Forest Park Nursing and Rehabilitation

Inspectors wroteBased on facility policy reviews, clinical record reviews, facility documentation review, hospital records review, and staff interviews, it was determined that the facility failed to ensure wound care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of four residents reviewed (Resident 1), which resulted in actual harm as evidenced by the need for surgical intervention for exposed hardware from a surgically repaired fracture for Resident 1.

Inspectors wroteBased on clinical record reviews, facility documentation review, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for three of four residents reviewed (Residents 1, 2, and 3).

Inspectors wroteBased on clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to implement interventions to ensure resident safety, which resulted in actual harm as evidenced by a frontal scalp laceration requiring sutures to repair for one of five residents reviewed (Resident 1).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed for one of one resident reviewed (Resident 6).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of three resident reviewed for pressure ulcers (Resident 2).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of five residents reviewed (Resident 6).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the needs of the residents for three of three residents reviewed for the use of hipsters (Residents 1, 2, and 3).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide residents with private closet space for all 46 semi-private rooms within the facility.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for three of nine residents reviewed (Residents 7, 8 and 9). Findings Include:Review of Resident 7's clinical record revealed diagnoses that included hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident 7's TAR (Treatment Administration Record), dated November 2025, revealed the following orders: weekly body audit, every evening shift every Friday; cleanse left heel pressure wound with normal saline solution, apply betadine and leave open to air, every day and evening shift; catheter care every shift; enhanced barrier precautions due to Foley catheter every shift; [...]

Inspectors wroteBased on facility policy review, employee record reviews, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed an active nurse aid certification for one of eight employee files reviewed (Employee 8).

Inspectors wroteBased on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, comfortable, and home-like interior in two of three unit spas (Evergreen and Laurel Lane).

Inspectors wroteBased on facility policy review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure all alleged violations involving abuse were reported in a timely manner for two of three residents reviewed (Residents 1 and 2).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for six of 23 Residents reviewed (Residents 6, 7, 34, 42, 57, and 68). Findings Include: Review of facility policy, titled Dignity, with a last review date of February 3, 2025, revealed, in part, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are e. provided with a dignified dining experience; 10. Staff protect confidential clinical information. Examples include the following: b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. [...]

Inspectors wroteBased on clinical record reviews, observation, facility document review, and resident and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards for four of 23 residents reviewed (Resident 5, 64, 68, and 88).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for one of seven residents reviewed for nutrition (Resident 72).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to adequately monitor possible side effects and target behaviors for two of five residents reviewed for unnecessary psychotropic medications (Residents 68 and 80).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food items in accordance with professional standards for food service safety in the main kitchen and three of three nourishment areas.

Inspectors wroteBased on facility policy review and staff interview, it was determined that the facility failed to establish and implement an antibiotic stewardship program to monitor the use of antibiotics.

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to notify the resident/resident representative of a resident's transfer, in writing, to include: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, name, and address (mailing and email) for two of four resident records reviewed for hospitalization (Residents 21 and 80).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the resident and/or the resident's representative were provided the bed-hold notice upon transfer for two of four residents reviewed for hospitalizations (Residents 21 and 80).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 26 residents reviewed (Residents 64 and 72).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 26 residents reviewed (Residents 65 and 88). Findings Include: Review of Resident 65's clinical record revealed diagnoses that included congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs) and difficulty walking not elsewhere classified (a medical term used when someone has difficulty walking but the cause cannot be more precise). Observation of Resident 65 on March 3, 2025, at 11:22 AM, revealed Resident 65 lying in bed, and Resident 65's rolling walker was sitting beside the Resident's bed. Interview with Resident 65 at that time revealed that she is able to walk with the rolling walker. [...]

Inspectors wroteBased on facility policy reviews, product information review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of six residents observed during medication preparation and administration for (Residents 25 and 65) and for one of one resident observed for treatment administration (Resident 68).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 68).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of one resident reviewed for oxygen use (Resident 57).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents reviewed for pain management (Resident 64).

Inspectors wroteBased on policy review, observation, record review, and staff interviews, it was determined that the facility failed to complete a risk benefit analysis and obtain consent for enabler bar use for one of 23 residents reviewed (Resident 56).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication recommendation, and failed to provide a monthly medication regimen review for one of five residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review (Resident 23).

