff interview, the facility failed to administer medications as ordered by the physician. This affected one (#34) of four residents reviewed for medication administration. The current census is 78.

Inspectors wroteBased on review of a facility submitted Self-Reported Incident (SRI), resident and staff interview, review of the facility investigation, medical record review and review of the facility policy, the facility failed to ensure residents were free from neglect when Resident #01 was left outside overnight. This affected one (#01) of three residents reviewed for abuse and neglect. The facility census was 73.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to report allegations of neglect timely to the State Survey Agency (SSA). This affected one (#01) of three residents reviewed for abuse and neglect. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure smoking assessments were completed for residents who smoked. This affected one (Resident #01) of three residents reviewed for smoking. The facility census was 73.

Inspectors wroteBased on medical record review, review of facility submitted Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to ensure accurate medical records. This affected two (Resident #01 and #21) of three residents reviewed medical record documentation. The facility census was 73.

Inspectors wroteBased on record review, resident and staff interviews, observations, review of the facility's investigation and incident reports, hospital record review, policy review, and review of an instruction manual, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Actual Harm on 05/15/25 when Resident #01 fell from a Hoyer lift during a transfer sustaining a fractured lumbar vertebral compression fracture. In addition, the facility failed to ensure Resident #61 received adequate supervision and assistance with bathing to prevent the resident from falling and failed to investigate Resident #61's falls which placed the resident at potential risk for more than minimal harm that was not Actual Harm. This affected two (#01 and #61) of three residents reviewed for falls. The facility census was 73.

Inspectors wroteBased on staff interview and review of facility staffing documentation, the facility failed to ensure a registered nurse (RN) worked for eight hours daily in the facility. This affected all 77 residents residing in the facility on 06/03/25.

Inspectors wroteBased on medical record review, resident interview, staff interview, observation, and review of facility policy, the facility failed to ensure timely incontinence care was provided and perineal care was provided to promote cleanliness. This affected one (#1) of three residents reviewed for the provision of incontinence care in a facility census of 73.

Inspectors wroteBased on closed medical record review, family interview, staff interview, review of staff statements and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) assistance for Resident #100, who was found unresponsive, absent of breaths, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when Licensed Practical Nurse (LPN) #300 responded to Resident #100's room and assessed the resident to be unresponsive and absent of vital signs. [...]

Inspectors wroteBased on medical record review, staff interview, Carryout Attendant (CA) interview, review of facility video surveillance, and review of the facility policy, the facility failed to provide adequate supervision to ensure Resident #53, who had a diagnosis of schizoaffective disorder (a severe mental illness characterized by symptoms of schizophrenia, such as hallucinations and delusions, and a mood disorder), was assessed to be at risk for elopement, had a history of numerous elopement attempts, had a WanderGuard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to her wheelchair, and who was on 15-minute staff supervision checks, did not elope from the facility without staff knowledge. [...]

Inspectors wroteBased on medical record review, staff interview, review of radiology results, radiology vendor interview, review of electronic mail (e-mail) correspondence, review of hospital records and review of the facility policy, the facility failed to ensure X-ray results were received timely to prevent a delay in treatment. This resulted in Actual Harm to Resident #49 on 05/05/25 at approximately 9:58 A.M. when the radiology vendor faxed stat (immediate) X-ray results to the facility, showing the resident had a right hip fracture, the facility did not receive the results, and then failed to follow up with the radiology vendor to verify the outcome until 05/06/25. [...]

Inspectors wroteBased on observation, staff interview, resident interview, medical record review, review of personnel job descriptions, review of self-reported incidents (SRIs) and review of facility policies, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 79 residents residing in the facility. The facility census was 79.

Inspectors wroteBased on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure call lights were within residents' reach. This affected two (#3 and #11) of three residents reviewed for call lights. Additionally, the facility failed to ensure a sufficient supply of clean linens were available for resident use. This affected Resident #41 with the potential to affect all residents, except for 14 (#6, #23, #28, #35, #36, #38, #44, #45, #50, #51, #52, #60, #71, and #76) residents identified as residing on the secured memory care unit. The facility census was 79.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure the environment was maintained in good repair. This had the potential to affect all residents, except 14 (#6, #23, #28, #35, #36, #38, #44, #45, #50, #51, #52, #60, #71, and #76) residents who resided on the secured memory care unit. The facility census was 79.

Inspectors wroteBased on closed medical record review, staff interview, and review of facility policy the facility failed to notify the provider of a missed dose of total parenteral nutrition (TPN - intravenous delivery of nutrition) to a resident that required nutritional needs to be met by methods other than oral intake. This affected one (#101) of one resident reviewed for notification of change. The facility census was 79.

