Fairmont Rehabilitation and Healthcare Center LLC

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure there were sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being. This was a random opportunity for discovery throughout the complaint survey process. Resident Identifiers: #78, #79, #74, and #65. Facility census: 97.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident preferences were honored related to when a resident was put to bed. This was a random opportunity for discovery throughout the complaint survey process. Resident Identifier: #74. Facility Census: 97.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure it reported results of all abuse/neglect investigations to the appropriate state offices within 5 working days of the incident and/or the initial report. This was true for two (2) of 10 facility reported incidents reviewed throughout the complaint survey process. Resident Identifiers: #63 and #14. Facility census: 97.

Inspectors wroteBased on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to take corrective action to prevent further potential abuse/neglect by failing to complete education with staff on transfers. This was true of one (1) of five (5) residents reviewed for abuse during a complaint survey. Resident identifier: #102. Census: 97.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a resident's discharge documentation was completed for a resident discharged to the hospital This failed practice had the potential to affect a limited number of residents. Resident Identifier: #100. Facility Census: 97.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain adequate grooming and hygiene. This was true for two (2) out of six (6) residents reviewed for showers throughout the complaint survey process. Resident Identifiers: #78, and #79. Facility census: 97.

Inspectors wroteBased on review of policies, records, resident interviews, and staff interviews, the facility failed to protect the residents' right to be free from abuse, resulting in mental anguish for Resident #47, #34, and #83. Specifically, Resident #73 was reportedly touching female residents in the breast and vaginal area. This situation indicates that an unlimited number of female residents had the potential to be affected. The facility's lack of action to identify this unwelcome sexual contact and prevent its recurrence placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. Using the reasonable person concept, the facility's failure to protect the residents' right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #47, #34, and #83. Resident identifiers: [...]

Inspectors wroteBased on policy review, record review, resident interview, and staff interview, the facility failed to protect the residents' right to be free from abuse that resulted in mental anguish for Residents #47, #34, and #83. Resident #73 was reportedly touching female residents in the breast and vaginal area. An unlimited about of female residents had the potential to be affected. The facility's failure to thoroughly investigate, correct, and prevent inappropriate sexual contact placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. This cread an immediate jeopardy situation. Facility census: 103.

Inspectors wroteBased on staff interviews, electronic medical record, facility record review and Operation Policy the facility failed to implement their written policy for thoroughly investigating allegations of sexual abuse. This was true of one (3) of three (3) residents reviewed for sexual abuse. Resident identifiers: #34, #83 and #47. Facility census: 103. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, revealed that residents had the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. [...]

Inspectors wroteBased on facility record review, medical record review, and interview, the facility failed to ensure a resident's Medical Power of Attorney (MPOA) was notified immediately concerning an allegation of abuse and to keep the MPOA updated on the findings. This practice affected two (2) of four (4) residents reviewed. Resident identifiers: #34. Facility census: 103.

Inspectors wroteBased on policy review, observation, staff interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance to prevent accidents. The facility failed to provide a fire blanket, fire extinguisher, a metal can with a self-closing lid, and staff supervision when Resident #25 was observed smoking in the designated smoking area. Additionally, treatment carts were left unlocked and unattended on the 100 Hallway and the 300 Hallway. Resident Identifier: #25. Facility Census: 106. [...]

Inspectors wroteBased on interview, record review and investigation, the facility's management, by their inaction, and decisions in administering the facility, contributed to the following deficient practice, namely a failure to train, educate, and verify the competency of the nursing staff to ensure that they could appropriately assess and care for the resident population residing in the facility. Resident Identifiers: Resident #7 and Resident #45. Facility Census: 106. [...]

Inspectors wroteBased on interview and observations the facility failed to provide residents a confidential way to file a written grievance. This findings had the potential to affect more than a limited number of residents. Facility census: 96.

