Fair Havens Senior Living

Inspectors wroteBased on interview and record review, the facility failed to complete wound monitoring and failed to follow Physician's orders for wound care for one resident (R8) and failed to transcribe and provide Physician ordered wound care for one resident (R6). This failure affects two (R8, R6) of three residents reviewed for wound care in the sample list of 22. This failure resulted in R8's left foot wound becoming infested with parasitic fly larvae (maggots) and leaving R6 feeling mortified and upset. Findings Include: R8's Census Detail and Minimum Data Set List (undated) documents R8 was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a comfortable and safe temperature level between the temperature range of 71 to 81 F for two (R10 and R19) of three residents reviewed for comfortable environment in the sample list of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents remained free from physical abuse for two (R3, R4) of three residents reviewed for abuse in a sample list of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a sanitary kitchen by not covering porous construction surfaces in food preparation and cooking areas, failed to obtain food service temperatures at each meal and failed to maintain an effective pest control program. These failures have the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide two (R4, R5) residents their entire physician ordered diets out of five reviewed for Dietary Services in a sample list of five residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of an indwelling (foley) catheter anchoring device for three (R1, R4, R5) of four (R1, R3, R4 and R5) residents reviewed for catheters in the sample of six residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to place the call light within reach of one (R2) of five (R1, R2, R3, R5 and R6) residents reviewed for alternative communication methods in the sample of six residents.

Inspectors wroteBased on observation, interview, and record the facility failed to maintain an effective pest control program by failing to ensure sanitation interventions were implemented according to their pest control policy for three (R2, R4, R7) of five residents reviewed for insects on the sample list of seven and has the potential to affect all 91 residents residing in the facility. The facility's Pest Control Policy with a revision date of 2/3/2022 contains documentation stating the facility shall maintain an effective pest control program. This policy contains prevention and intervention which includes eliminating sites of breeding and entry and regularly removing garbage and trash. On 4/30/2026 at 9:30 AM, food debris was covering the floor in the kitchen preparation and storage areas. There were cardboard boxes sitting on top of a wet floor. The bottom of the boxes was wet. On 4/30/2026 at 9: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free from physical abuse for four (R3, R6, R7, R10) of six residents reviewed for abuse on the sample list of twelve residents. Findings 1. The facilities abuse investigation dated 3/15/2026 at 8:45 PM documents that R3 became agitated with R10 accusing R10 of being in R3's house. R3 began hitting R10 on the head with a shoe. This investigation documents V10 Licensed Practical Nurse witnessed R3 hitting R10 on the head with a shoe. On 3/24/2026 at 12:46 PM, when asked about the incident occurring on 3/15/2026 at 8:45 PM, R10 stated R10 recalls being hit a few times with a shoe by R3. R10 stated R3 was accusing R10 of being in R3's home. R10 stated this interaction scared R10. R10 stated the shoe was a house slipper. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure transportation staff were trained according to manufacturer's instructions to safely secure a wheelchair in the transportation van and failed to check a security strap when a resident reported movement of the wheelchair. These failures resulted in R3 sliding forward in the wheelchair when the transportation van was moving down a hill away from the facility which then resulted in the wheelchair flipping forward and R3 sliding out of the wheelchair onto the floor causing R3's left leg to become entangled in the foot pedal and underneath R3's body. After landing on the floor from the wheelchair, R3 was screaming in severe pain and sustained a 17-centimeter laceration to the left lower leg which required eight sutures and fractures of the left tibia and fibula (lower leg) which required hospital admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R1) of eight residents reviewed for abuse in the sample of list of eight. This failure resulted in R1 obtaining fingernail marks and bleeding to the right forearm when R2 scratched R1 during a physical altercation. Findings Include:The Facility Abuse Prevention and Reporting policy effective 11/2017, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. [...]