Inspectors wroteBased on observation, staff interview, resident interview and review of the facility policy, the facility failed to ensure residents had working lights in their rooms. This affected two residents (#3 and #11) of three residents reviewed for functional lights. The facility census was 79.

Inspectors wrote2. Review of the medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, and hypertension with congestive heart failure. Review of the annual MDS assessment, dated [DATE], revealed Resident #100 had mild cognitive impairment. Further review of the MDS assessments revealed on [DATE], an assessment was completed for Resident #100's death in the facility. Review of a physician order dated [DATE] revealed Resident #100 had an order for Full Code status. Review of the care plan initiated [DATE] revealed Resident #100 had a Full Code status. Interventions included to call 911 for transport to a local hospital, initiate Cardiopulmonary Resuscitation (CPR) in the absence of a pulse, notify family and physician of changes in condition. [...]

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to investigate an incident of resident elopement. This affected one (#53) of three residents reviewed for elopement. The facility census was 79.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received showers as scheduled and further failed to ensure dependent residents received assistance with all activities of daily living (ADLs) timely. This affected three (#39, #45, and #53) of five residents reviewed for ADLs. The facility census was 79.

Inspectors wroteBased on resident interview, staff interview, observation, review of the medical record and review of facility policy, the facility failed to ensure timely incontinence care. This affected one (#1) of three residents reviewed for incontinence care. The facility census was 79.

Inspectors wroteBased on closed medical record review, staff interview and review of the facility policy, the facility failed to ensure total parenteral nutrition (TPN - intravenous nutrition) was administered per physician orders. This affected one (#101) of two residents review for TPN. The facility identified two (#101 and #102) residents who required TPN administration for nutritional support. The facility census was 79.

Inspectors wrote2. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included acute chronic systolic (congestive) heart failure, malignant neoplasm of prostate, cocaine use, major depressive disorder, and nonrheumatic aortic stenosis. Review of the MDS assessment, dated [DATE], revealed the resident was moderately cognitively impaired and required supervision assistance with toileting, shower/bathes, upper and body lower dressing, applying footwear, and personal hygiene. Review of a nursing progress note, dated [DATE] at 9:56 A.M., revealed Resident #49 complained of right hip pain when he moved. Resident #49 rated the pain as a 10 on a zero to 10 pain scale. The physician was notified and received an X-ray order for the right hip. An X-ray was completed. [...]

Inspectors wroteBased on medical record review, resident interview and staff interview, the facility failed to ensure adequate services were available to treat substance use disorders. This affected three (#49, #43, and #33) of three residents reviewed for substance use. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure insulin medications were administered per physician orders. This affected one resident (#27) of three residents reviewed for medication administration. The facility census was 79.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, resident interview, staff interview, review of facility self-reported incident, and review of the facility investigation report, the facility failed to ensure the safety and psychosocial health of a dependent resident. This resulted in actual harm when Resident #46 experienced sexual abuse while receiving a shower from facility staff. This deficient practice affected one (#46) of three residents reviewed for physical abuse. The facility census was 73.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, resident interview, staff interview, review of a self-reported incident, review of the facility investigation, review of staff schedules, an employee personnel file and training log, the facility staff failed to report suspected sexual abuse timely. This deficient practice affected one (#46) of three residents reviewed for physical abuse. The facility census was 73.

Inspectors wroteBased on resident interview, staff interview, and record review the facility failed to ensure a dependent resident received timely incontinence care. This affected one (Resident #46) with the ability to affect the 48 incontinent residents identified by the facility. The facility census was 73.

Inspectors wroteBased on personnel record review, staff interview, and policy review, the facility failed to ensure employed State Tested Nursing Aides (STNA) were properly licensed with the State of Ohio. This had the ability to affect all 77 residents. The facility census was 77.

Inspectors wroteBased on review of the medical record, staff interview, and review of the facility policy, the facility failed to conduct timely fall reviews for three residents (#5, #70 and #71) and further failed to complete a quarterly fall assessment for a resident identified as a high fall risk (Resident #62). This affected four (#5, #70, #62 and #71) of four residents reviewed for falls. The facility census was 68.

Inspectors wroteBased on medical record review, facility policy review, facility investigation, and staff interviews, the facility failed to report a resident elopement to the state agency as required. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68.

