Edgewood Manor Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one sampled resident (Resident #2) out of three sampled residents. On 5/1/26 Resident #3 threw coffee on Resident #2 while he/she was sitting in a chair watching television, resulting in first degree burns to Resident #2's chest. Resident #2 had redness and complained of pain and burning to his/her right upper chest and face area treated with first aid. The facility census was 69 residents. On 5/11/26, the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 5/4/26. All staff received education prior to working their next shift. The deficiency was corrected on 5/4/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent abuse for one sampled resident (Resident #8) out of fourteen sampled residents. On 4/2/26, Resident #7 attacked Resident #8 while Resident #8 was in bed, resulting in superficial scratches on Resident #8's face, arm, abdomen and back. The facility census was 72 residents. Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which could include staff-to-resident abuse and certain resident-to-resident altercations. Purposely included beating, striking, wounding or injuring any resident or in any manner mistreating or maltreating a resident in a brutal or inhumane manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the guardian/responsible party for one sampled resident (Resident #4) of 14 sampled residents. On 3/24/26 Resident #4 had a fall was transported and admitted to the hospital. The legal guardian was not notified until 3/25/26. The facility census was 72 residents. Review of the facility's Incidents and Accidents Policy dated 5/18/24 showed:-The resident's family or representative should be notified of the incident/accident and any orders obtained or if the resident was to be transported to the hospital. -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, orders obtained and all follow-up interventions. 1. Review of Resident #4's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate, necessary behavioral health services for one sampled resident (Resident #7) out of 14 sampled residents. On 04/2/26, facility staff failed to implement the resident's care plan for behavioral interventions related to environment. The facility census was 72 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep two sampled residents (Resident #1 and Resident #2) free from misappropriation and exploitation. On 3/31/25, Resident #1 gave the Social Worker Director (SSD) 400 dollars from his/her spend down Trust account to purchase a recliner chair, but no chair was purchase. On 11/20/25, Resident #2 gave Certified Nursing Assistant (CNA) A 1,000 dollars to pay his/her rent and later, around 11/24/25 Resident #2 gave his/her debit card to CNA A and Housekeeper (HK) B an additional 200 dollars to pay the electric bill and take a trip. On 11/26/25 Resident #2 gave Activity Assistant A 280 dollars to pay a car payment out of three sampled residents. The facility census was 80 residents. The Administrator was notified on 1/20/26 of Past Non-Compliance which occurred on 3/31/25, 11/20/25 and 11/24/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were provided when the physician ordered diagnostic testing that was not completed for three sampled residents (Resident #5, Resident #8, and Resident #10) out of 11 sampled residents. The facility census was 79 residents. Review of the facility's policy titled Diagnostic Testing Services Policy dated 6/26/24 showed:-The facility would provide the appropriate diagnostic services requires to maintain the overall health of its residents and in accordance with State and Federal guidelines.-The facility would maintain a schedule of diagnostic tests in accordance with the physician's orders.-Documentation of diagnostic tests, the results, and date/time Physician notification would be maintained in the resident's electronic health record.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment by not sweeping and mopping the floors in the dining room, cleaning the carpet in the common area, cleaning resident rooms and bathrooms and ensuring urine odors were not present throughout the facility. The facility census was 79 residents. Review of the facility Housekeeping - Deep Cleaning Policy dated 6/29/23 showed: -Purpose was to ensure all rooms are clean. -Deep cleaning was to be completed as scheduled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident was free from physical abuse when on 5/29/25 Resident #2 touched Resident #1 on his/her shoulder and struck Resident #1 on the buttocks twice, causing Resident #1 to feel violated and pain to his/her buttocks out of 12 sampled residents. The facility census was 79 residents. On 5/7/25 the Administrator was notified of the failure and immediately began an investigation, the residents were separated to ensure safety and law enforcement was contacted. Upon