Fountain Care at Sunset Hills

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate and attempt to resolve one resident's refusal to take medications scheduled at 8:00 A.M., because he/she was sleeping. Review of the resident's 1/2026 medication administration record (MAR) from 1/1/26 through 1/26/26, showed the resident did not receive eight of eight medications scheduled at 8:00 A.M. on 10 separate days, and two of three doses of one medication scheduled at 8:00 A.M. every Wednesday (Resident #8). The facility also failed to ensure one resident (Resident #2) with a new order for Azithromycin (antibiotic) for pneumonia received the first dose timely. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's physician and obtain treatment orders for skin issues/wounds they identified on a skin check upon the resident's admission on [DATE]. As of 12/23/25, when the resident passed away, the facility had not contacted the resident's physician regarding the skin issues/wounds, had not received treatment orders and had not documented the skin issues/wounds on the electronic treatment administration record (TAR) for on-going monitoring and assessment. Three residents were sampled for wounds, and problems were identified with one (Resident #1). The census was 84. Review of the facility's Skin Program Policy and Procedure revised 12/2023, showed:Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's physician and obtain treatment orders for a pressure ulcer/injury (localized damage to the skin that usually occur over a bony prominence as a result of pressure) on one resident's coccyx (tailbone) that was identified on a skin check upon the resident's admission on [DATE]. As of 12/23/25, when the resident passed away, the facility had not contacted the resident's physician, had not received treatment orders and had not documented the pressure ulcer/injury on the electronic treatment administration record (TAR) for on-going monitoring, assessment and treatment. Three residents were sampled for wounds, and problems were identified with one (Resident #1). The census was 84. Review of the facility Skin Program Policy and Procedure revised 12/2023, showed:Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident rooms and resident-use areas in the facility in a clean and homelike manner. Concerns were noted with three of 18 sampled residents' rooms (Residents #9, #195 and #194), and multiple resident-use areas on the Fountain Hall. The facility census was 89. Review of the facility's Cleaning and Disinfecting of Environmental Surfaces and Equipment policy, revised July 2024 showed: -Reusable items such as durable medical equipment shall be disinfected after each use and between residents; -Housecleaning surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when the area is visibly soiled; -Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for one out of three narcotic books reviewed. The census was 89. Review of the facility's Controlled Substance Storage policy, revised January 2018, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented on the shift verification of controlled substance count. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the kitchen equipment clean and floors free of trash and grime. The census was 89. Review of the facility's kitchen department sanitation policy, dated 1/2021, showed: -Purpose: to ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with federal, state, and local guidelines and regulations governing food sanitation and safety; -Policy: the department sanitation shall be maintained in a manner to support procedures for food safety. Staff shall be responsible for daily and weekly cleaning assignments as determined by the Dietary Manager and/or his/her designee. Cleaning assignments shall include all equipment, storage areas, walls, floors and refrigeration units. Cleaning of equipment condensers, lighting fixtures, vents, etc. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for thee residents (Residents #195, #15, and #24) who required EBP for wounds requiring treatment or centrally inserted devices used for dialysis (the process of filtering the blood for individuals with kidney failure). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow acceptable nursing practice when the facility's staff left medication in two residents' room (Resident #194 and Resident #44), who did not have a physician order for self-administration or medications to be left at the bedside. The sample was 20. The census was 89. Review of the facility's Bedside Medication Storage policy, revised January 2018, showed: -Policy: Bedside medication storage is permitted for residents wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team; -Procedures: A written order for the bedside storage of medications is present in the resident's medical record; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards by not performing accurate and timely skin assessments for one resident, in accordance with the facility's policy (Resident #96). The sample size was 20. The census was 89. Review of the facility's Skin Program Policy and Procedure, revised, 1/15/25, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is observed and evaluated on admission and comprehensive and interdisciplinary care plan is developed and maintained to treat actual and or prevent potential skin problems. -Policy: All residents are observed and evaluated upon admission and as needed for actual and/or potential skin problems. All residents will receive an individualized preventive skin plan of care at the time of admission. -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents received activities of daily living (ADL) care (Residents #195, #194 and #58). The sample was 20. The census was 89. Review of the facility's personal care needs policy, dated 1/24, showed: -Protocol: the facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The Interdisciplinary Plan of Care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident Plan of Care. Personal care and support include but is not limited to the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 27 opportunities observed, four errors occurred, resulting in a 14.81% error rate (Resident #44 and Resident #58). The census was 89. Review of the facility's Medication Administration policy, reviewed January 2024, showed: -Purpose: -To administer the following: -Right medication; -Right dose; -Right dosage form; -Right route; -Right resident; -Right time; -Procedure: -Read the Medication Administration Record (MAR) for the ordered medication, dose, dosage form, route, and time; -Review the resident's allergies; -Verify the pharmacy prescription on the drug and the manufacturer's identification system matches the MAR; -Verify that any further medication identifiers match the label and the medication; Identifiers may include, but are not limited to -Drug size; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a palatable, safe, and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F). This affected 2 of 20 sampled residents (Residents #15 and #34). The census was 89. Review of the facility's meal service temperature policy, dated 1/2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: foods shall be provided at point of service to support resident/patient satisfaction. Temperatures of hot food shall be supported to promote service temperatures of hot foods to about 120 degrees F and cold foods to below 50 degrees F. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receiving dialysis (medical procedure that filters blood when the kidneys are unable to) received breakfast before dialysis. The facility identified 11 residents as receiving dialysis. Of the 11, four were included in the sample of 20 and issues were identified with two residents (Residents #15 and #80). The census was 89. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; -Receives dialysis while a resident; -Diagnoses included type 2 diabetes and kidney failure. Review of the resident's Physician Order Sheet (POS), dated 4/21/25, showed an order, dated 2/13/25, in house dialysis Tuesday, Thursday and Saturday. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call lights were accessible for two residents (Residents #15 and #58). The sample was 20. The census was 89. Review of the facility's call light protocol policy, dated 1/2022, showed: -Purpose: to respond to resident/patient's request and needs; -Procedure: answer call light in a reasonable amount of time. Respond to request. When unable to meet request, obtain assistance from caregiver that can meet request. Assist resident/patient as needed to a comfortable position with call light within reach. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make accessible for examination, the results of the most recent survey, certifications, and complaint investigations of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility available to residents, visitors, and resident representatives. The sample was 20. The census was 89. [...]