Inspectors wroteBased on record review and staff interview, the facility failed to report a five day follow up on allegations of abuse or neglect in a timely fashion to the appropriate state agencies. This was a random opportunities for discovery. Resident identifiers: #82. Facility census: 106.a) Resident #82 On 04/10/25, the facility shared an Initial Reporting of Allegations regarding alleged mental/verbal abuse to Resident #82 by Licensed Practical Nurse (LPN) #201 where she called resident an asshole. In an interview, 7/30/24 at 9:10 AM, the Administrator acknowledged the facility had failed to submit a five (5) day follow up to the appropriate state agencies. The administrator reported the facility's investigation into this incident, as well as any staff education, could not be found due to new ownership and files before 05/2025 were not available.

Inspectors wroteBased on interviews and record review, the facility failed to provide dependent residents with the assistance needed for showers and personal hygiene. This was true for three (3) of four (4) residents sampled. Resident Identifiers: #24, #72 and #76. Facility Census: 106. Findings Includea) Resident #24During an interview on 07/29/2025 at 10:39 AM, Resident #76 stated that she was scheduled for showers on Tuesday and Friday. The resident explained that the availability of showers depended on staffing levels. She further stated that she was admitted on [DATE] and her first shower occurred on 07/15/25. Record review on 07/29/25 at approximately 10:45 AM revealed that Resident #24 had received a shower on 07/15/25 and 07/19/25. The record also revealed that Resident #24 refused showers on 07/22/25 and 07/25/25. Resident denies refusing showers. She stated, I'll take anything that I can get. [...]

Inspectors wroteBased on Interview, and record review, the facility failed to ensure that the nursing staff were adequately educated and trained in the assessment and care of residents on dialysis. This failed practice had the potential to cause serious harm to any dialysis resident in the facility. The facility's failure to monitor and ensure that the nursing staff were accurately assessing resident's dialysis accesses, placed all residents on dialysis, currently residing in the facility at risk for serious bodily harm and/or death. These failures were determined to place all dialysis residents in an Immediate Jeopardy (IJ) situation. This was true for two (2) of two (2) residents sampled. Resident Identifiers: Resident #7 and Resident #45. Facility Census: 106. The facility was notified of the Immediate Jeopardy (IJ) at 11:47 AM 07/31/25. [...]

Inspectors wroteBased on facility record review and staff interviews, the facility failed to complete Nurse Aides (NA) annual evaluations. This was true for two (5) of five (5) reviewed for staffing during the Long-Term Survey Process (LTCSP). Nurse Aide Identifiers: #70, #56, #10, #96, and #100. Facility census: 106.

Inspectors wroteBased on record review and staff interview the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This failed practice had the potential to affect all residents in the facility. Facility census: 106. In an interview with the Kitchen Manager #60, on 07/31/25 at 10:30AM, he stated his Food Handlers Certification had expired on 07/06/25 and stated he thought he had a 30 day grace period and that he andEmployee #19 were scheduled for a Food Handler's Course on 07/31/25. He also stated that he was a salaried worker and works at least 40 hours weekly. On 07/31/25 at 10:35AM, during a record review of kitchen staff certifications, it was verified that employees identified as #60 and #19 were working in the kitchen on expired Food Handlers Certifications. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the Kitchen and Nourishment Room. This had the potential to affect all residents in the facility. Facility census 106.

Inspectors wroteBased on record review and staff interview, the facility failed to document the vaccination status of each staff member (i.e., immunized or not). This was a random opportunity for discovery. Facility census: 106. During an interview on 07/30/25 at approximately 3:50 PM, the Director of Nursing (DON) reported that the facility only had a total number of staff that received COVID vaccine. The facility did not have any documentation readily available that detailed which staff had received or had not received the COVID vaccine.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents had a dignified existence. Urinary catheter bags were found uncovered. This failed practice was a random opportunity of discovery. Resident Identifier: #115. Facility Census: 106Findings included:a) Resident #115On 07/28/25 at 2:05PM, during a resident interview, it was observed that Resident # 23's catheter bag did not have a bag cover. The uncovered catheter bag was placed on the side but near the foot of the bed which could be seen by any passerby in the hallway. During an interview, on 07/28/25 at 12:10 PM, Licensed Practical Nurse (LPN) #54 acknowledged the catheter bag was not covered.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to provide reasonable accommodations of needs, by not ensuring Resident #90's call light was within her reach. This failed practice was a random opportunity for discovery. Resident identifier #90. Facility Census: 106.