completion of the investigation it was determined the interaction was considered abuse. Training was completed immediately for 100% of all staff on abuse and neglect prior to being allowed to work and completed by 5/30/25. Supervision was increased and Resident #2 was set for alcohol rehabilitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from verbal and physical abuse by two staff members, Licensed Practical Nurse A and Certified Nursing Assistant (CNA) A. Multiple facility staff observed the interaction and did not intervene. LPN A and CNA A worked the entire shift after the abuse incident. The facility had 78 residents. The Administrator was notified on 3/20/25 at 1:13 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 3/12/25. The facility started their investigation on 3/13/25 and suspended LPN A and CNA A and they were terminated on 3/14/25. The facility in-serviced staff before the start of their next shift. The IJ was corrected on 3/14/25. Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report abuse for one sampled resident (Resident #1). Facility staff Licensed Practical Nurse (LPN) A, Certified Nursing Assistant (CNA) A, CNA B, CNA C, CNA D, and CNA E all watched abuse and did not report. The facility census was 78 residents. On 3/20/25, the Administrator was notified of the past non-compliance which occurred on 3/12/25. Facility staff were educated on reporting abuse requirements. The deficiency was corrected on 3/14/25. Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/24, showed: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to educate staff on how to de-escalate one sampled resident (Resident #1) with known intellectual and mental health needs per facility policy and the resident's care plan. This effected one out of three sampled residents. The facility census was 78 residents. Review of the facility's policy titled Behavioral Emergency Policy, dated 6/26/24, showed: -The purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to correctly care for the resident in a behavioral crisis, and to ensure that the resident was not being coerced, punished, or disciplined for staff convenience. -Non-physical interventions were the first choice as an intervention unless safety issues demanded immediate physical intervention. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Federal, State and Local Laws to ensure the facility van was licensed legally and proper maintenance was performed to ensure a safe and legal transport for all residents. This failure has the potential to affect all residents in need of transport to and from the facility. The facility census was 77 residents. 1. Review of the facility van service invoice dated [DATE] showed the facility van had brakes serviced and six new tires. Review of facility monthly credit card approval sheet dated [DATE] through [DATE] showed gas for the van on: -[DATE] for $30.75. -[DATE] for $89.27. -[DATE] for $75.03. -[DATE] for $78.62. -[DATE] for $74.74. -[DATE] for $83.20. -[DATE] for $63.26. Review of email dated [DATE] at 4:28 P.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety when on 6/19/24 Agency Certified Nursing Assistant (CNA) E transferred one sampled resident (Residnet #17) identified as a fall risk, by himself/herself that caused a fall which resulted in a closed right sided tibial fracture (a tibial fracture occurs along the length of the bone, below the knee and above the ankle), and failed to complete a fall investigation for the fall, out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled Safe Resident Handling Transfers Policy, revised 5/14/24, showed: -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were locked when staff was not in sight of the cart, failed to ensure medication carts were clean and did not contain other non medical objects, failed to ensure the medication refrigerator's temperature was within temperature range by not checking it daily, failed to ensure nursing staff was counting narcotics at the beginning and end of each shift for three sampled residents, (Resident #61, #42, and #325) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, Medication Storage Policy, dated 5/18/24 showed: -All drugs and biologicals would have been stored in locked compartments under proper temperature controls. -During a medication pass, medications must be under the direct observation of the person administering medications or locked. [...]

Inspectors wroteBased on observation and interview the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to safeguard against foreign material possibly getting into food and/or beverages; failed to keep trash dumpsters lidded; failed to consistently measure and document hot food temperatures at the oven and/or stove, or steam table to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; failed to store foodstuffs within acceptable temperature parameters; [...]

