Elizabeth Adam Crump Health and Rehab

Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility failed to ensure that the accommodation of resident needs and preferences was provided for six of 76 residents in the survey sample, Residents #5, #101, #118, #81, #40 and #117.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide a clean, comfortable, homelike environment for eleven of seventy-six residents in the survey sample, on one of three units and in one of sixty-five rooms (Residents #45, #81, #5, #101, #118, #181, #55, #73, #76, #74, #156, C-wing, room A-4).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for three of 76 residents in the survey sample, Residents #173, #76 and #6.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician and/or responsible party for a change in condition for two of 76 residents in the survey sample, Residents #174 and 175.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure pressure relieving device was in place to prevent pressure ulcers for one resident, Resident #112 (R112) out of a survey sample of 76 residents.

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean comfortable home-like environment for 2 of 3 nursing units (Unit A, Unit B) and in a survey sample of 13 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure that residents were free from unnecessary medications for 1 Resident (#2) in a survey sample of 13 residents. For Resident #2 the faciltiy staff failed to ensure that the resident was free from unnecessary drugs related to duplicate drug therapy. Resident #2 was admitted to the facility on [DATE] with diagnoses that include but were not limited to fracture of left femur, COPD (Chronic Obstructive Pulmonary Disease), asthma, chronic respiratory failure, abscess of lung, major depressive disorder, generalized anxiety disorder, acute hepatitis C, and insomnia. Resident #2 had a BIMS (Brief Interview of Mental Status) Score of 11 out of a possible 15 indicating moderate cognitive impairment. [...]

Inspectors wroteFor Resident #2 the facility staff failed to order and administer the correct dose of quetiapine fumarate (Seroquel, an antipsychotic) causing the resident to be given double the amount ordered on 2 occasions, and furthermore failed to notify the physician, or consult with the pharmacy when alerts for drug-to-drug interactions appeared. Resident #2 was admitted to the facility on [DATE] with diagnoses that include but were not limited to fracture of left femur, COPD (Chronic Obstructive Pulmonary Disease), asthma, chronic respiratory failure, abscess of lung, major depressive disorder, generalized anxiety disorder, acute hepatitis C, and insomnia. Resident #2 had a BIMS (Brief Interview of Mental Status) Score of 11 out of a possible 15 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure resident rights to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 residents in a survey sample of 13 Residents. (Residents #7, #8, #9, #10, #11).

Inspectors wroteBased on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an abuse/neglect free environment for 1 Resident (Resident #3) in a survey sample of 13 Residents.

Inspectors wroteBased on observations, staff and resident interviews and record review, the facility staff failed to ensure appropriate resident care and services were provided in accordance with accepted professional standards of care for 3 residents (Resident #4, #5 and #6) in a survey sample of 13 residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive care to prevent the development of pressure ulcers for 1 Resident (Resident #1) in a survey sample of 13 Residents.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to ensure safe practice for infection prevention for one 5 staff memebers in the kitchen. For the facility, the facility staff failed to ensure that hair covering was worn by all staff entering the kitchen area. On 10/29/25 at approximately 12:15 PM LPN #1 was observed as she walked from hall past surveyor and went into the kitchen. There were no hairnets at this entrance. Surveyor was standing in doorway entrance awaiting staff to get hairnets. LPN #1 was observed going into the kitchen and walking out of the surveyors view to the other side of the kitchen. Surveyor spoke to dietary staff who alerted the dietary manager. [...]

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents care plans were reviewed and revised for 1 Resident (#2) in a survey sample of 5 Residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure each Resident receives adequate supervision to prevent accidents, for 1 Resident (#2) in a survey sample of 5 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 2 Residents (#'s 1 & 3) in a survey sample of 5 Residents.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to verify through the Department of Health Professions certification of five of five newly hired (October 12, 2023) Certified Nursing Assistant (CNA), (CNA #11 through #15), in the survey sample.

Inspectors wroteBased on observations, staff interviews, and review of the clinical record the facility staff failed to ensure a resident not assessed to be safe to self administer medications be allowed to have medications left on the over the table to be self administered when desired for 1 of 29 residents (Resident #8), in the survey sample.

