Edith Lane of Cincinnati

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the facility had properly operating phones system in place. This had the potential to affect all residents who resided in the facility. The facility census was 145. Observation of Secured Women's Behavioral Unit on 03/18/26 at 11:24 A.M. with Certified Nursing Assistant (CNA) #182, revealed the phone at the nurses station did not work. Observation of a second phone within the unit revealed it was unplugged and not operational. During an interview on 03/18/26 at 11:24 A.M., CNA #182 verified the Secured Women's Behavioral Unit did not have a working phone. CNA #182 stated if a resident's family member tried calling in, there was no way to reach the staff. Observation of Secured Men's Behavioral Unit on 03/18/26 at 11:31 A.M., with CNA # 319, revealed the phone was not plugged in. [...]

Inspectors wroteBased on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to provide a sanitary, clean, and safe environment, This had the potential to affect all 12 Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, and #12) who resided on the Secured Women's Behavioral Unit and 34 Residents (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76 and #77) who resided on the One [NAME] Unit and utilized the main entrance. The facility census was 145.1) Review of the medical record for Resident #12 revealed an admission date of 02/09/24. [...]

Inspectors wroteBased on observation, staff interview, resident interview, staff interview, and policy review, the facility failed to maintain a safe smoking environment. This had the potential to affect all 12 Residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, and #12) who resided on the Secured Women's Behavioral Unit and 34 Residents (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76 and #77) who resided on the One [NAME] Unit and utilized the main entrance. The facility census was 145. 1) Observation of the Secured Women's Behavioral Unit on 03/18/26 at 2:08 P.M. with Certified Nurse Aide (CNA) #182, revealed the door exiting to the smoking area contained numerous discarded cigarette butts lying all over the ground and near the door. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide a clean, safe, and comfortable environment. This affected 31 (#682, #86, #127, #120, #122, #147, #146, #99, #134, #140, #142, #125, #136, #137, #128, #121, #138, #145, #123, #133, #135, #130, #124, #131, #148, #149, #144, #126, #129, #132, and #139) of 31 residents reviewed for environment residing in Building #2, and further affected four (#34, #50, #692 and #694) with the potential to affect all residents on the 2 west unit of Building #1. The facility census was 144. 1. Observations of Building #2 on 12/22/25 from 3:45 P.M. to 4:20 P.M. with Maintenance Assistant (MA #333) revealed the following: [...]

Inspectors wroteBased on medical record review, observation, staff interviews, and review of a facility policy, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected 14 (#103, #69, #91, #95, #17, #27, #43, #87, #51, #58, #107, #18, #88 and #117) of the 25 residents who resided on the secured men's behavioral unit reviewed for call lights. The facility census was 118.

Inspectors wroteBased on medical record reviews, observation, staff interviews, and policy review, the facility failed to ensure residents were provided with a safe, clean, comfortable and homelike environment. This affected two (#11 and #18) of the seven residents reviewed for environmental concerns. The facility census was 118.

Inspectors wroteBased on observation and staff interview, the facility failed to store foods in a manner to prevent spoilage and failed to ensure kitchen staff appropriately wore hair restraints while in the kitchen. This had the potential to affect all 119 residents at the facility. The facility census was 119. Findings Included: 1. Observation on 04/08/25 from 9:50 A.M. through 10:00 A.M. revealed an opened and undated quarter pound package of ham lunch meat, two halved tomatoes wrapped in plastic that were undated, an opened and undated package of yellow cheeses with a quarter pound left, and three ham sandwiches, three bologna sandwiches, and six peanut butter sandwiches individually packaged in plastic bags that were not labeled or dated in refrigerator. Interview on 04/07/25 at 9:58 A.M. [...]

Inspectors wroteBased on observation, resident and staff interviews, medical record review, review of service reports, and policy review, the facility failed to ensure residents were provided a homelike environment. This affected six (#29, #79, #88, #101, #109, and #118) of 17 residents reviewed for environmental concerns. The facility census was 119. Findings Include: 1. Review of the medical record for Resident #29 revealed an admission date of 06/10/23 and diagnoses that included chronic obstructive pulmonary disease, chronic congestive heart disease, and acute kidney failure. Review of Resident #29's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Observation of Resident #29's room on 04/08/25 at 9:47 A.M. revealed an air conditioning unit sitting in an opening in the outer wall. The air conditioning unit did not fit properly in the opening. [...]

