Estates of Perryville, LLC, the

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for 11 residents (Residents #2, #3, #4, #6, #8, #13, #30, #49, #59, #73, and #90) out of 20 sampled residents. The facility census was 98. Review of the facility's policy titled, Use of Psychotropic Drugs, reviewed 08/24/24, showed: - Residents who have not used antipsychotic (medication primarily used to manage psychosis (a mental disorder with a severe loss of contact with reality)) drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #11 and #13) out of 20 sampled residents and for one resident (Resident #88) outside the sample. The facility census was 98. Review of the facility's policy titled, MDS Policy, reviewed 08/02/24, showed: - The Resident Assessment Instrument (RAI) Manual serves as the policy by which the facility follows the process of completing MDS assessments. Review of the RAI Manual, dated October 2025, showed: - J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services; - Code all high-risk drug class medications according to their pharmacological classification, not how they are being used; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive care plan with specific interventions tailored to meet individual needs for two residents (Residents #4 and #13) out of 20 sampled residents. The facility census was 98. Review of the facility's policy titled, Care Plan and Care Plan Conference, dated 08/24/24, showed:- A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders when administering medications for five residents (Residents #4, #17, #30, #49, and #86) out of 12 residents. The facility census was 98. Review of the facility policy titled, Physician Orders, dated 08/24/24, showed: - Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Medication Technicians (CMT) are expected to review orders prior to administering medications and/or performing a treatment; - The RNs, LPNs, and CMTs are to follow the orders as written. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnosis of hypertension (high blood pressure); - An order for clonidine (a blood pressure medication) 0.1 milligrams (mg) by mouth four times a day for hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 36 opportunities with two errors made, for an error rate of 5.56%, which affected two residents (Residents #17 and #86) out of six sampled residents. The facility census was 98. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures for four residents (Residents #7, #25, #57, and #73) out of 20 sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 99. Review of the facility's policy titled, Food Temperature Control, dated February 2024, showed:- All potentially hazardous foods will be stored, prepared, held, and served at proper temperatures;- Food temperatures will be monitored, documented, and corrective action taken when necessary;- Temperature standards for hot food: greater than or equal to 140 degrees Fahrenheit ( F). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and promote an environment which recognized each resident's rights for one (Resident #1) out of six sampled residents. Resident #1, who is responsible for his/her own decisions, was restricted from an independent leave of absence (LOA) from the facility. The facility's census was 88. Review of the facility policy titled, Resident Rights, dated 01/24/25, showed: - It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. [...]

Inspectors wroteBased on record review and interview the facility failed to provide adequate supervision for one of three sampled residents. Resident #1 was assessed as needing 24-hour supervision for safety and had a history of making suicidal threats/ideations and aggression towards others and staff. The resident exited the facility's secured behavioral unit without staff knowledge and was gone for approximately 12 hours. Facility staff failed to implement the facility policy for rounding and making observations of residents. While away from the facility, the resident used a broken piece of glass and attempted suicide by inserting it into her skull. The facility census was 100. The administration was notified on 09/11/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 09/06/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when another resident (Resident #2) open handed slapped the resident, in the face three times. Resident #2 said Resident #1 had behaviors that bothered him/her and hit Resident #1 repeatedly. Resident #1 sustained contusions, redness, and swelling to the right side of his/her face and was sent to the Emergency Department (ED) by ambulance. The facility census was 103. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 04/08/24 showed:Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a staff member punched the resident in the face. Resident #1 was observed with escalating behaviors and pushed a staff member. Certified Nurse Aide (CNA) A approached the fighting resident and staff member and proceeded to punch Resident #1 with a closed fist, in the right eyesocket. This resulted in an injured eyelid and broken nose for Resident #1. The census was 101. The administration was notified on 06/10/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 06/05/25. On 06/05/25, upon notification, the facility administration immediately started an investigation, notified the police department and the Department of Health and Senior Services of the physical abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to have documenation of one resident with serious mental illness and intellectual disability diagnoses (Resident #1's) Level I preadmission screening/resident review (PASRR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities (IDD) completed before admission to the nursing facility or the more indepth Level II PASRR screening