Inspectors wrote2. Review of the facility's policy titled Tuberculosis Testing dated 6/29/23 showed new employees would receive a two-step Tuberculin Skin Test (TST-used to screen for TB). Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 7/16/24. -Employee B was hired on 6/25/24. -Employee C was hired on 5/29/24. -Employee D was hired on 8/27/24. -Employee E was hired on 6/25/24. -Employee G was hired on 4/17/24. -Employee H was hired on 8/6/24. -Employee J was hired on 7/2/24. Review of the above employees' employee files showed employees A, B, C, D, E, G, H, and J did not have any TSTs completed. During an interview on 9/24/24 at 3:46 P.M., the Human Resources Director said: -He/She started working at the facility at the end of July 2024. -He/She asked the Director of Nursing (DON) to make sure the employee TSTs were completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as an Infection Preventionist (IP) for the facility's Infection Prevention control program. The facility census was 74 residents. The certifications were requested for all employees who were certified in the IP program and were not received at the time of exit. 1. Review of the Centers for Disease Control (CDC) online IP course showed: -The Minimum Data Set (a federally mandated assessment tool completed by facility staff for care planning) Coordinator had completed 15 of the 26 modules for the CDC IP course. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 9:32 A.M. the MDS Coordinator said: -He/She had started the IP course a couple of years ago. -He/She had not finished the IP course. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment including, but not limited to, unbroken furniture and/or window treatments, clean and comfortable sleeping conditions, and a physical layout of the facility that maximized people with disabilities' independence, met The Americans with Disabilities Act (ADA) requirements, and did not pose a safety risk and/or tripping hazards. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in at least four locations throughout the building. This facility had a census of 74 residents with a licensed capacity of 91 residents at the time of the survey. 1. Observation on 9/24/24 at 11:48 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three sampled residents (Residents #33, #73, and #40) out of 19 sampled residents. The facility census was 74 residents. Review of the Facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy dated 5/14/2024 showed: -Any resident transferred or discharged under a Facility-Initiated Transfer or discharge the Facility must: --Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notification to a resident or resident representative upon transfer or discharge for three residents (Resident #40, #33, and #14) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Bed Hold Policy, date 11/6/23, showed: -When a resident was admitted to the facility, they received a copy of the bed hold policy from the admission Packet. -When a resident was discharged to the hospital or went on therapeutic leave, the facility provided a a copy of the Bed Hold Policy to the resident or resident representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess the resident's dental status for two sampled residents (Resident #33 and #51), and failed to accurately assess and implement strategies for unintended weight gain and loss for one sampled resident (Resident #19) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0, Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed: -The purpose of the policy was to ensure the MDS was completed accurately. -The dental health section of the MDS was to be completed by nursing staff. -The dental health section of the MDS was to be used to document any dental problems. -Section K (swallowing/nutrition status): [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for four sampled residents (Residents #33, #54, #20 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 6/26/24 showed: -The facility staff would develop and implement a comprehensive, person-centered care plan for each resident to meet the resident's needs. -The care plan would include resident-specific interventions. 1. Review of Resident #33's baseline care plan dated 2/5/21 did not include anything about the resident's teeth. Review of the resident's dental progress note dated 2/13/23 showed: -The resident was interested in dentures. -Four teeth were removed. Review of the resident's dental progress note dated 2/16/23 showed: [...]

Inspectors wrote2. Review of Resident #33's quarterly MDS dated [DATE] showed the resident had not fallen since admission or prior assessment, whichever was more recent. Review of the resident's health status note dated 4/7/24 showed the resident was sent to the hospital emergency department related to his/her altered mental status after a fall. Review of the resident's discharge assessment dated [DATE] showed the resident had two or more non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's discharge assessment dated [DATE] showed the resident had one non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's quarterly MDS dated [DATE] showed the resident had one non-injury fall since admission or prior assessment, whichever was more recent. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA). The facility census was 74 residents. Review of the facility Nursing Assistant Training Program Policy dated 5/18/24 showed: -Each nursing assistant shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. -It is the responsibility of the employee to attend/complete mandatory in-service training's to maintain employment status with the facility. -A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. -Some of the minimum training includes: --Dementia management and care of the cognitively impaired. --Abuse, neglect, and exploitation prevention. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing was posted correctly including the total number and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Nursing Assistants (CNA's), and Certified Medication Technicians (CMT's) directly responsible for resident care per shift which could have the potential to affect all residents, staff, and visitors of the facility. The facility census was 74 residents. Requested the facility policy for daily posted staffing and did not receive it. 1. Review of the Facility assessment dated [DATE] showed nursing services required daily was: -1 Director of Nursing (DON) full time days. -4 LPN's. -4 CMT's. -10 CNA's. Observation on 9/23/24 at 10:10 A.M., of the glass case bulletin board in the common area near the 600-hall showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Residents #14 and #49) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 74 residents. Review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff for care planning) was accurate for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled MDS 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed: -Section L is used to document any dental problems. -Section L was to be completed by nursing staff. -The MDS defined the dental health of the resident and included an assessment of mouth and facial pain. -The focus of section L was the relationship between poor oral health, the quality of life, and the nutritional status of the resident. -MDS's must be kept current and up to date. 1. Review of Resident #17's clinical admission assessment, dated 4/3/24 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess a resident who experienced a significant change in status for one sampled resident (Resident #33) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Significant Change dated 11/6/23 showed: -The facility staff would identify within 14 days a significant change in two or more areas of decline or improvement in the resident's physical or mental condition. -If the resident showed a decline or improvement in two or more areas a significant change assessment would be completed within 14 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly administer medications by not having a physician's order stating the resident was able to self administer medications , failed to administer medications within the allotted time frame, and failed to ensure prescribed medications were available for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, General Medication Administration Process dated 6/26/24 showed: -Keep medication cart stocked with adequate supplies. -Ensure medications were administration were followed; right time. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. -Observe resident consumption of medication. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow physician's orders for obtaining Prothrombin Time (PT: a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder) and International Normalized Ratio (INR: calculated from a PT result and is used to monitor how well the blood-thinning medication is working to prevent blood clots) labs for one sampled resident (Resident #17) on Coumadin (an anticoagulant) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled High Risk Medications Anticoagulants Policy, revised 6/26/24, showed: -Routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulation medication. -Results shall be communicated to the physician in a timely manner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide toenail care or an appointment with a podiatrist for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. A podiatry policy was requested and not provided. 1. Review of Resident #17's Face Sheet showed the resident was admitted to the facility with the following diagnoses: -Morbid obesity. -Dysfunction of lower extremity. Review of the resident's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/11/24 showed the resident: -Was cognitively intact. -Required maximal/substantial assistance with personal hygiene. During an interview on 9/23/24 at 1:22 P.M. the resident said: -He/she had requested to see a podiatrist to care for his/her toenails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure communication between the facility and dialysis (a mechanical way to filter the blood and remove waste when the kidneys stop functioning) treatment center was maintained and ongoing to ensure the continuum of care and failed to maintain and implement post dialysis assessment orders to ensure safety for one sampled resident (Resident # 38) out of 19 sampled residents. The facility census was 74 residents. A dialysis policy was requested but not received. 1. Review of Resident #38's Care Plan dated 11/15/22 showed the resident: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician(s) for two sampled residents (Resident #19 and #45) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Medication Regimen Review Policy, dated 6/26/24, showed: -Each resident was reviewed at least once a month by a licensed pharmacist. -The MRR was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. -Review of the medical record was to prevent, identify, and resolve medication-related problems, medications errors and other recommendations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services to two sampled residents (Resident #33 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Dental Services dated as revised on 6/26/24 showed: -The dental needs of each resident were identified through the physical assessment and Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessment process and were addressed in each resident's plan of care. -The oral/dental status of the resident would be documented according to assessment findings. -Oral care and denture care would be provided for identified needs and as part of the resident's plan of care. -Referrals to a dental provider were to be made as appropriate. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visits and communication with hospice staff, and failed to obtain pertinent documentation of the delivery of hospice care services for one sampled resident (Resident #42) out 19 sampled residents. The facility census was 74 residents. 1. Review of Resident #42's admission Record showed he/she was admitted on [DATE] and admitted to hospice on 9/11/24 with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss) 4/16/24. -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) 4/16/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received or were provided education for the pneumococcal (vaccine that protects against the bacteria that causes pneumonia) vaccinations for two sampled residents (Resident #24 and #325) out of five residents sampled for vaccines. The facility census was 74 residents. Review of the facility's policy, Infection Prevention and Control Program, dated 5/7/24 showed: -Residents should have been offered the pneumococcal vaccines recommended by the Centers for Disease Control upon admission, unless contraindicated or had received the vaccinations elsewhere. -Education should have been provided to the residents and or their representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. -Residents would have had the opportunity to refuse immunizations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Residents #24 and #325) out of five residents sampled for vaccines were offered the Coronavirus Disease ((COVID-19) is an infectious disease caused by a virus that causes symptoms of a respiratory illness) vaccine. The facility census was 74 residents. Review of the facility's policy titled COVID-19 Vaccine: Educate and Offer dated 6/26/24 showed: -All residents would be offered the COVID-19 vaccine unless the immunization was medically contraindicated, or the resident had already been vaccinated. -If the resident already received the COVID-19 vaccine, the facility would ask for documentation of the vaccination. -The facility would provide a copy of the package insert for the COVID-19 vaccine being offered. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of approximately $1100.00 cash, taken from a wallet in a safe, which belonged to one sampled resident (Resident #1) out of seven sampled residents. The facility census was 55 residents. On 8/23/24, the facility Administration was notified of the past noncompliance which occurred on 8/1/24. Facility staff were educated on abuse and neglect policy, resident funds policy, resident rights policy and resident trusts policy. The resident's money was returned to him/her. The locks on the safe was changed and only necessary personal have access to the new code. The deficiency was corrected on 8/9/24. Review of the facility's Resident Rights policy, revised on 7/5/23 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to preserve one sampled resident's (Resident #3) dignity when agency Certified Nurses Aide (CNA) B slapped the resident's hand and made inappropriate comments to the resident while he/she provided incontinence care out of seven sampled residents. The facility census was 77 residents. On 4/18/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 4/4/24. The facility administration had all staff including agency staff in-serviced on abuse and neglect, customer services, resident rights and dignity. The deficiency was corrected on 4/5/24. Review of the facility's policy for Resident's Rights dated 6/29/23 showed: -Every resident had the right to be treated with dignity and respect. -All staff should speak to all residents with dignity and respect. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety and protective oversight for one sampled resident (Resident #5) who left the faciity on 2/15/24 around 5:02 P.M., without the knowledge of the facility staff and was gone overnight from the facility out of 10 sampled residents. The facility resident census of 62 residents. On 2/27/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 2/15/24. The facility administration was notified on 2/16/24 of the resident's elopement and facility investigation of the resident elopement immediately begun on 2/16/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #3) remained free from abuse. On 12/20/23 Resident #2 struck Resident #3 on top of his/her head with his/her fist causing Resident #3 to complain of a headache, a knot on top of his/her head, neck pain and was sent out to the emergency room (ER) for treatment out of four sampled residents. The facility census was 62 residents. Review of the facility Abuse and Neglect Policy dated 1/5/23 showed: -Purpose: --To outline procedures for reporting and investigating complaints of abuse and to define terms of types of abuse. --To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Physical abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services for one sampled resident (Resident #2) who had refused his/her psychoactive medications on a consistent basis and was experiencing a change in his/her mental status. On 12/20/23 Resident #2 struck Resident #3 on top of his/her head with his/her fist causing Resident #3 to complain of a headache, a knot on top of his/her head, neck pain and was transfer to the emergency room for treatment out of four sampled residents. The facility census was 62 residents. Review of the facility Behavioral Emergency Policy dated 1/5/23 showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to refrigerate opened condiment containers; to prevent grease build-up on the inner range hood vent; to properly thaw potentially hazardous raw meat and to maintain the meat in a safe temperature zone, and to date opened, shelved, out-of-box food items. This deficient practice of not handling foods appropriately could potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partook of the meals prepared by the dietary staff. The facility census was 66 residents at the time of the survey. 1. Observations on 2/5/23 between 7:03 A.M. and 8:18 A.M. in the kitchen, showed the following: -At 7:03 A.M., there was no dietary staff in the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide notice to the resident and/or the resident's representative in writing of the residents transfer to an acute care hospital for two sampled residents (Resident #23 and #26), and to provide a notice of facility-initiated transfers and discharges within 30 days of discharge and the location to which the resident was discharged to the Office of the State Long Term Care (LTC) Ombudsman for one sampled resident (Resident #68) who was transferred on an emergency basis to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, revised 7/12/22 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had a Pre-admission Screening/Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) level II when the DA-124 (PASRR) Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a level II PASRR screening was required) showed that the resident had a qualifying psychiatric condition as required, for three sampled residents (Resident #15, #23, and #60) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy entitled PASRR Assessments and DA 124 A&B dated 4/16/2017 and revised 7/9/2021 showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop activity care plans that were comprehensive, individualized and represented the resident's current interests and needs for three sampled residents (Resident # 64, #58, and #61) who were dependent upon staff to meet their activity needs out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Comprehensive Care Plans and Baseline Care Plans policy and procedure, revised 1/19/22 showed: -The facility must develop a comprehensive care plan within 14 days of admission for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. [...]