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to protect the dignity and psychosocial wellbeing for two residents (R26, R69) reviewed for dignity out of a sample list of 49. This failure resulted in psychosocial harm for R26, R69 with feelings of disrespect. Findings Include: 1.) The Minimum Data Set, dated [DATE] documents that Resident R26 is severely cognitively impaired, requires maximum assistance with activities of daily living, and has a diagnosis of dementia. On 12/07/2025 at 8:30 AM, R26 was observed lying in bed on the left side, with the right side of the head positioned partially on a pillow and partially against the wall. The wall next to the bed, which was flush with the west wall, had noticeable dried brown hand wipes on the white surface. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly transfer a resident (R2) for one of two residents reviewed for accidents in the sample list of 49. This failure resulted in bruising and pain to R2's right leg.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hygienic catheter care, monitor urinary catheter output, and timely treat symptoms of urinary tract infection for three of four residents (R2, R5, R49) reviewed for urinary catheters/urinary tract infections (UTIs) in the sample list of 49. These failures resulted in R49 developing urinary retention, UTI, urosepsis, acute kidney injury, and hydronephrosis that required hospitalization and urinary stent placement.

Inspectors wroteF575 Required PostingsBased on observation, interview, and record review the facility failed to post the name, address, and telephone number of the state agency in an accessible location in the facility. This failure has the potential to affect all 95 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve meals at the posted times. This failure has the potential to affect all 95 residents in the facility. Findings Include:On 12/10/25 Record Review of DIET [NAME] SERVICES POLICY documents the dietary department shall maintain and keep current a policy and procedure manual inaccordance with applicable state and local requirements for food-service that ensures efficient operation and delivery of appropriate food service to residents. The policy further documents three (3) well-planned meals will be served at regularly scheduled hours. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/7/25 documents a census of 95 residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's right to be free from misappropriation of medications by an employee. This failure affects five of five residents (R11, R49, R2, R14, R51) reviewed for misappropriation of medications in the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered for two of six residents (R2, R49) reviewed for medication administration in the sample list of 49. This failure resulted in 8 errors out of 25 opportunities (a 32% medication error rate).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications are administered timely resulting in significant medication errors for three of five residents (R2, R49, R56) reviewed for medication errors in the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not expired, discard discontinued medications, ensure multiuse vials were labeled with opened dates, maintain medications in their original packaging, and lock the medication cart when not in use. This failure affects five of six residents (R2, R17, R49, R51, R14) reviewed for medication storage in the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate infection control practices during medication administration, failed to wear appropriate (Personal Protective Equipment (PPE)) when caring for residents on EBP or Contact Precautions, failed to post proper signage for residents requiring EBP or Contact Precautions, failed to ensure PPE supplies were readily available outside resident rooms for ten (R2, R7, R8, R18, R21, R30, R49, R56, R64, R89) out of ten residents reviewed for Infection Prevention and Control on a sample list of 49. These failures have the potential to compromise resident safety and increase the risk of transmission of infectious agents.

Inspectors wroteBased on observation, interview, and record review the facility failed to reassess blood pressure with a manual cuff to verify accuracy and report an elevated blood pressure to the physician for one of six residents (R2) reviewed for medication administration in the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pressure relieving interventions for one of two residents (R49) reviewed for pressure ulcers in the sample list of 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer gastrostomy tube feeding per physician's order and facility policy for one of one resident (R7) reviewed for gastrostomy tubes in the sample list of 49.

Inspectors wroteBased on interview and record review the facility failed to offer and administer pneumococcal vaccinations for two (R21,R53) of five residents reviewed for immunizations on a sample list of 49. This deficient practice has the potential to place residents at an increased risk for developing pneumonia.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean, safe, sanitary environment to prevent cross contamination of food service areas and cooking utensils, free of German cockroach infestation. This failure has the potential to affect all 95 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a qualified licensed nurse administered medication to an undetermined number of residents. This failure has the potential to affect all 95 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to prevent cockroaches in the kitchen and serving/steam table area. This failure has the potential to affect all 95 residents in the facility. Findings Include:On 11/21/25 at 2:06pm Policy and Procedure: Pest Control Policy and Procedure dated 2/3/2022 documents this facility shall maintain an effective pest control program. On 11/19/25 at 9:40 AM the floor areas throughout the resident meal serving/steamtable area adjacent to the kitchen was observed with remnants of pest/cockroaches on glue boards and remnants/carcasses of dead cockroaches were also noted on the back counter/back splash area. [...]