Inspectors wroteBased on staff interviews, review of the medical record, and review of the facility investigation, the facility failed to ensure a complete and thorough investigation was conducted for a resident elopement. This affected one resident (Resident #3) of three residents reviewed for wandering and elopement risk. The facility census was 68.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to timely assist dependent residents with showers. This affected three of three residents (#8, #57, #22) reviewed for showers. The facility census was 68.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to complete weekly skin assessments per physician order. This affected two residents (#8, #57) of three residents reviewed for skin assessments. The facility census was 68.

Inspectors wroteBased on observation, staff interview, record review, review of facility policy, and review of manufacturer's instruction for use the facility failed to ensure insulin pens were primed prior to administration resulting in a significant medication error. This affected two residents (Resident #42 and #38) of three residents observed for insulin administration. The facility census was 68.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure the timely physician notification of laboratory results affecting one Resident (#57) of three residents reviewed for physician laboratory services. The facility census was 68.

Inspectors wroteBased on observation, staff interview, and review of the planned menu, the facility failed to ensure vegetables were provided per the planned menu. This affected seven (#15, #16, #17, #18, #19, #20, and #71) of 66 residents who received the noon meal. The facility identified two (#35 and #69) residents received nothing from the kitchen. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policies, the facility failed to ensure fall investigations were completed, and failed to ensure post-fall assessments were completed. This affected two (#12 and #14) of three residents reviewed for falls. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure antibiotics were prescribed appropriately to treat Urinary Tract Infections (UTI). This affected one (#12) of two residents reviewed for treatment of UTIs. The facility census was 68.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to use appropriate hand hygiene while preparing and serving food items. This directly affected all residents with the exception of two (#5 and #43) residents who were identified to receive no food from the kitchen. The facility census was 67.

Inspectors wroteBased on review of previous survey results, medical record review, and staff interview, the facility failed to established an effective Quality Assessment and Assurance committee to identify quality deficiencies and take action to ensure these deficiencies were properly reviewed and acted upon. This had the potential to affect all 67 residents in the facility. The facility census was 67.

Inspectors wroteBased on review of Quality Assessment and Assurance (QAA) committee sign-in sheets and staff interview, the facility failed to ensure all required members of the QAA committee attended meetings at least quarterly. This had the potential to affect all 67 residents residing in the facility. The facility census was 67.

Inspectors wroteBased on observation, resident and staff interview, and review of the facility policy, the facility failed to maintain a homelike environment for four (#7, #34, #51, and #54) of four residents reviewed for environmental concerns. The facility census was 67.

Inspectors wroteBased on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure residents received timely and adequate assistance with activities of daily living tasks. This affected four (#10, #19, #26, and #43) of five residents reviewed for activities of daily living. The facility census was 67.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure resident medications were properly labeled and stored. This affected five (#2, #32, #35, #41, and #52) of 15 residents reviewed for medication storage in a facility census of 67.

Inspectors wroteBased on observation, staff interview, and review of the menu, spreadsheet, and facility recipe, the facility failed to ensure pureed meals were prepared according to the recipe. This affected four (#25, #42, #44, and #62) of four residents ordered a pureed texture diet. The facility census was 67.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure pureed foods were served at an appropriate texture and failed to ensure residents received diets at an appropriate texture to meet their needs. This affected four (#25, #42, #44, and #62) of four residents ordered a a pureed texture diet and one (#11) of two residents reviewed for nutrition. The facility census was 67.

Inspectors wroteBased on observation, staff interview, medical record review, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure infection control procedures were followed regarding enhanced barrier precautions (EBP) and failed to ensure urinary catheter drainage bags were maintained in a manor to prevent infection. This affected eight (#7, #11, #16, #25, #56, #65, #171, and #220) of eight residents reviewed for infection control. The facility census was 67.

Inspectors wroteBased on medical record review, review of resident fund account documentation, and staff interview, the facility failed to provide notification of a spend down when residents reached $200.00 less than their maximum Supplemental Security Income (SSI) benefit. This affected three (#18, #13, and #28) of five residents reviewed for resident funds in a facility census of 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two (#7 and #56) of three residents reviewed for urinary catheters. The facility census was 67.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide resident-centered activity opportunities. This affected one (#35) of 24 residents reviewed for the provision of activities in a facility census of 67.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure ancillary services were provided to residents with hearing impairments. This affected one (#170) of one residents reviewed for hearing. The facility census was 67.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of the facility wound treatment policy, the facility failed to ensure resident pressure ulcer treatments were applied in accordance with physician orders. This affected two (#25 and #65) of two sampled residents reviewed for pressure ulcer treatment in a facility census of 67.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents received sufficient services to promote incontinence needs were provided suprapubic catheter care and maintenance as needed. This affected two (#11 and #65) of five sampled residents reviewed for incontinence and urinary bladder needs in a facility census of 67.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure nutrition assessments were completed upon admission and quarterly. This affected one (#22) of two residents reviewed for nutrition. The facility census was 67.