Inspectors wroteBased on staff interviews, clinical record review, and review of facility documents, the facility staff failed to protect 1 of 3 residents (Resident #28), in the survey sample from staff abuse.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse within two (2) hours to the State survey and certification agency for 1 of 28 residents in the survey sample, Resident #1.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide incontinent care for a dependent resident for one Resident (Resident #1) in a survey sample of 28 residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer CPR (cardio pulmonary resuscitation), per the resident's wishes, for one of one expired resident reviews, Resident #140 (R140). On [DATE], when the resident was found to be without respirations and pulse, the facility staff failed to administer CPR per the resident's wishes, as documented by the facility staff and the hospice nurse. This failure resulted in harm.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to promote dignity for four of 66 residents in the survey sample, Residents #135, #87, #122 and #85.

Inspectors wrote3. The facility staff failed maintain the wall behind the head of the bed in Resident 81's (R81's) room in good repair. (R81) was admitted to the facility with diagnoses that included but were not limited to: a stroke. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 06/24/2022, coded (R81) as scoring a 15 out of 15 on the brief interview for mental status (BIMS) which indicated (R81) was cognitively intact for making daily decisions. On 08/15/2022 at 2:48 p.m., an observation of (R81's) room revealed gouges, scrapes and missing paint on the wall behind the head of the bed covering an area approximately two feet high by three feet long. [...]

Inspectors wroteBased on staff interview, clinical record review, facility document review, and during the course of a complaint investigation, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff for ten out of 66 residents in the survey sample that were transferred to the hospital; Resident #'s 29, 103, 135, 242, 120, 81, 94, 96, 85 and 102.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification was provided when ten out of 66 residents in the survey sample were transferred to the hospital; Residents #'s 29, 103, 135, 242, 120, 81, 94, 96, 85 and 102.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when eight out of 66 residents in the survey sample who were transferred to the hospital; Residents # 29, 103, 135, 242, 94, 96, 85 and 102.

Inspectors wroteBased on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for seven out of 66 residents in the survey sample, Residents #289, #290, #36, #291, #85, #95, and #61.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide ADL (activities of daily living) care to dependent residents for three of 66 residents in the survey sample, Residents #135, #189, and #122.

Inspectors wroteBased on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide care and services to promote the highest level of well being for eight of 66 residents in the survey sample, Residents #290, #36, #85, #135, #71, #11, #116, and #122.

Inspectors wroteBased on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide treatment for pressure ulcers for three of 66 residents in the survey sample, Residents #95 (R95), #289 (R289), and #291 (R291).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to monitor and maintain residents nutritional status to prevent significant weight loss for 2 of 66 residents in the survey sample; Residents #22 and #96.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence ongoing communication with the dialysis center for two of 66 residents in the survey sample, Resident #93 and Resident #75.

Inspectors wrote5. The facility staff failed to provide sufficient staffing to meet resident needs. During the entrance conference on 8/15/22 at approximately 11:30 AM with ASM (administrative staff member) #1, the administrator, a request for as worked staffing schedules from 7/1/22-7/31/22 was made. When asked during the entrance conference if there were any staffing waivers, ASM #1 stated, No, there are no waivers. On 8/15/22 at 12:30 PM, a request was made for the as worked staffing sheets from 11/1/21-12/30/21 as part of a complaint survey for all residents. As worked staffing sheets were provided on 8/16/22 at approximately 2:15 PM by ASM #3, the regional director of clinical services. As a part of the sufficient staffing facility task and a complaint investigation the as worked staffing sheets for July 2022 and November-December 2021 sheets were reviewed. [...]

Inspectors wroteBased on resident interview, staff interview and facility document review, it was determined the facility staff failed to serve food at a palatable temperature on one of three units, Unit B.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to prepare and serve food in a sanitary manner in one of one kitchens and in one of three unit nourishment rooms.

Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation it was determined that the facility staff failed to maintain an accurate clinical record for two of 66 residents in the survey sample, Resident #397 (R397) and #396 (R396).

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain the dish washing machine in operating condition in one of one kitchens.

Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined that the facility staff failed to provide annual required training for five of five CNA (certified nursing assistant) record reviews. The facility staff failed to provide the required mandatory training for abuse, neglect and dementia training for five of five CNAs that were employed for greater than one year, CNA #1, #2, #3, #4 and #5.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to honor a resident's right to make choices about their day to day care and schedule for one of 66 residents in the survey sample, Resident #93.

Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed implement their neglect policy for reporting and investigating an allegation of neglect for one of 66 residents in the survey sample, Resident #396 (R396).