Inspectors wroteBased on record review and interview the facility failed repeatedly, to provide a dependent resident (R7) showers. R7 is one of six residents reviewed for Quality of Care on the sample list of 35.

Inspectors wroteBased on record review and interview the facility failed to maintain a Schedule IV, Controlled substance medication supply in a timely manner for one of sixteen residents (R13) reviewed for medication on the sample list of 35.

Inspectors wroteBased on interview and record review the facility failed to administer medication as ordered by the physician for one (R4) of 17 residents reviewed for medication administration in a sample list of 35. R4's care plan documents R4 admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur, Chronic Ulcer of Other Part of Right Lower Leg, Chronic Ulcer of Other Part of Left Lower Leg, and Abnormalities of Gait and Mobility. On 12/2/25 at 10:30am record review documents on 10/23/2025 at 2:15pm a physician's order was obtained for Hydromorphone HCl (pain) Oral Tablet 4 MG. Directions are to give 1 tablet by mouth every six hours as needed for pain. On 12/2/25 at 10:45am Record review of the Controlled Drug Receipt/Record /Disposition form documents R4 was administered on the following dates and times at less than six-hour intervals: [...]

Inspectors wroteBased on interview and record review the facility repeatedly failed to document administration of medication on the Medication Administration Record for one (R4) of three reviewed for medication administration. Findings Include:The Undated MEDICATION/TREATMENT ADMINISTRATION RECORD POLICY documents It is the policy of this facility that each medication/treatment administered will be promptly documented in the medication record after administration. The policy documents the purpose is to validate residents are receiving drugs and biologicals as ordered by the physician. 9. Documents Nursing personnel administering medication/treatments will abide by all Medical Records Policies. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a physician ordered wound treatment for one (R4) of three residents reviewed for treatments in the sample list of 35. Findings Include:The Undated MEDICATION/TREATMENT ADMINISTRATION RECORD POLICY documents It is the policy of this facility that each medication/treatment administered will be promptly documented in the medication record after administration. The policy documents the purpose is to validate residents are receiving drugs and biologicals as ordered by the physician. 9. Documents Nursing personnel administering medication/treatments will abide by all Medical Records Policies. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision during a shower (R19) and failed to provide supervision outside during smoking (R7) which resulted in falls. R19 and R7 are two of three residents reviewed for falls on the sample list of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a urinary indwelling catheter tube in a secure manner, to prevent pain for one of three residents (R1) reviewed for indwelling urinary catheters on the sample list of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a resident room free of odors from urine-soaked clothing. This failure affects one of three resident (R7) review for laundry services on the sample list of 35.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care for a resident dependent on staff for hygiene. This failure affects one (R7) of three residents reviewed for Activities of Daily Living in the sample list of eleven.

Inspectors wroteBased on interview and record review, the facility failed to remove a washcloth from the adult incontinence brief after cares were provided. This failure resulted in R2 experiencing a foul odor causing R2 to feel humiliated and embarrassed while in public. R2 was one of three residents reviewed for quality of care on a sample list of nine.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of two residents (R4, R2) out of two reviewed for dignity in a sample list of nine.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (R11) from verbal abuse for one of three residents reviewed for verbal abuse on a sample list of nine. Findings Include: Facility Abuse Prevention Program policy effective 10/2022, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure hot food was served to for three residents (R1, R2, R3) out of three reviewed for dietary services in a sample list of nine. Random observations were completed on 7/24/25 through 8/4/25 related to dietary services, during observations the hall tray cart was delivered to the hallway and nursing staff would deliver trays to the residents. The trays contained the afternoon meal on a plate with a cover. No hot plate under the ceramic plate to keep the food warm. The trays also contained cold food and the drinks. On 7/24/25 at 12:00 PM, the lunch food cart was delivered to the 300 hall by kitchen employee, nursing staff did not pass the trays for 12 minutes to residents. On 8/4/25 at 12:07pm the lunch cart was delivered to the 300 hall, nursing staff passed the meals from the cart at 12:18pm. [...]