Inspectors wroteBased on medical record review, resident and resident family interview, staff interview, review of incident reports, and policy review, the facility failed to ensure care conferences were conducted timely as required and failed to ensure care plans were updated timely when new interventions were implemented. This affected six (#59, #79, #98, #116, #118, and #120) of 32 residents reviewed for care plans. The census was 119.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This had the potential to affect five (#31, #54, #79, #84, and #109) of five residents observed in the hallway during medication administration. The facility census was 119. Findings Include: Observation on 04/09/25 at 9:00 A.M., during medication administration, Registered Nurse (RN) #260 was observed to discard two 300 milligram (mg) gabapentin capsules and one five (5) mg memantine tablet into the open trash receptacle on the end of the medication cart. RN #260 left the medication cart locked and unattended on four occasions to administer medications during observation. The medication cart was placed in a common area between the front entrance to the facility and the rehabilitation room. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected two (#42 and #77) of three residents reviewed for call lights. The facility census was 119. Findings Included: Review of the medical record for Resident #42 revealed an admission date of 11/25/2019. Diagnoses included palliative care, schizoaffective disorder, dementia, borderline personality disorder, brief psychotic disorder, type two diabetes, and adult sexual abuse. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was assessed with mil;d cognitive impairment. Resident #42 required supervision or touching assistance for eating meals. Resident #42 required partial to moderate assistance for dressing the upper body. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to notify the physician of a resident's significant weight loss. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admission date of 07/31/24. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. Resident #116 required supervision or touching assistance for meals and dressing the upper body. [...]

Inspectors wroteBased on medical record review, resident and staff interview, and review of resident lists, the facility failed to ensure residents received follow-up care for audiology services. This affected one (#10) of six residents reviewed for ancillary services. The facility census was 119.

Inspectors wroteBased on observation, medical record review, staff interview, interview with local health clinic staff, review of hospital documentation, and policy review, the facility failed to recognize potential hazards related to residents attending community appointments unsupervised an failed to ensure a resident was properly assessed for use of a sit-to-stand lift for transfers. This affected one (#75) of one residents sampled for community appointments and one (#5) of 10 residents reviewed for accidents and hazards. The facility census was 119.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to provide timely assistance for a resident who was dependent for incontinence care. This affected one (#5) of one residents reviewed for incontinence. The facility census was 119. Findings Included: Review of the medical record for Resident #5 revealed an admission date of 04/26/16. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Resident #5 required substantial assistance for meals, oral care, dressing the upper body, and personal hygiene. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to monitor weights on a consistent basis and failed to address and implement interventions for a resident with significant weight loss in a timely manner. This affected one (#116) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of Resident #116's medical record revealed and admission date of 07/31/24. Diagnoses included chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia severity with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain laboratory values as ordered by the physician. This affected three (#5, #116, and #118) of 32 resident medical records reviewed. The facility census was 119. Findings Included: 1. Review of medical records for Resident #5 revealed an admission date of 04/26/16. Diagnoses included spastic diplegic cerebral palsy, impulse disorder, epilepsy, psychotic disorder, bipolar disorder, dementia, intermittent explosive disorder, bipolar two disorder, anxiety disorder, and intellectual disabilities. Review of a physician order dated 02/19/24 revealed Resident #5 had an order for laboratory tests for a complete blood count (CBC), renal panel, and Dilantin level every February, May, August, and November. [...]

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to serve food in a form to to meet resident needs. This affected one (#28) of eight residents reviewed for nutrition. The facility census was 119. Findings Included: Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included dysphagia oropharyngeal phase, cognitive communication deficit, occlusion and stenosis of the right carotid artery, chronic diastolic heart failure, type two diabetes, atrial fibrillation, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of the physician order dated 11/04/24 revealed Resident #28 was ordered a regular diet with mechanical soft texture and thin liquids. [...]