Inspectors wroteBased on facility policy review, observation, and staff interview, it was determined that the facility failed to properly label and store prescribed medication or preventative creams in one of two treatment carts observed (Evergreen Way/Stepping Stones).

Inspectors wroteBased on clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for three of six residents reviewed (Residents 4, 12, and 13).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for four of four residents reviewed (Residents 1, 6, 7, and 8).

Inspectors wroteBased on observations, facility document review, policy review, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention and control program for two of four unit hallways observed (Evergreen Way and Laurel Lane).

Inspectors wroteBased on policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure appropriate care and services were provided for an indwelling urinary catheter for one of two residents reviewed for urinary catheter (Resident 1).

Inspectors wroteBased on observations, clinical record review, facility document and policy review, and resident and staff interviews, it was determined that the facility failed to provide a sufficient number of staff for the administration of medications for one of four units observed, which resulted in the missed or late administration of medications for four of 12 residents reviewed for medication administration (Residents 4, 5, 9, and 10).

Inspectors wroteBased on clinical record review, facility document review, facility policy review, and staff interviews, it was determined that the facility failed to ensure the resident record was complete and accurately documented for one of three residents reviewed for change in medical condition (Resident 14).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to provide sufficient space for residents to participate and observe an activity for one of one activity observed in the Florida Room lounge.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to post the required daily staffing in a prominent place for review by the residents and visitors.

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by failing to provide orientation and/or training to agency staff and failed to ensure agency staff responded to a medical emergency, which resulted in a delay in emergency services to a resident who went unresponsive (Resident 1). This failure placed a total of 48 residents in an immediate jeopardy situation who would require emergency intervention if found unresponsive (Residents 2-49). Findings Include: Review of facility policy, titled Identifying Neglect, dated [DATE], revealed, 'Neglect' is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. [...]

Inspectors wroteBased on policy review, facility document review, observations, and staff interviews, it was determined that the facility failed to implement infection control policies and procedures to help prevent the development and spread of a communicable disease for four of four units observed (Laurel Lane, Evergreen, Stepping Stone, and Dementia units).

Inspectors wroteBased on clinical record review, facility document review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for two of 11 residents reviewed (Residents 4 and 5). This failure resulted in continued decline of one resident (Resident 4), which required an emergency transfer to the hospital for low blood oxygen levels and difficulty breathing which contributed to cardiac arrest and resulted in death. This failure placed the residents residing on one of four units (Laurel Lane) in an immediate jeopardy situation.

Inspectors wroteBased on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found lying in the parking lot of the facility and was medically compromised as evidenced by a low body temperature and abrasions. This failure placed a total of five residents in an Immediate Jeopardy situation who were identified as at risk for elopement and not on a locked unit (Residents 1, 6, 7, 9, and 10).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the resident's right to a clean, comfortable, and homelike environment in the multi-purpose room and four of four nursing units observed (Evergreen, Laurel Lane, Stepping Stones, and Chapelwood). Findings Include: Observation in the hallways on Laurel Lane, Evergreen, and Stepping Stones, on October 8, 2024, at 9:20 AM, revealed dried, dark spills on the floors throughout the hallways as well as miscellaneous debris on the floors. Observation of the hallway to the multi-purpose room on October 8, 2024, at 10:30 AM, revealed dark spots of dried liquid on the floor and a dead bug near the door to the courtyard. Observation of the multi-purpose room at this time revealed miscellaneous debris, including paper, food and dead bugs, on multiple places on the floor of the room. [...]

Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of five residents reviewed (Resident 4).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of three residents reviewed (Residents 1 and 3).

Inspectors wroteBased on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide transportation services to maintain highest practical level of health and well-being for one of 10 residents reviewed (Resident 5).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure the posting of nursing staffing data on a daily basis for two days reviewed (June 16 and 17, 2024).