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to provide sufficient linens to ensure a safe sanitary environment for residents. This failure has the potential to affect all 98 residents who reside in the facility. Findings Include: The facility's Daily Census dated 6/2/25 documents a total of 98 residents reside at the facility. On 6/2/25 at 8:50AM, one washing machine was working out of three in the facility and two driers were running and two were broken. In a locked cabinet in the laundry room and on 100 East Hall approximately three dozen each hand towels and washcloths where stored. On 6/2/25 at 8:50AM, V15, Housekeeping Aide stated that most of the time V15 hears the Certified Nursing Assistants asking for more linens and they run out especially on the weekend. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide showers for five residents (R1, R7, R19, R21, R22) of eight residents reviewed for Activities of Daily Living (ADLs) in a sample list of 24. Findings Include: On 6/2/25 at 12:37PM, the Resident Counsel President, [NAME] President and residents that normally attend Resident Counsel Meetings were at the table in the activities room. R1, R7, R19, R21 and R22 all had food on their shirts, oily appearing hair, and dirt under their nails. R19 had food on his beard. On 6/2/25 at 12:37PM a Resident Council Meeting was conducted with R1, R7, R19, R21 and R22. During this meeting, R1, R7, R19, R21 and R22 stated they have not had showers in the past week, and staff are stating to residents there are no linens. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for controlled medications and document shift to shift controlled medication counts for seven (R3, R4, R5, R9, R15, R16, R22) of seven residents reviewed for controlled medications in the sample list of 24.

Inspectors wroteBased on interview and record review the facility failed to administer medications timely and as ordered and timely reorder medications resulting in significant medication errors for four (R3, R15, R16, R25) of five residents reviewed for medications in the sample list of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications were stored appropriately and destroy controlled medications when discontinued for two (R3, R15) of seven residents reviewed for controlled medications in the sample list of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications according to physicians orders and manufacturer recommendations for five of 15 residents (R1, R2, R3, R4 and R14) reviewed for medication administration on the sample of 15. The facility had five medication errors out of 37 opportunities resulting in a medication error rate of 13.51 percent.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident from staff verbal abuse for one of three residents (R1) reviewed for abuse in the sample of 36. These failures resulted in R1 feeling intimidated and verbally abused by V4 (RN/Registered Nurse) and R1 experiencing ongoing mental anguish, fear, and anxiety.

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of abuse for one residents (R1) and protect residents from the alleged perpetrator until an investigation was completed for 36 of 36 residents (R1-R36) reviewed for protection from abuse in the sample of 36.

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of abuse to the State Agency for one of three residents (R1) reviewed for Abuse in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the shower rooms in a homelike and functional condition. This failure has the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dishwasher water temperatures at a level to sanitize dish wares. These failures have the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a qualified Social Worker for their facility with a bed capacity of 154. This failure affects all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to control of dishwasher sewer surges of water, and sink drain sewer water leakage to prevent to infestation of pests. These failures have the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain door alarms and computer based door monitoring systems in functional condition to operate as designed. This failure has the potential to affect all 102 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess residents for their smoking status, and failed to accurately encode minimum data sets for tobacco use. This failure affects three residents (R11, R12, R13) out of five reviewed for smoking status on the sample list of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to timely assess residents for risk of developing pressure ulcers, and to complete pressure ulcer treatments according to physician orders. These failures affect three residents (R4, R5, R6) out of three reviewed for wound care on the sample list of 24 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to employ a full-time Director of Nursing. This failure affects all 109 residents residing in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's right to dignified care by failing to provide timely incontinence care. This failure affected one of three residents (R7) reviewed for dignity/incontinence care on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure a resident's right to a clean, safe, comfortable homelike bathroom. This failure affects one of nine residents (R8) reviewed for resident rights/environment on the sample list of 14.