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions. This affected one (#67) of three residents sampled for enhanced barrier precautions. The facility census was 119. Findings Include: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included chronic viral hepatitis C, type II diabetes, morbid obesity, cannabis and other stimulant dependence, unspecified psychoactive substance abuse, unspecified anxiety and mood disorders, paraplegia, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on observation, resident and staff interviews and review of facility policy, the facility failed to maintain comfortable air temperatures and failed to provide a homelike environment. This affected 10 (#01, #02, #03, #04, #05, #06, #07, #08, #09, and #10) out of 123 residents that resided at the facility. The facility census was 123.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents had full visual privacy as required. This affected nine (#01, #02, #03, #04, #05, #06, #08, #09, and #10) out of 123 residents that resided at the facility. The facility census was 123.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, and review of online guidelines per the American Heart Association (AHA), the facility failed to administer cardiopulmonary resuscitation (CPR) per the facility policy and per professional standards of care. This affected one (Resident #132) of three residents reviewed for change in condition. The facility census was 128 residents.

Inspectors wroteBased on review of the medical record, staff interview, and review of the facility policy, the facility failed to implement timely care and treatment for trauma wounds. This affected one (Resident #64) of three residents reviewed for skin impairment. The facility census was 129 residents.

Inspectors wroteBased on review of the medical record, staff interview, and review of the facility policy, the facility failed to implement timely care and treatment for pressure ulcers. This affected one (Resident #64) of three residents reviewed for skin impairment. The facility census was 129 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was below five percent. The medication error was eight percent (%) with two errors out of 25 medication opportunities observed. This affected one (Resident #61) of three residents reviewed for medication administration. The facility census was 129 residents.

Inspectors wroteBased on medical record review, staff interview, observation, and review of the facility policy, the facility failed to adequately assess residents' skin and failed to ensure adequate care and services were provided to residents to prevent the development and worsening of pressure ulcers. This resulted in Actual Harm for Resident #135 when the facility staff failed to adequately assess the resident's skin and failed to implement timely interventions for a pressure ulcer until the ulcer reached an advanced stage. Actual Harm also occurred for Resident #01 when the facility staff failed to assess the resident's skin and the resident developed an unstageable pressure to the right heel caused by a removable splint device. This affected two (Residents #135 and #01) of the three residents reviewed for pressure ulcers. The facility census was 128.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of facility Self-Reported Incidents (SRIs), review of facility investigation records, and review of the facility policy, the facility failed to ensure residents were free from abuse. This affected one (Resident #25) of three residents reviewed for abuse. The facility census was 128 residents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide adequate catheter care for residents with an indwelling urinary catheter. This affected one (Resident #57) of three residents reviewed for urinary catheter use. The facility census was 128 residents.

Inspectors wroteBased on medical record review, review of hospital discharge record, observation, resident interviews and staff interview the facility failed to provide needed and timely therapy services to residents. This affected one (Resident #57) of three residents reviewed for therapy services. The facility census was 128 residents.

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to provide an operational call light system which would allow for residents to alert staff of their individual needs. This affected one (Resident #57) of five residents reviewed for functioning call lights. The facility census was 128 residents.

Inspectors wroteBased on medical record review, staff interview, review of the facility's investigation, review of witness statements, review of the hospital records, and policy review, the facility failed to ensure residents were free from resident-to-resident abuse. This resulted in Actual Harm on 05/31/24 when Resident #52, a resident with a known history of aggressive behaviors towards other residents, intentionally ran over Resident #14 with his wheelchair. Subsequently, Resident #14 was sent to the local hospital where she was diagnosed with a closed fracture of the right tibial plateau initial encounter. The facility also failed to ensure Resident #60 was free from resident- to-resident abuse when Resident #52 intentionally ran into the resident with his wheelchair causing the two residents to become involved in a physical altercation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received therapy services as evaluated by the therapy department and ordered by the physician. This affected one resident (#900) out of three residents reviewed for therapy services. The facility census was 126.