Inspectors wrote2. Record review of Resident #60's annual MDS dated [DATE] showed he/she was cognitively intact. During an interview on 2/5/23 at 7:11 A.M. the resident said: -He/she was not invited to his/her care plan meetings. -He/she would like the facility to include him/her in his/her care plan meetings. Record review of the resident's medical record on 2/7/23 showed no information regarding his/her care plan meetings. Based on interview and record review, the facility failed to the extent practicable, to include residents and/or their representatives in the care planning process and to conduct care plan conferences to include resident/resident representative participation for three sampled residents (Residents Resident #61, #60 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities for three sampled residents (Resident #61, #64 and #58) out of 17 sampled residents; and to provide daily activities for the residents who would like to participate in scheduled activities. The facility census was 66 residents. Record review of the facility's Activities policy revised 2/26/21 showed: -All residents in the facility were provided an ongoing program designed to meet, in accordance of their comprehensive assessment, their interests and their physical, mental and psycho-social well-being. -If a resident required more intensive interventions for activities, one on one activities would be provided based on their specific needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative services were provided to maintain, improve, or prevent decline in Range of Motion (ROM the range on which a joint can move) for three sampled residents (Resident #61, #2 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. Record review of Resident #61's admission Record showed: -The resident had a diagnosis of Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). -Quadriplegia (paralysis of all four extremities and usually the trunk). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain catheter (a tube inserted into the bladder to drain urine) bags (the urine collection device) and tubing (the clear tubing extending from the end of the catheter to the collection bag) off the floor for two sampled residents with catheters (Resident #26 and #27); to ensure a physician's order with a diagnosis for one sampled resident's catheter (Resident #26); and to ensure one sampled resident (Resident #15) had his/her suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) changed per the physician's order out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Urinary Catheter Care policy, revised 2/26/21 showed: -The facility would ensure urinary catheters were maintained to prevent infection. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Medication Technicians (CMT's), and Certified Nursing Assistants (CNA's) directly responsible for resident care per shift and the resident census. The facility census was 66 residents. 1. Observation on the following dates, and times showed posted staffing did not include actual hours worked for RN's, LPN's, CMT's, and CNA's and did not include the resident census: -On 2/5/23 at 5:24 A.M. - On 2/6/23 at 10:43 A.M. -On 2/7/23 at 10:08 A.M. -On 2/8/23 at 12:16 P.M. During an interview on 2/9/23 at 2:04 P.M. the Director of Nursing (DON) said: -He/she did not know who was responsible for posting staffing hours and resident census. -He/she did not know where staffing hours and census was posted in facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy Medication Regimen Reviews (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications) were completed and in the resident's medical record for five sampled residents (Resident's #37, #49, #47, #62, and #34) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy titled Monthly Drug Regimen Review dated 7/5/22 showed: -The nurse/Director of Nursing (DON) will forward the pharmacists recommendations to the attending physician within 48 hours of receiving the recommendation. The nurse/DON will document the date and time that the physician was notified of the recommendation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pro Re Nata (PRN-as needed) antianxiety medication (a controlled substance medicine that calm and relax people with excessive anxiety, nervousness, or tension) was not ordered for more than fourteen days without physician assessment for one sampled resident (Resident #34); to ensure the physician responded to a pharmacist recommendation related to a antipsychotic medications (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) for one sampled resident (Resident #7); [...]