Inspectors wroteBased on observation, medical record review, staff interview, personnel file review, and memory care unit criteria documentation review, the facility failed to ensure residents with diagnosis of dementia received appropriate care and services and staff working with those resident were provided sufficient education to ensure those care and services needs were met to ensure the residents maintained their highest practicable physical, mental, and psychosocial well-being. This affected one (#35) of one residents reviewed for dementia related behavioral services in a facility census of 67.

Inspectors wroteBased on review of the pharmacy recommendations, review of the medical record, and staff interview, the facility failed to ensure laboratory tests were completed per pharmacist recommendations or physician orders. This affected three (#7, #10, and #35) of five residents reviewed for unnecessary medications. The facility census was 67.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide ongoing rehabilitation services or restorative services to address range of motion and contracture prevention. This affected one (#43) of one residents reviewed for rehabilitation and range of motion in a facility census of 67.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, and review of a facility policy, the facility failed to ensure each resident's electronic medical record was complete and accurate. This affected two (#19 and #220) of 19 resident records reviewed. The facility census was 67.

Inspectors wroteBased on observation, record review, staff interview, hospice staff interview, and review of the facility policy, the facility failed to ensure communication and coordination of care occurred between the facility and the hospice provider. This affected one (#65) of one residents reviewed for hospice care. The facility census was 67.

Inspectors wroteBased on observations, staff interviews, review of product information, and review of the facility policy, the facility failed to ensure food was cooked to the proper temperature before serving to residents. This affected all residents in the facility except 14 residents identified by the facility who did not consume the fish ( #13, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30). The facility census was 68.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents were safely transferred using a mechanical lift. This affected one (#17) of one resident reviewed for transfers. The facility census was 68.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure the residents received timely incontinence care. This affected two (#13 and #14) of three residents observed for incontinence care. The facility census was 68.

Inspectors wroteBased on record review, staff and pharmacist interview, observation, review of the manufacturer instructions, and review of the facility policy, the facility failed to procure an insulin pen needle to properly administer insulin via an insulin pen to the resident according to manufacturer instructions. This affected two (#15 and #16) of two residents reviewed for insulin administration.

Inspectors wroteBased on observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call lights were answered in a timely manner. This affected one (Resident #05) of one resident reviewed for call lights. The facility census was 67.

Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received assistance with bathing as scheduled. This affected one (Resident #05) of three residents reviewed for activities of daily living. The facility census was 67.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure corridor floor tile was maintained free of damage, debris, heavy stains and extensive tracking. This affected 62 residents residing in the north and south nursing units, excluding three residents (#20, #21, #22) residing in the dementia unit. Facility census 65.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents received baths and/or showers as scheduled. This affected two (Residents #3 and #19) of five sampled residents reviewed activities of daily living. The census was 65.

Inspectors wroteBased on observation, staff interview, and review of a kitchen cleaning schedule, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all 57 residents identified by the facility as receiving food from the kitchen. The facility census was 57.

Inspectors wroteBased on observation, resident and staff interview, review of pest control services reports, and review of a facility policy, the facility failed to maintain an effective pest control program. This had the potential to affect all 57 residents of the facility. The facility census was 57.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This had the potential to affect 18 (#1, #4, #6, #7, #11, #15, #16, #20, #26, #29, #30, #35, #36, #38, #42, #48, #55, and #56) residents identified by the facility as residents who smoke. The facility census was 57.

Inspectors wroteBased on medical record review, observation, resident interview and staff interview, and review of facility policy, the facility failed to ensure residents were provided assistance with nail care and shaving. This affected one (#14) of three residents reviewed for activities of daily living. The facility census was 57.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of information from the National Pressure Injury Advisory Panel (NPIAP) the facility failed to timely implement interventions and treatments to prevent and promote pressure ulcer healing. This resulted in Actual Harm when Resident #283 was admitted to the facility with an open area observed to the left and right buttock, assessed as a partial thickness wound, and preventative treatment was not initiated as ordered. The wound declined and was assessed as an unstageable pressure ulcer five days later and developed a new deep tissue injury to the right heel. In addition, the facility failed to give nutritional supplements to aid in wound healing as ordered for Resident #37 and Resident #49 and had not provided ordered pressure ulcer treatments for Resident #49. [...]