Inspectors wroteBased on observation, interview,record review,review of the weather via website www.timeanddate.com, and facilities policy review, the facility failed to maintain a comfortable environment for 40 Residents in Building One when temperatures were below 71 degrees Fahrenheit for 15 hours. This affected all residents in Building One, (Residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#27,#28,#29,#30,#31,#32,#33,#34,#35,#36,#37,#38,#39 and #40). The total facility census was 140.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents had the right to have use of a telephone where calls could be made in privacy. This affected three residents (#30, #74, and #125) of three residents reviewed for resident rights. The facility census was 136 residents.

Inspectors wroteBased on medical record review, review of facility self-reported incident (SRI), review of facility investigations, observations, staff and resident interviews, and review of a facility policy, the facility failed to ensure residents were free from abuse. This resulted in Actual Harm for when Resident #118 was physically abused by Resident #72 and subsequently required hospital evaluation/treatment for a right wrist fracture, and when Resident #117 was physically abused by Resident #95 and subsequently required hospital evaluation/treatment for a broken jaw. Additionally, the facility failed to ensure Resident #19 was free from staff-to resident abuse and failed to ensure Resident #41 and #53 were free from resident-to-resident abuse which placed the residents at risk for more than minimal harm that did not result in actual harm to the residents. [...]

Inspectors wroteBased on employee record review and staff interview, the facility failed to provide annual evaluations to State Tested Nursing Assistants (STNA's). Additionally, the facility failed to provide the annual 12 hours of in-services to STNA's. This had the potential to affect all 121 residents residing in the facility. This had the potential to affect all 121 residents residing in the facility. The in-house facility census was 121.

Inspectors wroteBased on observation, staff interview, and policy/procedure review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. In addition, the facility failed to maintain food storage in a clean, safe, and sanitary manner. This had the potential to affect all 121 residents. The facility census was 121.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a safe, clean comfortable and homelike environment. This affected 45 Residents (#3, #6, #7, #10, #11, #12, #13, #22, #25, #32, #35, #37, #38, #39, #43, #45, #46, #55, #61, #63, #64, #66, #69, #73, #74, #76, #77, #78, #81, #84, #85, #88, #89, #93, #98, #100, #101, #102, #103, #108, #112, #113, #117, #121 and #325) of 121 residents reviewed for a homelike environment. The facility census was 121.

Inspectors wroteBased on medical record review, observations, staff and resident representative interviews and policy review, the facility failed to have the quarterly care conferences with residents, the residents representative or with the interdisciplinary team. Additionally, the facility failed to review and revise residents plan of care when there was a change in the residents condition/interventions. This affected six (##13, #88, #101, #57, #97 and #117) out of 37 residents reviewed for care conferences and care planning. The facility census was 121.

Inspectors wroteBased on observations, staff interviews and review of the facility policy, the facility failed to ensure hazardous chemicals were securely stored out of the reach of confused and independently mobile residents. This had the potential to affect nine (#57, #58, #21, #6, #54, #23, #40, #71 and #5) residents identified by the facility as cognitively impaired and independently mobile. The facility census is 121.

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to ensure residents taking psychotropic medications had documentation for routine monitoring of behaviors and effectiveness of psychotropic medications. This affected five (#19, #42, #90, #6, and #117) of five residents sampled for psychotropic medications. The facility census was 121.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications were prepared properly, labeled, and expired medications were disposed of. This had the potential to affect one resident (#31) whose medications were prepared and not given, four residents (#17, #62, #24, and #106) whose insulin injection pens were not correctly labeled, and two residents (#71 and #77) whose prescribed stock medications were expired. The facility census was 121.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the call system was functioning on a secured unit to allow residents to call for staff assistance. This affected three rooms (#408, #410 and #418) out of 8 rooms with two residents occupying each room reviewed for operational call lights. The facility census was 121.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure privacy was provided during perineal care. This affected one (#97) of one resident reviewed for personal hygiene. The facility census was 121.