Inspectors wroteBased on record review and interview, the facility failed to report an injury of unknown origin in a timely manner, to the State Agency. This failure affects one of three residents (R1) reviewed for bruises/injury of unknown origin on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one of three residents (R1), reviewed for injury of unknown/bruises on the sample list 14.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer with a mechanical stand lift. This failure affected one of three residents (R2) reviewed for injury of unknown origin/bruises on the sample list of 14.

Inspectors wroteBased on interview and record review the facility failed to document the danger of a resident's transfer or discharge would impose on the safety of other residents nor the specific resident needs that cannot be met at the facility. This failure affects one (R1) of three residents reviewed for readmission. Findings Include: On 9/6/2024 at 11:34 PM progress note documents increasing agitation and behaviors by R1. Same note documents that R1 had hit and punched staff, then was transferred to a local hospital by EMS (Emergency Medical Services), police and fire department assisting in the transfer. On 9/6/2024 R1's medical record documents Discharge Return Anticipated MDS (Minimum Data Set) completed, submitted and accepted. On 10/31/2024 at 4:06 PM the nursing home hotline received a complaint that facility refuses to re-admit R1 to the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to employ a Director of Nurses. This failure has the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of three residents (R8, R2) residents reviewed for abuse in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care for three (R4, R6, R7) of seven residents reviewed for incontinence care in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R4) resident out of seven residents reviewed for incontinence care in a sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food storage areas and failed to maintain sanitary food service areas (floors, walls, equipment surfaces). These failures have the potential to affect all 98 residents in the facility. Findings Include: 1. On 8/11/24 at 8:31 AM the kitchen walk-in cooler floor had food debris and packets of unopened butter on the floor. 2. On 8/11/24 at 8:40 AM a fan facing the drain board area was soiled with accumulations of gray colored dust. 3. On 8/11/24 at 8:40 AM the floor areas throughout the kitchen and adjacent dishwashing areas were heavily soiled with accumulations of decomposing food and grease deposits. Thick deposits of dark grease and decomposed food covered all areas of the baseboards and adjacent floor and wall areas of the dishwashing area and kitchen. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident living spaces and resident rooms were organized, clean, and free of debris, with walls and furniture in good repair. These failures have the potential to affect all 98 residents residing in the facility. Findings Include: The facility's undated Infection Prevention and Control Manual/ Environmental Services/ Housekeeping/ Laundry policy documents the facility shall be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area in the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. On 8/11/24 and 8/12/24 at 9:15 AM the dining room floors were sticky. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to prevent drain flies and flies in the kitchen area. This failure has the potential to affect all 98 residents in the facility. Findings Include: On 8/11/24 at 8:40 AM the floor areas throughout the kitchen and adjacent dishwashing areas were heavily soiled with accumulations of decomposing food and grease deposits. Thick deposits of dark grease and decomposed food covered all areas of the baseboards and adjacent floor and wall areas of the dishwashing area and kitchen. The drain board area where staff remove clean dishes from the dishwasher was heavily soiled with food particles, dirt and grease deposits. Live drain flies and flies were observed in the area of the mechanical dishwasher. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to a dignified existence by failing to knock and gain permission before entering a resident's room and by failing to provide timely care. These failures affected five of five residents (R36, R4, R19, R40 and R78) reviewed for Dignity on the sample list of 39. Findings Include: The facility's Resident Rights Protocol for All Nursing Procedures policy dated August 2008 documents residents have the right to dignity and respect. When staff needs to enter a resident's room, the staff must first knock and gain permission before entering the resident's room. The staff must also introduce themselves if the resident is unfamiliar with them and explain the reason for their visit. 1. R36's Medical Diagnoses list dated August 2024 documents R36 has Cataracts and Anxiety. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) mask and failed to maintain and store respiratory equipment in a clean sanitary manner, off the floor and failed to date respiratory equipment when changed. These failures affect four of six residents (R14, R34, R37, R41) reviewed for respiratory/oxygen on the sample list of 39. Findings Include: The facility's Departmental (Respiratory Therapy) Prevention of Infection Policy with a revision date of August 2008 documents the following: Change pre-filled humidifier when the water level becomes low. Change the oxygen cannula and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing in a plastic bag when not in use. 1. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure a resident was deemed appropriate to self-administer medications before leaving medications unattended for residents to self-administer. This failure affected two of two residents (R72, R90) reviewed for self-administration of medications in the sample list of 39. Findings Include: The Medication Administration Policy dated March 2014 documents the same licensed nurse or QMA (Qualified Medication Aides) who prepare the medications shall also administer those medications to residents for whom they are ordered. The same policy documents residents will be positively identified (i.e. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the physician and dietician of a change in condition (significant weight change) for one of one resident (R10) reviewed for weights on the sample list of 39. Findings Include: The facility's undated Weight Assessment and Intervention Policy documents any weight change of greater than five pounds within 30 days will be retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The facility's undated Notification Of Resident Change In Condition Policy documents a licensed nurse shall promptly inform the resident, consult the resident's physician, notify the resident's legal representative or an interested family member of a significant change in the resident's physical, mental or psychosocial status. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident. This failure affects two of three residents (R72, R253) reviewed for abuse in sample list of 39. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. One way this will be done is by identifying occurrences and patterns of potential mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. [...]

