Edgemere Estates

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 7 residents (Resident #96, Resident #43, Resident #66, Resident #82) reviewed for infection control. The facility failed to ensure the urinary catheter bags for Resident #96, Resident #43, Resident #66, and Resident #82 was anchored and secured to prevent infection. This failure could place residents at risk of infection due to improper care practices. Resident #96 Record review of Resident #96's face sheet dated 06/03/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 of 8 residents (Resident #64) reviewed for ADL care. The facility failed to ensure Resident #64's nails were trimmed and filed on 06/01/2026. This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 3 of 12 residents (Resident#32, #51 and Resident # 84) reviewed for accidents. The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (Resident #32), a syringe in one room(Resident#51 and Resident #84) ,and blood-stained alcohol prep pads in two rooms (Resident #32, #51 and Resident #84). This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster was closed on 06/01/2026. -The facility failed to ensure refuse, including construction debris and organic food waste, was disposed of inside the dumpster and not left exposed in a trash cart on 06/01/2026. These failures could place residents, staff, and visitors at risk of infestation of rodents and insects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 1 (Residents #4) of 4 residents reviewed for abuse. The facility failed to ensure residents were free from physical abuse when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to hit and started cursing when Resident #4 told Resident #2 that he was in the wrong room. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents (Resident #2) reviewed for dementia care. -The facility failed to provide or address the customary routines, preferences, and choices to enhance Resident #2's well-being when he refused care, refused labs, and became physically and verbally aggressive from August 2025 - December 2025. -The facility failed to implement interventions related to behavioral issues related to dementia, when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to strike and was cursing when Resident #4 told Resident #2 that he was in the wrong room. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 (Resident #2) of 4 residents reviewed for unnecessary medications. The facility failed to ensure Resident #2 had behavior monitoring documentation on the Treatment Administration for his prescribed Valproic Acid (an antipsychotic medication), Hydroxyzine (an antianxiety/anticholinergic medication used to treat anxiety) and Trazodone HCL (used to treat insomnia). This failure could put residents at risk of harm from adverse reactions or harmful side effects.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 4 of 11(LVN E, CNA L, CNA G, and Activities Director) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia and Behavior Management. The facility failed to keep copies of documentation of the required annual Dementia and Behavior Management training for LVN E, CNA L, CNA G, and Activities Director before the change of ownership was completed on December 04, 2025. This failure placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 4 of 22 residents (#36, #53, #68 and #70) reviewed for accidents. -The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (resident# 36 and resident#53's room) -The facility failed to properly dispose of blood-stained alcohol prep pads in two rooms (resident#36,#53,#68 and #70 rooms) This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to store frozen vegetables, frozen cookie dough and sausage patties, in a closed box and sealed bag inside the freezer to prevent food contamination and freezer burn. The facility failed to keep a 1-gallon bottle of Worcestershire's sauce free of dry drippings and residues on the bottle. The facility failed to keep the ice machine and its filters clean and free of dust and lint. The facility failed to keep the deep fryer free of food particles, grease accumulation, and burnt oil, and the stove wall next to the fryer was not free of oil splatter and food particles. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 15 rooms from hallway 400. The facility failed to clean food and stains from the floor that looked like smeared fruit. The facility failed to clean the carpets of trash, debris, and food crumbs. The facility failed to clean an alcohol pad with dried blood from the floor. These failures placed residents and staff at risk of living, working, and visiting in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 of 22 residents (Resident #16 and #178). The facility failed to ensure resident call lights were within reach for 2 residents (Resident #16 and #178). This failure placed residents at risk of having their needs unmet when they are unable to contact staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, for 1 of 3 nurse carts checked for medication storage. The facility failed to ensure liquid medication stored in the medication cart in one hall (300 hall) did not have dried drippings on the sides of the bottles. This failure could affect residents that received medications at the facility by placing them at risk of not having prescribed medications and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 3 (Resident #7, Resident #10 and Resident #11 ) of 5 residents reviewed for wounds. The facility failed to provide wound care for Resident #7's arterial wound (arterial ulcers, are painful injuries in your skin caused by poor circulation) of the right second toe. The facility failed to provide wound care for Resident #10's pressure wound to the right second toe. The facility failed to provide wound care for Resident #11's dehiscence wound right forefoot. This failure could affect others by placing them at risk of potential medical complications related to wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 5 residents reviewed for pressure ulcers/wounds. The facility failed to provide wound care for Resident #3's pressure ulcer stage 3 to the left buttock on 02/01/25 and 02/02/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #3) reviewed for baseline care plan. Resident #3 did not have a baseline care plan developed within 48 hours of admission that addressed his services that were being provided. This failure could place newly admitted residents at risk of not receiving the care and services and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 (Resident #3) of 3 residents reviewed for discharges. The facility failed to ensure Resident #3 had a safe discharge when he left AMA to his home. This failure could place residents at risk of inappropriate transfers and diminished continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #3) of 4 reviewed for medication administration. The facility failed to administer on 02/01/25, to Resident #3's medication of Ciprofloxacin HCL oral tablet 500 mg which to given two times a day for infection and was not given in the morning. The facility failed to administer on 02/01/25, to Resident #3's medication of Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg by mouth two times a day for infection and was not given in the morning. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 3 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's was having incontinence care was documented by the facility. This deficient practice could place residents at risk of not receiving needed services although services are stated they are being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. This failure could place residents at risk for falls or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and Resident #7) of 8 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #4 who required mechanical lift transfer. The facility failed to develop a comprehensive person-centered care plan for Resident #7 who no longer required a Hoyer lift transfer and was a 2 person assist transfer. [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies that prohibit and prevent abuse for 1 (Resident #7) of 8 residents reviewed for abuse. The facility failed to implement their abuse policy when they failed to immediately suspend CNA B after Resident #7's RP reported a physical restraint allegation. This failure could place residents at risk of potential continued mistreatment and abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents environment remained as free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 1 (Resident #4 ) of 8 residents reviewed for transfers. The facility failed to ensure Lead CNA placed breaks on the mechanical lift when lifting Resident #4 from her wheelchair and lowering to her bed. This failure could place residents at risk for falls or injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 (Resident #2 and #3) of 6 residents reviewed for vehicle safety. -Maintenance Director failed to ensure Resident #2 and #3 were secured in the vehicle on 06/17/2024, while transporting residents back to the facility from dialysis visit, which resulted in falls with injuries. The noncompliance was identified as PNC. The IJ began on 06/17/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of accidents and potential harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 4 (Resident #5, #9, #10, and #11) of 6 residents observed for oxygen management. -Resident #5, Resident #9, Resident #10, and Resident #11 were on oxygen and did not have oxygen signs posted outside their bedrooms. These failures could place visitors, staff, and others at risk of not knowing oxygen was being used in the room and to not smoke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for 1 (Resident #2) of 6 residents reviewed for call light button placement. -The facility failed to ensure that Resident #2's call light was within her reach. These failures could place residents at risk of not being able to have their needs met.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed for baseline care plans. The facility failed to ensure Resident #1 had a baseline care plan developed and implemented within 48 hours upon admission on [DATE]. The facility failed to ensure Resident #1's baseline care plan addressed the resident as being a high fall risk. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 14 residents reviewed for neglect in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A who was responsible for Resident #1 did not know the process and procedures that were to be followed when a full-code resident was found unresponsive, resulting in the resident not being provided CPR. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 14 residents reviewed for physician's orders for provision of basic life support in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A went to the resident's room and checked him for signs of life but did not know how to respond when she did not find a pulse, and did not immediately start CPR or other life-sustaining measures, resulting in Resident #1's wishes to be resuscitated not being honored. An IJ was identified on [DATE] at 10:25 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents has a right to a dignified existence for 1 resident (Resident #2) out of 14 reviewed for rights to a dignified existence in that: Therapy Staff G told Resident #2 she should be working and not talking, and that tape would be put on her mouth if she continued to talk, leaving Resident #2 feeling embarrassed, and reluctant to talk to anyone while involved in therapy. This failure could result in residents feeling embarrassed, reluctant to talk and reluctant to engage in therapy, affecting their progress in achieving their goals for rehabilitation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for1 (Resident #37) of 21 residents reviewed for an environment free of accident hazards as possible. The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in four of four halls reviewed for condition of handrails. The facility failed to ensure that the handrails throughout the facility did not have the paint worn off them. This failure could put residents at risk of feeling a decreased sense of well-being, and at increased risk for splinters because of the poorly maintained condition of the handrails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a form and manner accessible to residents, resident representatives contact information including telephone numbers for Long Term Care Ombudsman program for residents interviewed in a confidential group meeting. The facility failed to ensure the Ombudsman program information was posted in an area accessible for residents who required the use of wheelchair. This failure placed residents at risk of not being informed about the Ombudsman Program.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and were posted in a place readily accessible to residents, and family members and legal representatives of residents for residents interviewed in a confidential group meeting. The facility failed to have the survey manual readily accessible for the residents to view the survey. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey history.

Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident ' s physician when there was a significant change in a resident ' s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 21 (Resident #283) residents reviewed for change in condition. The facility failed to immediately inform NP/MD of Resident #283 change in condition addressing her behaviors towards wearing her Prevalon boots as orderd by the physician for healing of pressure ulcers. This failure placed Resident #283 at risk of serious decrease in health related to delayed treatment of healing her pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 2 of 6 (Resident #383 and Resident #61 ) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #383's family who complained of Resident #61. [...]

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. The facility failed to implement their abuse policy on reporting to State Office Resident #61's allegation of the Administrator slapping hand when forced out of her room. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. The facility failed to ensure Resident #61's allegation of the Administrator slapping hand when forced out of her room was thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review the facility failed to ensure that assessments accurately reflected residents ' status for 1 (Resident # 30) of 21 residents reviewed for accuracy of assessment. The facility failed to ensure that Resident #30 ' s MDS reflected her refusal to use her C-PAP machine (machine that uses air pressure to help breathing). This failure put residents at risk of poor sleep, increased incidence of sleep apnea (sleep disorder where breathing stops and starts).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #283) of five residents reviewed for treatment to address pressure ulcers. The facility failed to ensure that Resident #283 wore Prevalon boots while in bed as per physician ' s orders. This failure placed Resident #283 at risk of serious decrease in health related to delayed treatment of healing her pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #30) of four residents reviewed for provision of respiratory care. Resident #30 was not assisted in putting on her CPAP mask every night as per physician ' s orders. This failure could result in residents having increased difficulty sleeping, decreased sleep quality, and increased instances of sleep apnea (a sleep disorder where breathing stops and starts).