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to report an allegation of abuse in a timely manner for one of 66 residents in the survey sample, Resident # 396 (R396).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete MDS (minimum data set) assessment for 1 of 66 residents in the survey sample, Resident #87. The facility staff failed to complete sections C-Cognitive Patterns and D-Mood on R87's annual MDS with an ARD (assessment reference date) of 6/30/22.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to follow up as recommended on a Level II PASRR (preadmission screening and resident review) for one of 66 residents in the survey sample, Residents #11.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence PASARR (preadmission screening and resident review) screenings were completed for two of 66 residents in the survey sample, Residents #127 and #87.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement an accurate baseline care plan for one of 66 residents in the survey sample, Resident #140; and failed to provide a baseline care plan to the resident and/or responsible party for one of 66 residents in the survey sample, Resident #396.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for 3 out of 66 residents in the survey sample; Residents #22, #96, and #102.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free of accidents and hazard risks for 2 of 66 residents in the survey sample, Residents #87 and #120. 1. The facility staff failed to ensure a physician ordered fall mat was on the floor while Resident #87 (R87) was lying in bed. 2. The facility staff failed to check the placement and function of the wander guard according to the physician's orders for Resident #120.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services per physician orders to three of 66 residents in the survey sample, Residents #93, #59 and #116.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for three out of 66 residents in the survey sample, Residents #127, 106 and 102.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide routine dental services for one of 66 residents in the survey sample, Resident #189.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide an alternative meal choice in a timely manner for one of 66 residents in the survey sample, Resident #87. On 8/15/22, Resident #87 (R87) refused lunch and requested peanut butter and jelly sandwiches. R87 did not receive the sandwiches until 5:03 p.m.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide meals at regular times comparable to normal meal times for 2 of 66 residents in the survey sample, Residents #57 and #31. The facility staff failed to serve meals in a timely manner to Resident #57 (R57) and Resident #31 (R31) on 8/15/22.

Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for two of five CNA (certified nursing assistant) record reviews. The facility staff failed to provide the evidence of required certification for two of five CNAs that were employed for greater than one year, CNA #2 and CNA #4.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete infection control program during the medication administration observation for Resident #20, and failed to implement infection control practices for the storage of a resident's Yankauer suction catheter for one of 66 residents in the survey sample, Resident #112 (R112).

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to ensure one of one kitchens were free of ants.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for four of 52 residents in the survey sample, Residents #22, #47, #58 and #35.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan for three of 52 residents in the survey sample, Residents # 47, # 58 and #35. The facility staff failed to administer oxygen to Resident # 47, #58 and #35 at the prescribed flow rate according to the physician's orders.

Inspectors wroteBased on resident interview, clinical record review, facility document review and staff interview, it was determined that the facility staff failed to evidence a complete and current communication plan with the dialysis (1) center for one of three residents receiving dialysis, Resident #57.

Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined the facility staff failed to complete annual performance reviews and competencies for six of 22 CNAs (certified nursing assistants) that were employed for greater than one year, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8.

Inspectors wroteBased on observation, resident interview, staff interview, clinical interview and facility document review it was determined facility staff failed to secure prescribed medications for one of 52 residents in the survey sample, (Resident #104) and failed to label and store drugs and biologicals in a safe and secure manner in two of six medication carts, (Wing A medication cart-one, Wing A medication cart-two), and failed to ensure expired medications and biologicals were not available for use, in two of six medication carts and one of three medication storage rooms, (Wing A medication cart-one, Wing A medication room and Wing B medication cart-one).

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review it was determined facility staff failed to ensure confidentiality and privacy of medical information for one of 52 residents in the survey sample, Resident #50. A facility staff member and a hospice nurse were heard and observed discussing Resident #50's medical information in the hallway, with Resident #78 present in the hallway.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for documentation of a resident assessment for one of 52 residents in the survey sample, Resident #118. The facility staff failed to document in the clinical record the assessment completed to determine and declare the death of Resident #118 on 3/3/2021.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide ADL (activities of daily living) care for one of 52 residents in the survey sample, Resident #75, who was coded as dependant on staff for personal hygiene. The facility staff failed to provide nail care to Resident #75. Resident #75 was observed with long nails and a jagged broken nail on the middle finger of the left hand.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one of 52 residents in the survey sample, Resident #77. The facility staff failed to follow the physician's order for thickened liquids during the medication administration for Resident #77. On 3/17/21 at approximately 9:05 a.m., Resident #77 was administered their medication with regular water.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement professional standards of practice for the prevention of a pressure injury for one of 52 residents in the survey sample, Resident #22. The facility staff failed to frequently assess the skin under Resident #22's splints. On 12/15/20, the resident developed a pressure injury on the right arm.