Inspectors wrote2. A record review revealed Resident #62 was admitted on [DATE]. Diagnoses include anxiety, hypertensive heart and kidney disease, epilepsy, diabetes, congestive heart failure, atrial fibrillation, and depression. Review of the quarterly MDS dated [DATE] revealed Resident #62 has no cognitive deficits, requires extensive assistance with toileting, transfers, bed mobility, with total dependence with personal hygiene, dressing and is incontinent of bowel and bladder. Review of health status note dated 09/29/22 revealed Resident #62 with complaints of shortness of breath and a headache, upon assessment it was noted Resident #62 was having difficulty breathing with exertion in between communication. Vitals signs as follows: blood pressure 156/62, pulse 26, oxygen saturation 94% on room air, respirations 28 and temperature 98.2 with wheezing noted in bilateral lung upon auscultation. [...]

Inspectors wroteBased on medical record review, observation, interview, hospice staff interview, review of the hospice contract, and review of the hospice policy, the facility failed to designate a staff member for the collaboration of care and services. This affected one resident (#57) out of one reviewed for hospice services. This has the potential to affect five residents (#56, #57, #50, #97, #38) the facility identified as hospice clients. The facility census was 121.

Inspectors wroteBased on observations, resident interviews, staff interviews, and policy review, the facility failed to ensure information was available on how to contact the Ombudsman. This had the potential to affected 121 of 121 residents who resided in the facility. Facility census was 121.

Inspectors wroteBased on resident and staff interviews and review of the local post office business hours, the facility failed to ensure residents will have access to mail service on Saturdays. This affected six (#16, #50, #99, #109, #111, and #119) residents interviewed during resident council meeting and had the potential to affect all 121 residents in the facility. Facility census was 121.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to display the state agency survey results, where residents and visitors could visibly access them. This directly affected six (#16, #50, #99, #109, #111, and #119) residents interviewed during resident council meeting and had the potential to affect all 121 residents in the facility. Facility census was 121.

Inspectors wroteBased on observation, resident and staff interview, review of resident council minutes, the facility failed to ensure information was posted for residents and their representatives on how to file a grievances and who the facility designated as a Grievance Official. This had the potential to affect 121 of 121 residents in the facility. Facility census was 121.

Inspectors wroteBased on review employee personal files, staff interview, and policy review, the facility failed to implement their abuse policy by not doing the required reference checks on employee prior to hiring. This had the potential to all 121 residents residing in the facility. The facility census was 121.

Inspectors wroteBased on review of personnel files, review of job description and staff interview, the facility failed to have a Licensed Social Worker (LSW) employed on a full-time basis. This had the potential to affect all 135 residents of the facility.

Inspectors wroteBased on review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the facility failed to ensure appropriate plans of action were in place to correct any identified quality deficiencies. This had the potential affect all 135 residents residing in the facility.

Inspectors wroteBased on review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the facility failed to ensure quarterly QAPI meetings were being conducted. This had the potential to affect all 135 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to issue the Notice to Medicare Provider Non-coverage (NOMNC) form and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) forms when required. This affected five (#40, #41, #42, #239 and #240) of six residents reviewed for Beneficiary Protection Notification Review. The facility census was 135.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to provide notice to the resident and /or resident's representative for the reason for transfer and the resident's transfer notices to the Office of the State Long-Term Care Ombudsman. This affected seven (#11, #34, #40, #41, #42, #48 and #108) of seven residents reviewed for hospitalizations. The facility census was 135.

Inspectors wrote5. Record review for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included influenza, unspecified dementia with behavioral disturbance, psychotic disorder with delusions due to known physiological condition, chronic kidney disease, bipolar disorder, and Parkinson's disease. Review of the quarterly MDS assessment, dated 09/23/19, revealed the resident had a moderate cognitive impairment. Review of the nursing progress notes, dated 08/31/19, revealed Licensed Practical Nurse (LPN) #38 documented the resident was short of breath, had increased weakness, and reduced oxygen saturation levels on room air. The nurse noted that after assessment and notification of the physician, the physical advised LPN #38 to send the resident to the emergency department of a local hospital for evaluation. [...]