Inspectors wroteBased on interview and record review the facility failed to submit information for Preadmission Screening and Resident Review (PASARR) for a Level I evaluation for one of two residents (R2) reviewed for PASARR on a sample list of 39. Findings Include: The facility's undated admission Policy documents all potential admissions will have participated in the Pre-Screening process or will have wavered rights for Medicaid funds for one year, or be approved as an emergency admit by the PASARR agency. The Facility Census Report dated 8/14/24 documents R2's admission date was 3/26/21. R2's Medical Diagnoses List dated August 2024 documents R2 is diagnosed with Delusional Disorder. On 8/12/24 at 11:46 AM V6 Social Service Director stated that no Level I or Level II PASARR had been completed for R2.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete dressing changes as ordered by the physician for one of four residents (R90) reviewed for wounds in the sample list of 39. Findings Include: The facility's Pressure/Skin Breakdown-Clinical Protocol policy dated January 2017 documents, The Physician will authorize pertinent orders related to wound treatments, including pressure redistributing surfaces, wound cleansing and debridement, dressings and topical agents. The facility nursing staff will carry out treatments as ordered by Physician. R90's Physician Order dated 7/16/24 documents Cleanse R (right) medial foot and R heel with wound cleanser/NS (Normal Saline), pat dry, apply gauze moistened betadine to wound beds, cover with (padded dressing), wrap with (gauze wrap), and secure with retention tape. Every shift (twice daily) for wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate linens including; towels, washcloths, and bed sheets, and failed to mop dirty resident room floors for four (R1, R2, R3, R4) of four residents reviewed for a clean and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to complete wound treatments,wound measurements, and wound monitoring for a resident as ordered by the primary care physician. This failure affects one resident (R4) out of three reviewed for wound care on a sample of five. This failure resulted in R4's facial wound becoming infested with parasitic fly larvae (maggots).