Inspectors wroteBased on resident interview, staff interview and clinical record review, it was determined that the facility staff failed to ensure the medication regimen was free from unnecessary medications for one of 52 residents in the survey sample, Resident # 35. The facility staff failed to attempt or implementation non-pharmacological interventions prior to the administration of as needed pain medication to Resident #35.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for three of 52 residents in the survey sample, Residents #22, #118 and #35.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess two of five residents in the immunization review, Residents # 75 and # 46.

Inspectors wrote10. The facility staff failed to evidence that Resident #163 and/or their Responsible Party (RP) was provided with written information and the opportunity to formulate advance directives at the time of admission and that periodic reviews were conducted with the resident and/or their RP to ascertain if they wished to formulate advance directives. Resident #163 was admitted to the facility on [DATE]; diagnoses included but are not limited to paranoid schizophrenia, insomnia, diabetes, and major depressive disorder. The most recent MDS (Minimum Data Set), a quarterly assessment, with an ARD (Assessment reference date) of 5/5/19, coded the resident as scoring a 15 out of 15 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had no cognitive impairment for daily decision making. [...]

Inspectors wrote4. The facility staff failed to notify Resident #92's physician when the resident presented with a significant weight gain in March 2019. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to diabetes, heart failure and anxiety disorder. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/5/19, coded the resident as being cognitively intact. Section K inaccurately coded Resident #92 as having a weight loss of five percent or more in the last month or weight loss of ten percent or more in the last six months. Review of Resident #92's clinical record revealed the following weights: [...]

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide written notification to the resident/representative and/or ombudsman regarding transfers to the hospital for six of 71 residents in the survey sample, Residents #70, #140, #92, #50, #157, and #96. 1. Resident #70 was transferred to the hospital on 5/6/19. The facility staff failed to provide written notification of the transfer to Resident #70 and/or the resident's representative. 2. Resident #140 was transferred to the hospital on 4/16/19. The facility staff failed to provide written notification of the transfer to Resident #140 and/or the resident's representative. 3. Resident #92 was transferred to the hospital on 3/28/19. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. 4. [...]

Inspectors wrote6.a. The facility staff failed to implement Resident #144's comprehensive care plan for left gluteal fold (an area associated with the buttocks) wound care on 6/8/19. Resident #144 was admitted to the facility on [DATE]. Resident #144's diagnoses included but were not limited to heart failure, pain and diabetes. Resident #144's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 4/29/19, coded the resident as being cognitively intact. Section G coded Resident #144 as requiring extensive assistance of two or more staff with bed mobility. Review of Resident #144's clinical record revealed an initial non-decubitus (pressure) skin injury record dated 5/9/19 that documented Resident #144 presented with a left gluteal fold abrasion. [...]

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure three of 71 residents in the survey sample, received care and services in accordance with professional standards and the comprehensive care plan for Residents #158, #96, #157 and #144. 1. The facility staff failed to administer medications, Lasix and Digoxin to Resident #158 per the physician orders. 2. The facility staff failed to administer medication, Digoxin, per the physician orders for Resident #96. 3. The facility staff failed to administer an antibiotic per the physician order for Resident # 157. 4. The facility staff failed to provide treatment per physician's order for Resident #144's left gluteal fold (an area associated with the buttocks) abrasion on 6/8/19.

Inspectors wroteBased on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services consistent with professional standards of practice, the comprehensive person-centered care plan for four of 71 residents in the survey sample, Resident #158, #157, #76 and #27. 1. The facility staff failed to administer oxygen per the physician order for Resident #158. 2. The facility staff failed to store oxygen tubing in a sanitary manner for Resident #157. 3. The facility staff failed to administer oxygen per the physician order for Resident # 76. 4. The facility staff failed to obtain a physician's order for Resident #27's use of an incentive spirometer (1) and failed to ensure the incentive spirometer (1) mouthpiece in a clean and sanitary manner.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide pharmacy services for three of 71 residents in the survey sample, Residents # 158, #96 and #76. 1. The facility staff failed to provide the medication Apixaban for administration to Resident #158 as ordered by the physician. 2. The facility staff failed to provide the medications Potassium Chloride Solution, Keppra, Carvedilol, and Tramadol for administration to Resident #96 as ordered by the physician. 3. The facility staff failed to provide medication Tramadol for administration to Resident #76 as ordered by the physician.