Inspectors wroteBased on observation, medical record review, policy review and resident and staff interview, the facility failed to ensure oxygen cautionary/safety signs were posted where oxygen was in use and failed to change oxygen tubing every week as ordered by physician. This affected five (#16, #41, #42, #45, and #124) of five residents reviewed for respiratory care. This had the potential to affect 31 residents the facility identified as having oxygen equipment maintained in his/her room. The facility census was 135.

Inspectors wroteBased on record review, observation, staff interviews, review of facility policy and review of manufacturer recommendations, the facility failed to discard expired medications and failed to date opened insulin pens. The expired medications affected four residents (#2, #57, #112 and #118) and had the potential to affect all the residents that the facility identified as receiving medications and the insulin had the potential to affect nine residents the facility identified as receiving insulin by pens on the second floor of the [NAME] building. The facility census was 135.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure that food and beverage items were stored in the resident's snack and beverage utility rooms and in the refrigerators and were labeled and dated to prevent potential cross contamination and ensure only food/beverages used were not spoiled. This had the potential to affect 36 residents located on the Lighthouse unit, and the 33 residents located on the Two [NAME] unit. The facility census was 135.

Inspectors wroteBased on observation, staff interview, and review of maintenance/housekeeping work order requests, the facility failed to maintain a safe, sanitary and orderly environment for residents. This had the potential to all 36 residents located on the Lighthouse unit, a secured unit for residents with dementia. The facility further failed to provide a safe area for residents to smoke. This had the potential to affect 27 Residents (#14, #23, #25, #29, #35, #40, #43, #47, #50, #57, #59, #60, #64, #67, #70, #71, #72, #77, #81, #84, #93, #94, #98, #101, #104, #109 and #113) whom the facility identified as smokers and utilized the smoking area. The facility census was 135.

Inspectors wroteBased on record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure resident's were provided with water pitchers in their rooms in accordance with their needs and preferences. This affected three (#31, #103 and #127) of 35 residents residing on the Lighthouse unit. The facility census was 135.

Inspectors wroteBased on record review, observation, and physician and staff interview, the facility failed to notify the doctor of a change in condition in a resident's health status. This affected one (Resident #42) of three residents reviewed for pressure ulcers. The facility census was 135.

Inspectors wroteBased on record review, review of facility's Self-Reported Incidents, resident and staff interviews and review of facility policy, the facility failed to implement their policy when they did not report immediately to the administration Resident #117's allegation of misappropriation. This affected one (#117) of four residents reviewed for abuse. The facility census was 135.

Inspectors wroteBased on resident and staff interviews, observation, record review, review of facility's Self-Reported Incidents and review of facility policy, the facility failed to report an allegation of misappropriation to administration immediately. This affected one (Resident #117) of four residents reviewed for abuse. The facility census was 135.

Inspectors wroteBased on record review, and resident and staff interview, the facility failed to complete Minimum Data Set (MDS) assessments which accurately reflected each resident's status in regarding to falls, incontinence and pain medication regimen. This affected two (#46 and #127) of 28 residents who were reviewed for accurate MDS assessments. The facility census was 135.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to implement comprehensive person-centered care plans. This affected one (#80) of 26 residents reviewed for care plans. The facility census was 135.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to provide professional standards of care for wound care. This affected one (Resident #42) of three residents reviewed for wound care. The facility census was 135.

Inspectors wroteBased on observation, physician and staff interviews, and record review the facility failed to timely assess a pressure wound. This affected one (#110) of 28 residents reviewed for orders in the initial screening process. The facility census was 135.

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to provide ongoing podiatry care for residents. This affected one (#117) of one resident reviewed for foot care. The facility census was 135.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to administer resident's medications with a medication error rate less than five percent. There were two medication errors out of 30 opportunities. The faciliy had a 6.6 percent medication error rate This affected two (#17 and #126) of 10 residents observed for medication administration. The in-house facility census was 135.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure infection control was maintained during medication administration. This affected two residents (#17 and #101) of ten observed during medication administration. The facility census was 135.