Inspectors wroteBased on record review and interview, the facility failed to identify a newly evident diagnosis of Bipolar Disorder on the Preadmission Screening and Resident Review (PASARR). Resident Identifier: Resident identifier: #35. Facility Census:106. Findings Include:a) Resident #35 record review revealed an updated PASSAR dated 03/27/23, which did not identify any diagnosis of mental illness and stated, 'No Level II required.'The resident was diagnosed with bipolar disorder on 05/08/23. The facility failed to update the PASSAR and did not refer the resident for a Level II review, despite the newly evident disorder. During an interview with the Director of Social Services (DSS) #111 on 07/30/25 at 1:55 PM, she confirmed that she was aware that some PASSARs had not been updated. DSS #111 further stated that she was in the process of performing a whole-house review of PASSARs.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier: #35. Census 106. Findinbs included: a) Resident #35 During record review on 07/30/25 at approximately 12:10 PM, it was noted that Resident #35's initial PASSAR dated 05/12/22 did not identify any mental illness and stated, No Level II required. However, a review of the resident's diagnoses revealed a diagnosis of Major Depressive Disorder dated 01/27/22. During an interview with the Director of Social Services (DSS) #111 on 07/30/25 at 1:55 PM, she confirmed that she was aware that some PASSARs had not been updated. [...]

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive care plan that addressed the resident's diagnosis of Post Traumatic Stress Disorder (PTSD), failed to incorporate knowledge about PTSD into care plans, failed to identify trauma triggers, and failed to implement interventions and practices to address those triggers and prevent re-traumatization. This was true of two (2) of two (2) residents sampled. Resident Identifiers: #24, #72. Facility Census:106. Findings Include a) Resident #24 Record review 07/29/2025 9:30 AM revealed that Resident #24 has a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 07/10/25. A review of the resident's care plan revealed that PTSD was not addressed. In addition, the care plan failed to identify trauma triggers and failed to implement interventions and practices to address those triggers and prevent re-traumatization. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow a physician's order to administer medications to meet the needs of the resident. This was true for two (2) of seven (7) residents sampled. In addition, the facility also failed to ensure that residents were weighed as per the physician's order. Resident Identifiers: #7, #45, and #103. Facility Census: 106. Findings Include: a) Resident #7 During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, the resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays, Wednesdays, and Fridays. Record review on 07/29/25 at 10:35 AM revealed a physician's order for: [...]

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to follow currently recognized standards of care in providing assessments and care of a resident's dialysis access. This was true for two (2) of two (2) residents sampled. Resident Identifiers: Resident #7 and Resident #45. Facility Census:106. Findings Included:a) Resident #7Resident #7 had an order dated 06/19/25 by her physician stating, Dialysis: Site of AV shunt Check Bruit and Thrill every shift. During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, the resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays and Wednesdays and Fridays. She also stated that she had never had an Arteriovenous (AV) fistula or graft. [...]

Inspectors wroteBased on facility documentation and staff interview the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 106. Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no sign-in sheets for staff that attended the meeting quarterly. The facility provided copies of meeting signature pages that were copied, and the dates were changed per month. During an Interview 08/04/25, at 1:38 PM the Administrator verified the required members did not sing in for the quarterly QAA meetings. The Administrator said they just copied a page of signatures and changed the date.