Inspectors wroteBased on observations, policy review, select document review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in three of three nursing unit refrigerators, and one of two ice machines (Evergreen Way/Stepping Stones unit).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to ensure the resident's right to a clean, comfortable, and homelike environment for one of three shower rooms observed (Laurel Lane) and two of four nursing units observed (Evergreen and Chapelwood). Findings Include: Observations of Resident 9's wheelchair on the Chapelwood unit on April 15, 2024, at 9:29 AM; April 17, 2024, at 8:12 AM; and April 17, 2024, at 10:02 AM, revealed that the base of her wheelchair had a moderate amount of dry dusty appearing debris, and the seat cushion had a small amount of dried food debris. Observation of Resident 15's room on the Chapelwood unit on April 15, 2024, at 9:03 AM, revealed the following: one of the closet doors was off track, leaning into closet and causing the other closet door to be pushed outward at the floor; [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide notice of transfer to the resident and/or resident representative, as well as a notice to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility for seven of 10 residents reviewed for hospitalization (Residents 4, 32, 35, 63, 71, 72, and 89).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for seven of 10 residents reviewed for hospitalization (Residents 4, 32, 35, 63, 71, 72, and 89).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to submit Minimum Data Set (MDS) assessments within the required timeframe (14 days following completion) for 13 of 103 residents reviewed (Residents 2, 3, 8, 14, 32, 33, 36, 56, 61, 66, 68, 86, and 97).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Residents 32, 72, 89, and 407).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 29 residents reviewed (Residents 31, 32, and 73).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to implement fall interventions for three of 29 residents reviewed (Residents 31, 35, and 72). Findings Include: Review of Resident 31's clinical record revealed diagnoses that included hypertension (elevated blood pressure), muscle weakness, lack of coordination, and repeated falls. Review of Resident 31's current fall care plan revealed an intervention, in part, dated November 20, 2023, for a scoop mattress (a mattress with edges that are built higher than the center to help keep a resident from rolling off) to be placed on bed for fall safety. Observations of Resident 31 in their bed on April 15, 2024, at 9:16 AM; April 16, 2024, at 9:52 AM; and April 17, 2024, at 8:25 AM; all failed to reveal the presence of scoop mattress on their bed. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of one Residents reviewed (Resident 31).

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 30 residents reviewed (Resident 80).

Inspectors wroteBased on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually and that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 5 was hired in 2015; Employee 6 was hired in 2022; Employee 7 was hired in 2018; Employee 8 was hired in 2009; and Employee 9 was hired in 2008. Review of facility-provided employee performance evaluations for Employees 5, 7, 8, and 9 revealed: one was completed on February 20, 2019, for Employee 5; one was completed on July 28, 2019, for Employee 7; one was completed in December 2021 for Employee 8; and one was completed on March 23, 2023, for Employee 9. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist, responded to in a timely manner by the attending physician or prescriber, and that a rationale was provided for any declined recommendations for five of five residents reviewed for unnecessary medications (Residents 27, 32, 86, 89, and 407).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure as needed antipsychotic drugs were evaluated and renewed every 14 days for one of five residents reviewed for unnecessary medications (Resident 86).

Inspectors wroteBased on review of facility policy, test tray completion, review Resident Council Meeting minutes, and resident and staff interviews, it was determined that the facility failed to provide beverages that are palatable and at a safe and appetizing temperature for one of one meal observed on the Evergreen Way hall.

Inspectors wroteBased on facility document review and staff interview, it was determined that the facility failed to maintain an accurate data collection system of infection surveillance from June 2023 through September 2023. Findings Include: Review of facility form, titled Monthly Infection Control Log (Line List), revealed data to be collected and documented each month include resident's name, room number, unit, type of infection, date of infection, culture, antibiotic resistant, classification, and isolation precautions. Review of the facility's completed Monthly Infection Control Log (Line List) failed to reveal that any documentation of infections occurred for June, July, August or September in 2023. On April 18, 2024, at 8:36 AM, the Nursing Home Administrator stated the facility was unable to locate any infection tracking for June, July, August or September in 2023. 28 Pa. [...]

Inspectors wroteBased on personnel file review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 5, 6, 7, 8, and 9). Findings Include: Review of select facility documentation revealed that Employee 5 was hired in 2015; Employee 6 was hired in 2022; Employee 7 was hired in 2018; Employee 8 was hired in 2009; and Employee 9 was hired in 2008. Review of training records provided by the facility failed to reveal evidence that Employees 5, 6, 7, 8, and 9 received at least 12 hours of annual in-service training. During an interview with the Nursing Home Administrator on April 18, 2024, at 11:59 AM, she acknowledged the concern with the aforementioned nurse aides not completing 12 hours of in-service training annually. [...]