Inspectors wroteBased on interview and record review, the facility failed to document that a transfer of the resident was necessary for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed when a resident was transferred or discharged , the reason for the transfer/discharge must be documented in the resident's medical record. 1. Record review of Resident #23's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) tracking records (records of admission/discharge) showed he/she was discharged , return anticipated on 10/21/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the bed hold policy for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed: -When a resident was transferred to the hospital or other location the facility must provide to the resident or their representative a written copy of the bed hold policy. -This notice must be given at the time of transfer. -For emergency transfers the bed hold notice must be given within 24 hours of transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive falls investigations, determine a root cause (main cause) for the resident's falls and revise the resident's care plan following a fall for one sampled resident (Resident #26) out of 17 sampled residents. The facility resident census was 66 residents. Record review of the facility Focused Risk Assessment Plan Scope/Severity for Falls (FRAPSS) policy revised 7/9/23 showed: -The purpose of the policy included identifying precipitation factors for fall risk and to be proactive in implementing interventions to prevent or reduce further falls. -Residents will be assessed using the FRAPSS including in an acute situation where a resident has had a fall. -The FRAPSS assessment guide measures areas of precipitating factors, history of previous falls, sensory deficits, medications and resident compliance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments by having a licensed nurse assess the dialysis site for one sampled resident (Resident #49) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility policy entitled Dialysis dated 11/28/17 and revised 3/18/22 showed: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #60), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 17 sampled residents. The facility census was 66 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services for one sampled resident (Resident #7) with teeth in poor repair out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received. 1. Record review of Resident #7's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/17/21 showed the resident: -Was cognitively intact. -Had teeth in good repair. Record review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Was independent with Activities of Daily Living (ADLs-grooming, hygiene, self-care). -Was edentulous or had broken/fragmented teeth. Record review of the resident's care plan dated 12/16/22 showed the resident was independent with self-care and staff would monitor. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep three sampled residents (Residents #39, #21, and #9), free from verbal abuse from a facility employee when Resident #39 had felt bad' about him/herself, Resident #21 had felt worthless about him/herself and had thrown up and Resident #9 felt bad about him/herself after the verbal abuse from facility staff out of three sampled residents. The facility census was 48 residents. Record review of the facility's Abuse Policy dated 5/2019 showed: -The facility policy was to prohibit resident abuse where there was cause to believe a resident' mental health or welfare had been adversely affected by the abuse caused by another person. -Verbal was the use of oral, written or gestured language that included disparaging or derogatory terms within the resident's hearing distance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented to ensure no cross contamination was performed when two sampled residents' catheter bags (a flexible tube inserted through a narrow opening into the bladder, drains into a collection bag for removing fluid from the body) were on the floor (Resident #6 and #20); to ensure proper hand hygiene during catheter care for one sample resident (Resident #1) and during the transfer of one resident (Resident #20); to ensure proper storage of breathing tubing and masks when not in use for two sampled resident residents (Resident #32 and #33); and to include the following in its waterborne illness plan: a risk assessment of where opportunistic waterborne pathogens (e.g. Legionella sp. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to do the following: maintain the fan in Resident #33's room free of a heavy buildup of dust; maintain the backing support of the shower chair free of large rips, failed to maintain the shower mat in the 500 Hall shower room free of rips and tears which caused it to be not easily cleanable; failed to maintain the brakes of the wheelchairs that belonged to Residents #45 and #25 in working order; and failed to maintain the restroom ceiling vent in resident room [ROOM NUMBER] free of a heavy buildup of dust. This practice potentially affected at least 40 residents who used or resided in those areas. The facility census was 48 residents. 1. Observations with the Environmental Services Director and the Maintenance Director on 3/3/20, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication refrigerator temperature was monitored and maintained within the appropriate range for the refrigerated medications and vaccines. The refrigerator temperature was 52 degrees Fahrenheit (°F) Affecting a total of 85 medications including insulin, vaccine, antipsychotics and anti-anxiety medications. Two sampled residents (Resident #1 and #2) had been given medication out of that refrigerator that day. There were 13 sampled and 8 supplemental residents. The facility census was 48 residents. Record review of the manufacturers package insert for Desmopressin AC (used to increase urine concentration and decrease urine production) revised in July 2007 showed: -Store in refrigerator between 36 °F and 46 °F. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' dignity by not placing a privacy bag over the catheter bag for three sampled residents (Residents #6, #20, and #37) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #6's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, pneumonia, stroke, seizures, dysphagia (difficulty swallowing), high blood pressure, history of urinary tract infection and neurogenic bladder (lack of bladder control) with urinary retention. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/3/20, showed he/she: -Was alert, but had cognitive difficulty and memory problems. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an authorization from for the facility to hold and manage resident funds for one sampled resident(Resident #31) and to implement a system to ensure receipts were retrieved by the Business Office, after the resident's family member withdrew money from the resident's fund account, for expenses. This practice potentially affected one resident out of four residents sampled for the purpose of reviewing the resident fund's process at the facility. The facility census was 48 residents. 1. Record review of the authorization forms showed the absence of a signed authorization for Resident #31. During an interview on 3/2/20 at 12:41 P.M., the Business Office Manager (BOM) said: - Resident #31 signed up for the account in September of 2019. -The resident was physically and mentally unable to sign the authorization form. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the code status (instructions on what to do in case of cardiac or respiratory arrest) for one sampled resident (Resident #146) was transcribed to the resident's Physician Order Sheet (POS) out of of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #146's Face Sheet showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including brain injury, neck fracture, right femur fracture, left shoulder fracture, respiratory failure, dysphagia (difficulty swallowing), pneumonia, gastronomy (a tube that is placed directly into the stomach for long term administration of food, fluids, and medications) and tracheostomy (the surgical formation of an opening into the trachea through the neck especially to allow the passage of air). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care plans were comprehensive and updated to reflect the current status with interventions needed for one sampled resident (Resident #1) with and indwelling catheter (Foley catheter, a sterile tube that is inserted into the bladder to drain urine) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #1's admission Face Sheet showed he/she had been admitted to the facility on [DATE] with diagnoses of: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment for maintaining or improving range of motion was available for one sampled resident (Resident #20) out of 13 sampled residents. The facility census was 48 residents. Record review of Resident #20's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -History of brain hemorrhage (an emergency condition in which a rupture blood vessel causes bleeding inside the brain). -Other lack of coordination. -Hemiplegia (paralysis) and hemiparesis (slight paralysis/weakness) affecting the right side of the body following brain hemorrhage. -Generalized muscle weakness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe transfer for two sampled residents (Residents #38 and #15), and to ensure the accuracy of assessments and care planning related to safe transfer for one sampled resident (Resident #15) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #38's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including anxiety, muscle spasms, deformity of the lower leg, and cervical spondylosis (wear and tear affecting the spinal disks in your neck). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/4/19, showed he/she: -Was cognitively intact. -Needed limited assistance with bathing, dressing, toileting, and transferring. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for a resident to self-administrator his/her medications; to assess the resident ability to be able to self-administer medication and to ensure to update the resident respiratory care plan to reflect current health status for one sampled resident (Resident #33) out of 13 sampled resident. The facility census was 48 residents. 1. Record review of Resident #33 admission Face Sheet showed he/she was readmitted to the facility on [DATE] with diagnoses of: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -The resident was his/her own responsible person. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dead mouse and mouse droppings (the excrement of certain animals, such as rodents, sheep, birds, and insects) were removed from the kitchen furnace room for three days of the survey. This practice potentially affected one non-resident use area. The facility census was 48 residents. 1. Observations on 3/2/20 at 8:29 A.M., 3/3/20 at 10:23 A.M. and 3/4/20 at 8:27 A.M., showed the presence of a dead mouse and mouse droppings in the kitchen furnace room. During an interview on 3/3/20 at 10:22 A.M., the Maintenance Director said he/she did not know about the dead mouse in the kitchen furnace room. During an interview on 3/4/20 at 8:28 A.M., the Dietary Manager (DM) said he/she had not seen the mouse and the mouse droppings in the dietary furnace room. [...]