Inspectors wroteBased on observation and staff interview, The facility failed to maintain all patient care equipment in safe operating condition. This failed practice was a random opportunity for discovery. Resident identifiers : #73 and #18 Facility Census: 106 On 07/28/25 at 3:10 PM, during a resident interview and facility walk through in room [ROOM NUMBER], it was observed that Resident #73 and #18's bathroom had a strong smell of urine with a puddle of water around the toilet base on the floor. On 07/30/25 at 10:29 AM during an interview with the Director of Nursing, and administrator in room [ROOM NUMBER], it was observed that a towel was wrapped around the base of the toilet, they acknowledged the toilet had a leak and caused a puddle of water on the bathroom floor.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe and sanitary environment for residents and staff. A portion of the wall in the laundry room had a black-like substance growing on it. This was a random opportunity for discovery. Facility census: 106.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the nurse staffing information was posted in the facility accessible to residents and visitors. This has the potential to affect more than a minimal number of residents. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to implement the care plans for three (3) of six (6) residents who were care planned for the potential for falls. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the call system was accessible to residents while in their bed. This was a random opportunity for discovery. Facility census: 109.

Inspectors wroteThe facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Five (5) residents eating in their rooms did not have hand hygiene when their lunch trays were served. Proper infection control practices were not followed during medication pass. Additionally, laundry was not processed and transported properly. These were random opportunities for discovery that had the potential to affect all residents residing in the building. Resident identifiers: #69, #83, #74, #48, #2, and #31. Facility census: 105.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #31 had medication at her bedside. The medication was not secured and could be accessed by any wandering resident. This was a random opportunity for discovery during the care area of medication administration. Resident identifiers: #31, #51, #155, #40, and #156. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery and has the potential to affect more than an isolated number of residents. Facility Census: 105. Findings Included: a) Medication Refrigerator On 05/09/23 at 10:25 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator temperature logs were found to be incomplete. The following dates did not have the refrigerator temperatures logged: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered no temperatures were taken on the coolers or freezers, the threshold and freezer door was damaged. Water pitchers were not stored properly and the rice bin was not dated. This failed practice has the potential to affect more than an isolated number of residents. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete for 16 of 27 residents reviewed in the long-term care survey sample. Additionally, one of these residents also had an inaccurate medical diagnosis recorded in the medical record. Resident identifiers: #72, #2, #24, #32, #355, #357, #64, #10, #4, #59, #80, #36, #37, #93, #38, and #305. Facility census: 105.

Inspectors wroteBased on resident interview, family interview, and staff interview, the facility failed to ensure the arbitration agreement was explained to the resident and/or his representative in a form and manner that he or she could understand and decide whether or not to enter into such an agreement. This is true for two (2) of three (3) residents reviewed for the facility task of arbitration during the Long Term Care Survey Process. Resident identifiers: #98 and #205. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to provide Resident #38's Health Care Surrogate (HCS) the opportunity to participate in a conversation with the Physician Assistant to discuss treatment risks and benefits and to choose the options he would prefer. This was true for one (1) of 27 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #38. Facility census: 105.

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to ensure allegations of serious bodily injuries were reported immediately, but not later than 2 hours after the allegations were made to the administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services, in accordance with State law). The failed practice of reporting was discovered for three (3) of four (4) residents reviewed for falls with major injuries during the Long-Term Care Survey Process. Resident identifiers: #49, #59, and #38. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the bed hold policy during two (2) transfers to an acute care facility. This was true for one (1) of two (2) residents reviewed under the care area of hospitalization. Resident Identifier: #94. Facility Census: 105. Findings Included: a1) Resident #94 On 05/08/23 at 1:36 PM, a record review was completed for Resident #94. The review found the resident had been transferred to an acute care facility on 04/05/23 due to nausea and vomiting with a diagnosis of aspiration pneumonia. Upon reviewing the transfer paperwork, the review found no bed hold policy had been given to the resident. On 05/09/23 at 2:19 PM, the Administrator stated we couldn't find the bed hold paperwork. No further information was obtained during the long-term care survey. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to have an accurate Minimum Data Set (MDS) for Resident #51 regarding an active diagnoses. This was true for one (1) of 27 residents reviewed during the long-term survey process. Resident Identifier: #51. Facility Census: 105. Findings Included: a) Resident #51 On 05/08/23 at 2:06 PM, a record review was completed for Resident #51. The record review found the resident had a fall with a major injury resulting in a right femur fracture. The MDS with an assessment reference date (ARD) of 03/22/23 modification of a significant change did not list the right femur fracture as a diagnosis. On 05/10/23 at 3:00 PM, the Administrator stated, the diagnosis has been corrected on the MDS. No further information was obtained during the long-term survey process. .