Inspectors wroteBased on interview and record review, the facility failed to keep accurate measurements of resident wounds and skin conditions. This failure affects two residents (R2, R4) out of four reviewed for wound care on a sample of five.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for two (R10, R11) of four residents reviewed for abuse on the sample list of 8.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Agency within two hours for two (R10, R11) of four residents reviewed for abuse on the sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to remove an alleged perpetrator from further resident contact when an allegation of abuse was received for two (R10, R11) of four residents reviewed for abuse on the sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to privacy by discussing a private personal matter in front of floor staff. This failure affects one of three residents (R1) reviewed for privacy in the sample list of nine.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for two of three residents (R1 and R2) reviewed for abuse in the sample list of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care to a resident, provide supplies for the resident to do self-oral care, and ensure oral care supplies were within reach of the resident. These failures affects two (R1, R2) dependent residents of three residents reviewed for oral care in the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to supervise and assist a resident (R1)with a transfer and ambulation which resulted in a fall and subsequent injuries. R1 was sent to the emergency room and diagnosed with a left comminuted displaced oblique humeral diaphyseal fracture, a right displaced olecranon fracture, a right angulated impacted distal radial fracture, and a right displaced base of fifth proximal phalanx fracture which required emergency treatment, overnight hospitalization, and subsequent surgery. R1 is one of three residents reviewed for accidents/falls on the sample list of four. Findings Include: The facilities Falls and Fall Risk Managing policy, dated August 2008, documents the facility will identify interventions related to a resident's specific risks in an attempt to prevent the resident from falling and minimize complications from falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician ordered urine diagnostic test in a timely manner. This failure affected one of three residents (R4) reviewed for urinary tract infections in the sample of four. Findings Include: R4's Medical Diagnoses list, dated April 2023, documents R4 was diagnosed with Type II Diabetes, Urine Retention, Neuromuscular Dysfunction of the Bladder, and Malignant Neoplasm of Bladder. R4's Physician Communication and Progress Note, dated 3/1/23, documents R4 began to have Hematuria (blood in urine), R4's physician V18 was notified, and ordered a urine sample to be collected and sent to the lab for testing. R4's Lab Services Urine Microbiology Results, dated 3/5/23, documents R4's urine was collected and sent to the lab on 3/3/23. R4's urine's microbiology results detected Klebsiella Pneumoniae and Enterococcus Faecalis. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the right to be free from physical abuse by failing to prevent R2 from hitting R1 on the face. This failure had the potential to affect two (R1, R2) of three residents reviewed for abuse on the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide redirection when wandering behaviors occurred for one (R3) of three residents reviewed for elopement on the sample list of eight. This failure resulted in R3 exiting the facility unattended and then falling onto the ground.

Inspectors wroteBased on interview and record review, the facility failed to recognize/remove an accident hazard to prevent a fall for one of three residents (R3) reviewed for falls in a sample list of six residents. This failure resulted in R3 falling and sustaining a nasal fracture and hematoma.

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (R1,R4) were free from physical abuse by another resident (R2) of three residents reviewed for abuse in a sample list of six residents. Findings Include: R2's Care Plan, revised 12/21/23, includes the following diagnoses: Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Dementia, Mood Disorder, Anxiety, Alcohol Induced Psychotic Disorder. R2's Care Plan includes the following problem: (R2) has a behavior problem cursing, Verbal and physical aggression, Refusal of care, crawling around on the floor, socially inappropriate and sexual comments, removing clothing. 1. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours 7 days per week. This failure has the potential to affect all 95 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food service equipment, failed to maintain sanitary food storage areas, and failed to maintain sanitary food service areas (floors, walls, equipment surfaces). These failures have the potential to affect all 95 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a determination of any required specialized mental health services for a resident by failing to conduct a Level 2 Pre-Admissoin Screen and Record Review (PASARR Level 2). This failure affects one resident (R2) out of two reviewed for Pre-admission Screening on the sample list of 36.

Inspectors wroteBased on interview and record review, the facility failed to have a hospice plan of care for one (R301) of two residents reviewed for hospice on the sample list of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clothing in a closet was accessible for one (R8) of 24 residents reviewed for environment on the sample list of 36.