in the resident's record to ensure they were able to meet the resident's behavioral needs. The census was 74. The facility did not provide a policy related to PASRR screenings. Review of Resident #1's medical records showed: -The resident is his/her own responsible party; -The resident had diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Residents #1) 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). The facility's census was 101. The facility did not provide a policy on trauma-informed care or behavioral health management. Review of Resident #1's face sheet showed: - The resident was his/her own responsible party; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide staff with appropriate behavioral health training to develop competencies and skill sets in order to to provide services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for one sampled resident (Resident #1) when staff failed to implement de-escalation interventions when Resident #1 began exhibiting increased behaviors. The facility census was 74. The facility did not provide a policy on behavioral health management. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one resident (Resident #1) with severe mental illness and behaviors, when Resident #1 displayed agitated behaviors and staff did not attempt to de-escalate. The census was 74. The facility did not provide a policy on behavioral health management. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse from another resident when staff failed to prevent Resident #2 from hitting Resident #1 which caused a hematoma (a collection of blood outside of the blood vessel) to the left side of the head. The facility also failed to ensure the resident was free from abuse from staff when staff removed Resident #1 from his/her room against their will, and rolled him/her onto a blanket and dragged the resident on the floor through the facility causing the resident to become anxious and require medication to calm down. The census was 120. On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for two sampled residents (Resident #1 and #2) when staff failed to implement interventions preventing Resident #2 from hitting Resident #1 and interventions preventing staff from physically moving Resident #1 against his/her will. The census was 120. On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding the unit staffing needs or specialized training needed to work on a locked behavior unit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 115. Review of the facility's Handwashing policy, undated, showed: - Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures; - Wash hands and exposed portions of arms immediately before engaging in food preparation; - When to wash hands: after handling garbage or garbage cans, dirty trays or dishes, or anything soiled; as often as necessary during food preparation to remove soil/contamination, and to prevent cross contamination when changing tasks; any time a contaminated surface is touched; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal (peri) care (cleaning the genital and anal areas of the body) for two residents (Resident #4 and #66) outside the sample. The facility failed to implement enhanced barrier precautions (EBP) during perineal and wound care for one resident (Resident #6) out of 23 sampled residents and failed in the prevention of communicable disease in regard to tuberculosis (TB-a communicable disease that affects the lungs and is characterized by fever, cough and difficulty breathing) screening/testing of two residents (Resident # 8 and #23) out of five sampled residents. The facility's census was 115. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-24-08-NH, dated 03/20/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 115. Review of the facility's policy, Pest Control, dated 08/24/24, showed: - This facility will ensure the facility remains clean and free from pests; - Daily cleaning of facility will be maintained; - Monthly contracted pest control company will treat inside and outside of facility; - Entry points to facility will be kept in good repair; - Residents will be provided bags for their snacks they keep in their rooms. Observation of the kitchen on 12/01/24 at 7:17 P.M. showed: - Approximately two dozen live cockroaches in the oven that scattered when the oven door was opened; - A live cockroach crawling up the wall near the coffee maker. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 115. Review of the facility's policy, Maintenance Repair Policy, dated 08/24/24, showed: - All team members are orientated to the Maintenance Work Order log located at each nurses' station; - Any team member can complete the Maintenance Work Order; - Maintenance personnel shall address routine maintenance work orders throughout the day, within 24 hours, or the next business day; - Emergency work orders shall be addressed upon notification; - In the event a work order has not been addressed within the timeframe specified, any team member will contact the Maintenance Director; - A log of these work orders shall be retained by the Maintenance Director; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #12 and #96) were free from physical abuse when one resident (Resident #27) struck Resident #12 on the right side of the face and later that day, struck Resident #96 in the face. The facility's census was 137. Review of the facility's Abuse, Neglect and Exploitation Policy, updated 04/08/24, showed: - Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion; - Resident must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident family members, legal guardians, friends or other individuals; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for ten residents (Resident #8, #12, #15, #23, #26, #33, #35, #95, #111, and #315) out of 23 sampled residents and two residents (Resident #27 and #216) outside the sample. The facility's census was 115. Review of the facility's policy, Admission, Transfer and Discharge, revised 08/24/24, showed: - The facility may transfer or discharge the resident in compliance with facility standards and are as follows, but not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for nine residents (Resident #12, #15, #17, #23, #26, #33, #95, #111, and #315) out of 23 sampled residents, and three residents (Resident #5, #84, and #216) outside the sample. The facility's census was 115. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - It is the policy of this facility to notify the resident/responsible party of the bed hold policy. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #33 and Resident #57) out of 23 sampled residents and one resident (Resident #113) outside the sample. The facility's census was 115. Review of the facility's policy titled, MDS Policy, revised 08/02/24, showed: - Purpose: In Medicare, MDS stands for Minimum Data Set. It's a federally mandated process that involves a standardized assessment of each resident's health and functional capabilities in nursing homes certified by Medicare and Medicaid. The MDS assists nursing home staff identify health issues and potential problems, strengths, and preferences for residents. The assessment is completed electronically and transmitted to the state; - Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for six residents (Resident #9, #23, #33, #56, #57 and #87) out of 23 sampled residents. The facility's census was 115. Review of the facility's policy titled, Care Plan Policy, reviewed 08/24/24, showed: - A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents; - A comprehensive care plan will be generated through collaboration with the interdisciplinary team (IT), resident and responsible party, to be completed by the 21st day of admission; - The care plan will reflect a problem, goal and interventions to guide the IT team to assist the resident in achieving the desired outcome for a specific problem; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #8, #15, #20, and #57) out of 23 sampled residents and one resident (Resident #5) outside the sample. The facility's census was 115. Review of the facility's policy titled, Physician Orders, updated 08/24/24, showed: - The purpose of this policy is to ensure our residents receive the care prescribed by their physician; - Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Medication Technicians (CMTs) are expected to review orders prior to administering medications and/or performing a treatment; - The RNs, LPNs, and CMTs are to follow the orders as written. Review of the facility's document titled, Scale/Weights Action Timeline, undated, showed on September 11, 2024, temporary scales purchased. All non-wheelchair bound residents weighed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing program of activities to meet the interests and physical, mental, and psychosocial well-being of each resident. This practice affected three residents (Resident #8, #15, and #111) out of 23 sampled residents and four residents (Resident #5, #67, #82, and #102) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 115. Review of the facility's Activities Policy, reviewed 08/24/24, showed: - The purpose is to ensure that all residents of the facility have access to meaningful and engaging activities that enhance their quality of life, meet individual needs, and comply with state and federal regulations, including the Centers for Medicare & Medicaid Services (CMS) regulations; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) or contraindication for a GDR for two residents (Resident #15 and #20) out of 23 sampled residents. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility's census was 115. The facility did not provide a policy regarding GDRs. 1. Review of Resident #15's medical record showed: - An admission date of 04/23/21; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected two residents (Resident #111 and #315) out of 23 sampled residents and three residents (Residents #61, #77, and #83) outside the sample and had the potential to affect all residents in the facility. The facility's census was 115. The facility did not provide a food temperature policy. Observation of the lunch meal on 12/03/24 at 1:15 P.M. showed: - Macaroni salad with a temperature of 60 degrees Fahrenheit (F); - Pears with a temperature of 55 degrees F; - Deviled egg with a temperature of 51 degrees F; - Tomato with a temperature of 58 degrees F. Review of the steam table temperature logs for October and November showed: - No logs provided for the month of October; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 97. The facility did not provide a policy. Review of the facility's current employee list, dated 09/24/23, showed a hire date of 09/16/22 for the Dietary Manager (DM). During an interview on 09/26/23 at 10:59 A.M., the Administrator said she did not know the DM had been in her position for almost a year. She was aware the DM was not certified. The employee will be enrolled in an online course to start the certification process to meet the dietary manager requirement. During an interview on 09/27/23 at 11:19 A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to maintain proper infection control practices for glucose monitoring for one resident (Resident #15) out of 20 sampled residents and five residents (Resident #5, #7, #34, #38, and #65) outside of the sample, and failed to perform hand hygiene during medication administration for one resident (Resident #15) out of 20 sampled residents and two residents (Resident #34 and #65) outside the sample. The facility census was 97. 1. The facility failed to provide a policy regarding Legionella. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected ten residents (Resident #15, #22, #31, #43, #52, #55, #73, #86, #87, and #89) out of 20 sampled residents, five residents (Resident #28, #58, #71, #88, and #303), outside the sample, and had the potential to affect all residents. The facility's census was 97. Review of the facility's Pest Control Policy, last revised March 2022, showed: - The facility will remain clean and free from pests; - Daily cleaning of facility will be maintained; - Monthly contracted pest control company will treat inside and outside of facility; - Entry points will be kept in good repair; - Residents will be provided bags for snacks they keep in rooms. 1. Observation of Resident #15 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and a community shower, which put residents at increased risk for burns caused by scalding water. This practice affected five residents (Resident #15, #47, #56 #67, and #77) out of 20 sampled residents and seven residents (Resident #1, #26, #9, #53, #65, #75, and #90) outside the sample. This practice could have potentially affected all residents. The facility census was 97. Review of the Burn Foundation website showed hot water causes third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting of resident personal funds with the balance of those funds within thirty days of discharge for one resident (Resident #203) out of two closed records sampled in the resident fund review. The facility also failed to notify one sampled resident (Resident #15) out of 20 sampled residents and four residents (Resident #7, #13, #45, and #59) outside the sample and/or the responsible parties of the resident's fund balances remaining above $5,762.00 (the limit which should trigger a notification) for the months of August 2023 and September 2023. The facility census was 97. Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/23, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of resident's personal funds) for at least one and one half times the average monthly balance of the resident's personal funds for the last 12 consecutive months from September 2022 through August 2023. The facility census was 97. Review of the facility's policy titled, Management/Protection of Residents Funds, revised 04/03/2019, showed the facility has a surety bond to assure the security of the resident's personal fund deposited with facility. Review of the resident's personal funds account for the last 12 consecutive months from September 2022 through August 2023 showed: - The facility's approved bond amount equaled $100,000.00; - The average monthly balance of the resident's personal funds equaled $85,598.03; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required time frames for 13 residents (Resident #14, #15, #17, #18, #21, #29, #31, #34, #48, #54, #55, #68, and #89) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility) within the required timeframe for ten residents (Resident #14, #17, #18, #21, #29, #31, #34, #35, #47, and #55) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner and in accordance with guidelines for nine residents (Resident #14, #18, #31, #34, #35, #47, #54, #55, and #89) of 20 sampled residents. The facility census was 97. Review of the facility's policy titled, Policy and Procedure for MDS Assessments and Transmissions, dated 12/15/20, showed: - It is the policy of this facility to ensure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline; - Resident assessments will be initiated in accordance with the automated data processing requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for one resident (Resident #47) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy titled, Physician/Medication Order Policy, last reviewed 12/2018, showed: - For written transfer orders, implement if signed and dated by the resident's current attending physician; - If not signed by the current attending physician, the receiving nurse should verify the order with the current attending physician. Review of Resident #47's medical record showed: - Latest admission date of 09/08/2023; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for a Foley catheter (a flexible tube inserted into the bladder to drain urine), catheter care, and provide a diagnosis for the use of a catheter for one resident (Resident #47) out of 20 sampled residents The facility census was 97. Review of the facility's policy titled, Catheter Care Protocol, updated on 02/2021, showed: - Skin care guidelines should be followed once a day and more often as needed. Review of Resident #47's medical record showed: - An admission date of 03/24/21; - admitted to the hospital on [DATE] and returned to the facility on [DATE] with a Foley catheter; - No diagnosis for a Foley catheter; - The September 2023 Physician's Order Sheet, (POS) showed no order for the Foley catheter or for catheter care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #14) 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 20 sampled residents. The facility's census was 97. The facility did not provide a policy. Review of Resident #14's electronic medical record (EMR) showed: - admitted on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 97. Review of the facility's policy titled, Storage and Labeling of Medications, updated 2/13/23, showed: - Medications and biologicals are stored safely, securely and properly, following the manufacturer's recommendations or those of the supplier; - The facility receives medications dispensed by the provider pharmacy in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medication from one container to another or return partially used medication to the original container; - All medications dispensed by the pharmacy are stored in the container with the pharmacy label; [...]