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement the care plan for one (1) of 27 residents reviewed in the long-term care survey sample. Resident identifier: #102. Facility census: 105.

Inspectors wroteBased on medical record review and staff interview the facility failed to revise a person-centered, comprehensive care plan, to include changes in respiratory care. This was true for one (1) of 27 residents' care plans reviewed during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain medication was correctly followed for Resident #37. This failed practice was true for one (1) of one (1) residents reviewed for pain. Additionally, the facility to ensure a medication patch was dated and signed when applied to Resident #27. Resident identifiers: #37 and #27. Facility census: 105.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure eternal feeding care was provided according to professional standards of practice. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #357. Facility Census: 105. Findings Included: a) Resident #137 Upon the initial interview on 05/08/23 at 11:50 AM, Resident #357's bottle of Glucerna was found not dated upon administration. On 05/08/23 at 11:53 AM, Registered Nurse (RN) #22 confirmed the Glucerna bottle was not dated upon administration. On 05/09/23 at 10:14 AM, the Administrator was notified and confirmed the Glucerna bottle should have been dated upon administration. No further information was obtained during the long-term survey process. .

Inspectors wroteBased on observations and staff interviews the facility failed to provide respiratory services in accordance with professional standards of practice. This was true for three (3) of four (4) residents reviewed for respiratory care services. Resident #19 and #355, did not have respiratory equipment stored properly and Resident #4's oxygen tubing was not dated. Resident identifiers #19, #355, and #4. Facility census: 105.

Inspectors wroteBased on record review and staff interview the physician and or designee failed to respond to a Medication Regimen Review (MRR). This was discovered for one (1) of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 105.

Inspectors wroteBased on observation, record review and staff interview, the facility must provide special eating equipment for residents who need special equipment. This deficient practice was true for one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #2. Facility census: 105.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure residents' dignity. The residents' indwelling urinary catheter bedside urine collection bags did not have privacy covers for Resident #260, Resident #55, and Resident #102. Additionally, Resident #55 was left in a bed in the hallway without being covered. Resident identifiers: #260, #55, #102. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure three (3) of twenty-six (26) residents advance directives were communicated to staff in a clear and concise manner to allow staff to immediately determine the resident's code status in the event of an emergency. Resident identifiers: #411, #44, and #106. Facility census: 108.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure Residents #106 and #107 had a clean, safe and well maintained bathroom. In addition, Resident #106's bed linens were not clean, and the facility did not have an adequate number of wash clothes for daily use. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #106, #107. Facility census: 108.

Inspectors wroteBased on record review, resident review, and staff interview, the facility to develop and implement the comprehensive care plan for three (3) of 26 residents reviewed during the long-term care survey process. The facility failed to develop the comprehensive care plan in the area of anxiety and anti-anxiety medications for Resident #93 and in the area of pain for Resident #42. The facility failed to implement the care plan in the area of non-pressure wound treatments for Resident #410. Resident identifiers: #93, #410, #42. Facility census: 108.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Resident (R) #212's antibiotic was not administered for three days. The interdisciplinary team failed to coordinate services for R #49 between the facility and contracted Hospice services and ensure Hospice visitation records were included in the medical record. Physician orders for specialized treatments and lab work were not completed for Residents #55, #410 and #90. This is true for five (5) of 26 sampled residents reviewed during the long term care survey process. Resident identifiers: #212, #49, #55, #410, and #90. Facility census: 108.

Inspectors wroteBased on staff interview, resident interview, and observation, the facility failed to have sufficient nursing staff to ensure call lights were answered timely and room changes were completed in a timely manner. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Resident identifiers: #107, #55, #212, #69. Facility census: 108.