Inspectors wroteBased on observation, staff interview, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for three of 71 residents in the survey sample, Residents #135, #51 and #30. 1. The facility staff failed to maintain Resident #135's pillowcase in good repair. 2. The facility staff failed to maintain a pillow in Resident #51's former room in good repair. 3. The facility staff failed to maintain Resident # 30 bed pillows in good repair.

Inspectors wroteBased on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement abuse policies for two of ten employee records (OSM [other staff member] #9 and OSM #10). The facility staff failed to implment the abuse policy to obtain reference checks at the time of hire for Other Staff Member (OSM) #10 and OSM #9.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to complete quarterly MDS (minimum data set) assessments for three of 71 residents in the survey sample, Residents #1, #2, and #3. 1. The facility staff failed to complete Resident #1's quarterly MDS assessment at least every 92 days. The last MDS assessment completed was the admission assessment with an assessment reference date of 1/18/19. 2. The facility staff failed to complete Resident # 2's quarterly MDS assessment at least every every 92 days. The resident's most recent completed MDS was a quarterly assessment with an ARD (assessment reference date) of 01/16/2019. 3. The facility staff failed to complete Resident # 3's quarterly MDS assessment at least every every 92 days. [...]

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for two of 71 residents in the survey sample, Resident #30 and # 92. 1. The facility staff failed to attempt the BIMS (Brief Interview for Mental Status) interview and the Mood interview for Resident #30's quarterly MDS assessment with an ARD (assessment reference date) of 3/12/19. 2. The facility staff failed to accurately code Resident #92's weight gain on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/5/19. Instead, the resident was coded as having a weight loss.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for one of 71 residents in the survey sample, Resident #27. The facility staff failed to address Resident #27's use of an incentive spirometer (1) on the resident's baseline care plan.

Inspectors wroteBased on resident interview, resident representative interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for one of 71 residents in the survey sample, Resident #29. On 5/26/19 during the day shift, the facility staff failed to assist Resident #29 out of bed.

Inspectors wroteBased on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing of pressure ulcer for two of 71 residents in the survey sample, Residents #217 and #144. 1. The facility staff failed to administer the prescribed physician ordered treatment to Resident #217's pressure injuries* on multiple dates in September 2018 and on 10/18/18. The October 2018 TAR documented the above order. On 10/8/18, for Resident #217. 2. The facility staff failed to provide treatment per physician's order for Resident #144's sacral pressure injury on 6/8/19.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to implement assistive device interventions, per the plan of care to prevent accidents for one of 71 sampled residents, (Resident #50). Resident #50 was observed in bed with no fall mat down at the bedside and the bed was in an elevated position.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for three of 71 residents in the survey sample, Residents #144, #29 and #140. 1. The facility staff failed to assess Resident #144 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. 2. The facility staff failed to assess Resident #29 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. 3. The facility staff failed to assess Resident #140 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails.

Inspectors wroteBased on resident interview, resident representative interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to care for a resident's needs for one of 71 residents in the survey sample, Resident #29. On 5/26/19 during the day shift, the facility staff failed to assist Resident #29 out of bed due to insufficient CNA (certified nursing assistant) staffing.

Inspectors wroteBased on staff interview, facility document review and clinical record review it was determined the facility staff failed to report an irregularity to the physician during the MRR (Medication Regimen Review) for one of 71, sampled resident, Resident #158. The facility pharmacist at the last completed medication regimen review dated 6/7/19, failed to make a recommendation to the physician requesting a documented rational for the continued use of a PRN (as needed) anti-anxiety medication ordered on 4/29/`19 for Resident #158.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure PRN (as needed) psychotropic medications were reviewed for continued use every 14 days for one of 71 residents in the survey sample, Resident #158. Resident #158 had a physician order for a PRN anti-anxiety medication that was prescribed on 4/29/19; there was no documentation in the clinical record by the physician for the continued use of this medication. Forty-five days had elapsed since the initial order.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 71 residents in the survey sample were free of significant medication errors, Resident #96 and Resident #158. 1. The facility staff failed to administer Digoxin to Resident #96 as prescribed on 5/22/19 and 5/24/19. 2. The facility staff failed to administer Digoxin to Resident #158 as prescribed on two occasions and Lasix on two occasions.

Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to ensure a complete and accurate clinical record for one of 71 residents in the survey sample, Resident # 157. The facility staff failed to ensure another resident's information was not in the clinical record of Resident #157.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post notice of employee rights regarding reporting a suspicious crime.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food at temperatures palatable for food enjoyment.