Inspectors wroteBased on observation, staff interview, review of a facility staff roster, review of employee testing logs and forms, review of an employee COVID-19 vaccination status log, review of an employee COVID-19 positivity rates tracking log, review of employee and resident COVID-19 positive test log, review of the Centers for Disease Control and Prevention (CDC) website, and review of a facility COVID-19 policy, the facility failed to ensure employees unvaccinated against COVID-19 were tested for COVID-19 infection at appropriate intervals. This had potential to affect all 83 residents residing in the facility. The census was 83.

Inspectors wroteBased on observation, staff and resident interview, pest control logs, and policy review the facility failed to ensure proper pest control when flies were in the facility. This had the potential to affect all 83 residents who reside in the facility. The facility census was 83.

Inspectors wroteBased on review of resident council minutes and staff and resident interview the facility failed to ensure resident concerns were resolved and/or documented in the resident council meeting minutes. This affected four residents (#19, #22, #53, and #67) who regularly attended the resident council meetings. The facility census was 83.

Inspectors wroteBased on review of the resident council minutes and staff and resident interview the facility failed to ensure resident rights were discussed in monthly resident council meeting. This affected four residents (#19, #22, #53, and #67) who regularly attended the resident council meetings. The facility census was 83.

Inspectors wrote3. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnosis included peripheral vascular disease, anemia, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 10/13/21, revealed the resident was cognitively intact. Review of the Smoking Safety Screen dated 05/24/21 revealed Resident #19 was approved to smoke unsupervised and the facility was store the lighter and cigarettes. Interview on 10/18/21 at 4:07 P.M., with Resident #19 reported she had her cigarettes in her possession and presented them. Resident #19 reported she does not have a lighter however any resident's outside would light it for her. Interview on 10/20/21 at 9:43 A.M., with Resident #19 reported the facility was now making her lock up the cigarettes at the nurses station. 4. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure a clean and sanitary kitchen and sanitary meal distribution. This had the potential to affect 82 residents of 83 residents who receive nutrition from the kitchen. The facility identified one Resident (#7) who received no oral intake. The facility census was 83.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and policy review the facility failed to ensure proper infection control for resident's respiratory devices and urinary catheter. This affected two residents (#23 and #283) of two residents. The census was 83.

Inspectors wroteBased on observation, resident interview, staff interview and policy review the facility failed to ensure dependent resident's call lights and resident rooms were adapted for independence. This affected two residents (#46 and #283) of three reviewed for accommodation of needs. The facility census was 83. Findings Include: 1. Review of Resident #46's medical record revealed an admission date of 01/05/21. Diagnoses included cerebral infarction, cortical blindness, major depressive disorder, and communication deficit. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of 13 indicating Resident #46 was cognitively intact. Resident #46 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #46 displayed no behaviors during the review period. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure a comprehensive resident assessment was completed after a change in condition. This affected one resident (#49) of 19 residents reviewed for potential change in condition. The facility census was 83. Findings Include: Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses include deep vein thrombosis (blood clot) to the left lower extremity, hypertension, diabetes mellitus type II, protein calorie malnutrition, acute kidney failure, dehydration, hypotension, heart failure, depression, dementia, and muscle wasting. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had no cognitive issues, abnormal behaviors or rejection of care. [...]

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to implement a baseline care plan for a resident who had pressure ulcers on admission. This affected one resident (#283) of 19 residents reviewed for care plans. The facility census was 83.

Inspectors wroteBased on record review, resident and staff interview and policy review the facility failed to invite and offer quarterly care plan conferences. This affected two residents (#19 and #23) of two residents reviewed for comprehensive care plan conferences. The facility census was 83.

Inspectors wroteBased on medical record review, resident interview, staff interview and policy review the facility failed to ensure resident blood sugars were monitored according to physician orders. This affected one resident (#36) of one reviewed for blood sugar monitoring of seven residents reviewed for unnecessary medications. The facility census was 83. Findings Include: Review of of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, anxiety disorder, muscle wasting, cognitive communication deficit, and anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #36 was cognitively intact. Resident #36 required limited assistance with transfer and extensive assistance with dressing, toilet use, and personal hygiene. [...]

Inspectors wroteBased on medical record review, observation, and resident and staff interview the facility failed to ensure residents had adequate fluids, of the appropriately ordered texture, available for consumption. This affected one resident (#129) of two residents reviewed for hydration. The facility census was 83.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and policy review the facility failed to ensure medications were received as ordered. This affected two residents (#43 and #55) of 19 reviewed. The facility census was 83.