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of 23 Residents reviewed (Residents 9 and 31). Findings Include: Review of facility policy, titled Dignity, with a last revised date of February 2021, revealed, in part: 11. Staff promote, maintain, and protect resident privacy, including bodily privacy .; and 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a) helping the resident to keep urinary bags covered. Review of Resident 9's clinical record revealed diagnoses that included cerebral infarction (a stroke - damage to the brain from interruption of its blood supply), abnormal posture, and stiffness of left hand. [...]

Inspectors wroteBased on review of select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for one of two residents reviewed (Resident 60).

Inspectors wroteBased on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to investigate an injury of unknown origin to rule out abuse, neglect, or mistreatment for one of 29 residents reviewed (Resident 72). Findings Include: Review of facility policy, titled Forest Park Abuse Policy, with a review/revise date of April 24, 2018, revealed Injury of unknown source is defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: (a) the extent of the injury; or (b) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (c) the number of injuries observed at one particular point in time; [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a comprehensive assessment was completed every 12 months, as required, for one of 103 residents (Resident 73).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for two of 103 residents (Residents 31 and 45).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of four residents reviewed for pressure injuries (Resident 60) and one of four residents reviewed for dementia care (Resident 86).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 23 residents reviewed (Resident 9).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that respiratory care and services provided were consistent with professional standards of care for one of two residents reviewed for respiratory care (Resident 407).

Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to provided food per resident preference for two of 24 residents observed (Residents 96 and 358).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for two of 29 residents reviewed (Residents 9 and 35). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included cerebral infarction (a stroke - damage to the brain from interruption of its blood supply), abnormal posture, and stiffness of left hand. Review of Resident 9's physician orders revealed a diet order that included a Kennedy cup with meals, dated February 4, 2024. Review of Resident 9's current care plan revealed a care plan focus for being at risk for altered nutrition with an intervention for Kennedy cup, with a revision date of May 27, 2021. [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (fourth quarter, October - December 2023).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to reevaluate and update the discharge plan for two of four residents reviewed (Residents 1 and 4); and failed to develop an effective discharge plan for one of four residents reviewed (Resident 3).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined the facility failed to develop a discharge summary that included a recapitulation of the resident's stay, reconciliation of medications, and post-discharge plan of care that indicated where the individual plans to reside, any arrangements that have been made for the resident's follow-up care, and any post-discharge medical and non-medical services for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings Include: Review of facility policy, titled Discharging the Resident, revealed the following, in part: 5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions; and in section titled Documentation that The following information should be recorded in the resident's medical record: 1. [...]

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents transitioning to home by not making appropriate referrals for home care services for two of four residents reviewed (Residents 1 and 3); and failing to inform a resident of a change in their discharge plan for one of four residents reviewed (Resident 4). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure pharmaceutical services provide an accurate account for the obtaining of medications and disposition of medications during the discharge process for four of four residents reviewed (Residents 1, 2, 3, and 4).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure timely notification of the listed emergency contact person following a fall for one of six residents reviewed (Resident 1).

Inspectors wroteBased on record review, staff interview, and policy review, it was determined that the facility failed to accurately document information in the clinical record for one of three residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure each resident received proper treatment and assistive devices to maintain hearing abilities for one of nine residents reviewed (Resident 2).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for one of 10 residents reviewed (Resident 9).

Inspectors wroteBased on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to inspect Resident's personal medical equipment brought into the facility to ensure a safe and functional environment for one resident reviewed (Residents 1).

Inspectors wroteBased on review of the clinical records and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the resident need for one of four residents reviewed (Resident 4).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 11 Residents reviewed (Residents 3, 4, 5, 6, 7, and 9) and on three of three nursing units observed.

Inspectors wroteBased on clinical record reviews, policy review, observations, and staff interviews, it was determined that the facility failed to develop and/or implement a comprehensive person-centered care plan for four of 11 records reviewed (Residents 2, 6, 7, and 9).

Inspectors wroteBased on clinical record review, observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure dental services were provided to meet resident need for one of one residents reviewed (Resident 9).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to formulate an advance directive and facilitate follow-up procedures to provide information to the resident or resident representative at an appropriate time for six of 35 residents reviewed (Residents 34, 38, 54, 97, 207, and 209). Findings Include: Review of facility policy, titled Advance Directives, revised September 2022, revealed The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or he legal representative, about the existence of any written advance directives. 2. [...]