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 6 medications carts (Hall 200, 300 and 400) reviewed for medication storage and 4 (#283, #51, #29, & #30) of 14 residents reviewed for medication administration. -The facility failed to have physician ' s orders that documented prescribed amount of water for G-Tube flush before and after medication administration for Resident #283. -The facility failed to administer prescribed medications according to physician ' s orders for Resident #30. -The facility failed to administer Nebulizer Medications according to pharmacy policies and procedures for Resident #29. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that irregularities identified by reviews of resident's drug regimens by a licensed pharmacist were reported to the attending physician, the facility's medical director, and director of nursing, and that these reports were acted upon for 1 (Resident #40) of 14 residents whose drug regimens were reviewed. The consulting pharmacist failed to act upon the dispensing pharmacist recommendations to administer prescribed medications according to manufacture specifications. This failure placed residents at risk of not receiving medications according to manufacturer specifications placing them at increased risk of adverse drug effects and decline in their health status.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #65, Resident #24, and Resident #51) of 5 residents reviewed for unnecessary medications. Resident #65 was prescribed Seroquel/quetiapine (an antipsychotic) to treat depression. Resident #51 was prescribed Olanzapine (an antipsychotic) to treat major depression. Resident #24 was prescribed Seroquel/quetiapine (an antipsychotic) to treat restlessness and agitation. This failure put residents at unnecessary risk of side effects from psychotropic medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep 2 bottles of Dessert Sauce stored on a metal rack in the dry storage room free of dried drippings around the lids. -The facility failed to keep a plastic bottle of Baking Soda free of white residual around sides of bottle. -The facility failed to keep a gallon of Vanilla, a gallon of Soy Sauce, a gallon of Worcestershire Sauce, and a gallon of Imitation Maple Syrup Sauce stored on metal storage rack in the dry storage room free of grease build up, white powder residual, and dried dripping on sides of containers. -The facility failed to discard perishable foods stored, in the dry storage area. [...]

Inspectors wroteBased on the observations, interviews, and record review the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1, & #2) of 2 dumpsters reviewed for food safety requirements. -The facility failed to keep one of two plastic lids covered on Front Load Dumpster, making trash placed in dumpster visible. - The facility failed to keep the side metal door cover close on Side Load Dumpster, making trash placed in dumpster visible. This failure could place residents at risk of unsanitary conditions and risk for exposure to germs and diseases carried by insects and rodents.

Inspectors wroteBased on interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 (Resident #61) of 6 reviewed for allegations of abuse. The facility failed to ensure the Administrator followed internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating.

Inspectors wroteBased on interviews and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 3 (Resident #24, Resident #30, and Resident #61) of 21 residents reviewed for accuracy and completeness of clinical records. The facility failed to completely and accurately discontinue order provided to Resident #24 for puree diet. The facility failed to accurately document Resident #61 ' s allegation of a slap on the hand from the Administrator on her medical records. The facility failed to accurately document Resident #30 ' s use of her physician-ordered CPAP machine. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 13 of 14 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative and Infection Preventionist attended QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for three of three hallways and 1 resident (Resident #283) of 14 residents observed for infection control practices during enteral feeding. -The facility failed to store contaminated resident equipment in the designated storage area. -The facility failed to store reusable water containers off the floor in the Therapy Room. -The facility failed to store supply boxes off the floor in storage rooms. -The facility failed to prevent cross contamination was not storing clean and dirty equipment on separate racks.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (Resident #37) of 21 residents reviewed for safe operating condition of patient care equipment and for 1 of 1 kitchen reviewed for safe operating equipment. -The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. -The facility failed to keep the ice machine in safe operating condition. This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 6 (Resident #61) residents reviewed for right to receive written notification. The facility failed to provide Resident #61 a written notice of a room change before the resident was moved. This failure could place all residents at risk of being displaced without notice and/or reason and decrease of quality of life being in a new environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident with urinary incontinence, based on the resident ' s comprehensive assessment, the facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #32) residents reviewed for urinary catheter. The facility failed to ensure Resident #32 ' s subpubic catheter was properly secured. This failure placed residents at risk of possible pain and trauma due to the catheter not being properly secured on the leg.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 of 4 days reviewed and the census was wrongly documented. The facility failed to post the required staffing information for 3/11/24. The facility failed to accurately document the census for 60 days of 73 days reviewed in January 2024, February 2024, and March 1st through the 13th. This failure could place residents, their families, and facilities, and visitors at risk of not having access to correct information regarding staffing data and facility census.