Inspectors wroteBased on observation, and staff interview the facility failed to ensure staff possessed the appropriate competencies and skills sets to provide nursing and related services at a professional standard of care. Medications were not administered as scheduled. This was a random opportunity for discovery and had the potential to affect more than a limited number of staff. Resident identifiers: #76, #8, #44, and #83. Facility census 108.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to provide routine and prescribed pharmaceuticals for residents during the daily medication administration and failed to maintain complete and accurate narcotic records. This was found for two (2) of five (5) residents reviewed during medication pass but has the potential to affect all residents. Resident identifiers: #39 and #95. Facility census: 108.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. The initial kitchen tour found a dirty drip pan, food debris on the floor of the walk-in cooler and freezer, and missing floor tiles along the wall in the dish room. The flour in the flour bin was not dated after opening. These failed practices had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 108.

Inspectors wroteBased on staff interview and policy review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee had a system for monitoring departmental performance data routinely in order to identify deviations in performance and adverse events. The facility failed to identify quality deficiencies of which they should been aware of, related to antibiotic stewardship. This had the potential to affect all resident who resident at the facility. Facility census: 108.

Inspectors wroteBased on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Appropriate hand hygiene was not performed during medication administration. Additionally, proper infection control practices were not followed when emptying a urine collection bag. Resident identifiers: #102, #52, #46, #39, #95. Facility census: 108.

Inspectors wroteBased on policy, record review, and staff interview the facility failed to implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for seven (7) of seven (7) residents reviewed. Seven (7) residents received antibiotics in absence of the appropriate screening criteria need to determine the effectiveness of antibiotic therapy. Resident identifiers: #317, #38, #49, #314, #45, #315, and #27. Facility Census 108.

Inspectors wroteBased on staff interview and record review the facility failed to designate an infection preventionist who has completed specialized training in infection prevention and control. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 108.

Inspectors wroteBased on record review and staff interview the facility failed to vaccinate eligible residents with the influenza and/or the pneumococcal vaccine(s), for five (5) of five (5) residents reviewed. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #102, #3, #313, #8 and #24. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to inform residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of each a single confirmed infection of COVID-19. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Facility census 108.

Inspectors wroteBased on observation, staff interview and resident interview, the facility failed to ensure reasonable accommodations of needs for Resident #55 during a room change. Resident #55 was left in the hallway for an extended period of time without a call light and bed linens. This failed practice was a random opportunity for discovery. Resident identifiers: #55. Facility census: 108.

Inspectors wroteBased on observation and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection survey was placed in an area not easily accessible to residents. This had the potential to affect more than a limited number of residents. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure prompt efforts were made to resolve a residents grievance/concern. This was a random opportunity for discovery. Resident identifier: #86. Facility census: 108.

Inspectors wroteBased on record review, facility policy, and staff interview, the facility failed to implement their policy and procedure for reporting potential allegations of abuse and or neglect. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation is made. This was a random opportunity for discovery. Resident identifier: #261. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the timely completion and transmittal of a discharge Minimum Data Set (MDS) Assessment. This was a random opportunity for discovery. Resident identifier: #2. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the comprehensive care plan was revised when changes occurred or additional information should have been elicited. This had the potential to affect two (2) of 26 residents reviewed in the long-term care survey process. Resident identifiers: #5, #90. Facility census: 108.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed ensure the resident environment remains as free of accident hazards as is possible. Medications were left unattended on a bedside table belonging to Resident # 313. This was a random opportunity for discovery. Resident identifier: #313. Facility census 108.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. This failed practice was true for two (2) out of two (2) residents reviewed for catheter care. Resident identifiers: #102 and #260. Facility census: 108.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition maintained acceptable parameters of nutritional status. Facility staff incorrectly documented the percentage of food consumed for meals. Resident identifier: #692. Facility census: 108.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of dialysis was monitored for any possible complications after receiving dialysis treatments at an outpatient certified dialysis facility. Resident #86. Facility census: 108.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to ensure staff have the basic competencies needed to provide care to a resident with psychosocial disorders. This was true for one (1) of two (2) residents reviewed for choices. Resident identifier: #22. Facility census: 108.

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, clean environment. A broken outlet cover in a resident room with visible wiring showing and large hole in a over-the-bed table were observed . This was a random opportunity for discovery and has the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #8. Facility census: 89.