Inspectors wroteBased on clinical record review, observation, as well staff and resident interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Resident 38, 71, 73, and 99).

Inspectors wroteBased on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for five of 29 residents reviewed (Residents 1, 23, 68, 94, and 209). Findings Include: Review of facility policy, titled Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. [...]

Inspectors wroteBased on facility policy reviews, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of 26 residents reviewed (Residents 20, 49, 58, and 359).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and interviews with staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of three residents reviewed (Residents 23, 99, and 359).

Inspectors wroteBased on facility policy review, observations, record reviews, and interviews, the facility failed to complete a risk-benefit analysis and obtain consent for enabler bar use for three of 29 residents reviewed (Residents 30, 36, and 54).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for four of five residents reviewed for unnecessary medications (Residents 53, 54, 79, and 94).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for five of five residents reviewed for unnecessary medications (Residents 53, 54, 79, 94, and 209).

Inspectors wroteBased on observations, policy review, product manufacturer label, and interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen, in two of three nourishment rooms, one of two ice rooms/areas, and the activity room.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of 29 residents reviewed (Residents 29 and 38). Findings Include: Review of Resident 26's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus, stroke, amputation of left leg below the knee (BKA), and amputation of right leg above the knee (AKA). Observation of Resident 26 on April 24, 2023, at 2:03 PM, revealed Resident 26 in the hallway, in his motorized wheelchair. Resident 26 was observed to have a seatbelt in place. Resident 26 was asked about the seatbelt and if he was able to release it. Resident 26 stated yes. Observation of Resident 26 on April 25, 2023, at 11:19 AM, revealed Resident 26 in the hallway, in his motorized wheelchair, with a seatbelt in place. [...]

Inspectors wroteBased on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the implementation of infection control processes and procedures regarding posted transmission-based precautions signage for a COVID-19 positive individual (Resident 207) and failed to maintain an accurate data collection system of infection surveillance from July 2022 through March 2023. Findings Include: Review of facility policy, titled Isolation - Categories of Transmission-Based Precautions, revised January 2012, revealed, Signs - the facility will implement a system to alert staff and visitors to the type of precaution the resident requires. [...]

Inspectors wroteBased on review of facility provided documentation, review of facility policy, and review of clinical records, as well as staff interviews, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and provide education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine for five of five residents reviewed for immunizations (Residents 28, 59, 91, 93, and 97). Findings Include: Review of facility policy, titled Coronavirus Disease (COVID-19) - Vaccination of Residents, revised June 2022, revealed Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of 26 residents reviewed (Residents 71 and 79).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that informational postings located throughout the facility contained all pertinent state agency and resident advocacy contact information.

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three shower rooms (Evergreen Way/ Stepping Stones).

Inspectors wroteBased on clinical record review, review of facility incident reports, review of facility policy, and interviews with staff, it was determined that the facility failed to conduct a timely and thorough investigation to rule out abuse, neglect, or mistreatment following unwitnessed falls for two of two residents reviewed for falls (Residents 78 and 209). Findings Include: Review of facility policy, titled Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, All accidents and incidents involving residents .occuring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident /Accident form: [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 29 residents reviewed (Residents 38 and 78). Findings Include: Review of Resident 38's clinical record revealed diagnoses that included gangrene (dead tissue caused by an infection or lack of blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Review of Resident 38's quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated March 16, 2023, revealed that in Section M, Resident 38 was coded as having one unstageable pressure ulcer. [...]

Inspectors wroteBased on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 29 residents reviewed (Residents 26, 54, and 79). Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of December 2016, revealed the following: 1) The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident; 8) g. incorporate identified problem areas; and 10) identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. [...]

Inspectors wroteBased on staff and resident interviews and clinical record review, it was determined that the facility failed to update a resident's discharge plan in the clinical record for one of 29 clinical records reviewed (Resident 23).

Inspectors wroteBased on observation, test tray, and interviews, it was determined that the facility failed to provide food and beverage that are palatable and at a safe and appetizing temperature for one of one meal observed on the Stepping Stones hallway.

Inspectors wroteBased on review of regulations and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control, prior to assuming the role of the IP.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess for eligibility and offer the pneumococcal and/or influenza vaccines to three of five residents reviewed (Residents 28, 91, and 93). Findings Include: Review of facility policy, titled Influenza Vaccine, revised August 2016, revealed All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). [...]