Inspectors wroteSee deficiency cited at Event ID #172413 Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. [...]

Inspectors wroteSee Event 172412 Based on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: [...]

Inspectors wroteSee Event 172412 Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required time after residents were involved in resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11) The sample size was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). The resident fell during the transfer and sustained fractures to his/her ribs, legs, and left ankle. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by thoroughly investigating in a timely manner allegations of resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11). The sample was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: -The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required time after residents were involved in resident to resident altercations (Residents #15 and Resident #16, and Residents #10 and Resident #11) The sample size was 10. The census was 98. Review of the facility Abuse, Neglect, Exploitation or Mistreatment Policy, dated 5/1/2018, showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to address a recommendation from the Registered Dietitian (RD) for a resident with a significant weight loss, to prevent further weight loss (Resident #2). The sample was six. The census was 101. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed the following: -Severe cognitive impairment; -Dependent with activities of daily living (ADLs); -Diagnoses of a stroke; -Weight 157 pounds (lbs); -Gastronomy tube (g-tube, flexible, hollow tube that is inserted through the stomach wall and skin to deliver food and medicine directly to the stomach); -Risk for pressure ulcers(a localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #3) received care consistent with professional standards and facility policy to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility identified small break down on the resident's buttocks on 5/25/24. The area was not staged at that time. No treatment order was obtained and treatments were documented as provided from 5/25/23 until 7/3/24. Licensed nursing staff failed to complete weekly skin assessments between the dates of 6/15/24 and 7/3/24. On 7/3/24, a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) was discovered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the diversion (the unauthorized removal) of Schedule II controlled medications (medication with higher potential of dependency and abuse) for two residents (Resident #1 and Resident #2) of 4 sampled residents. This had the potential to affect all residents in the facility. The census was 92. The Administrator was notified on 7/23/24, of the past non-compliance which began on 7/4/24. The facility began an investigation, counted the medication carts, added a corrected count to all controlled substance logs, interviewed staff and residents, notified the police, the residents affected and their physician, in-serviced staff on abuse and misappropriation of resident property (including drug diversion) and terminated Licensed Practical Nurse (LPN) A. The deficiency was corrected on 7/10/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate immediate discharge letter to one of three sampled residents (Resident #2). The letter failed to contain the location to where the resident was being transferred and discharged , failed to disclose the appeal rights and the correspondence information and the name, address and telephone number of the designated regional long-term care ombudsman office. In addition, the facility failed to readmit the resident when the discharge was dismissed. The census was 93. Review of the facility's Room Changes, Transfers, and Discharges policy, dated 7/2022, showed: -The resident/patient's physician must document evidence in the resident/ patient's clinical record that a discharge is necessary for the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy when an injury of unknown origin was discovered and not reported, assessed, or investigated for one resident (Resident #1). The census was 92. Review of the facility's Accident and Incident Protocol, reviewed 7/2022, included: -The facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident); -The facility defines an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome; -The event may be an accident or a situation that could result in an accident. Accidents/incidents may include, but are not limited to the following: 1. Unexplained bruises/skin tears; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy by not obtaining a physician's order for a skin tear of unknown origin for one resident (Resident #1), thereby potentially increasing the risk of a negative outcome related to the healing process due to a diagnoses of Type 2 diabetes mellitus with diabetic chronic kidney disease. The census was 92. Review of the facility's Physician Orders policy, last revised 5/1/11, showed: -Protocol: At the time each resident/patient is admitted , the facility will have physician orders for their immediate care. Physician's orders will be verified by the attending physician at the facility. All physician orders will be dated and signed according to State and Federal regulations; -All clinicians may take verbal and/or telephone orders as permitted by their state licensure board; Procedures included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #104) with a diagnosis of dysphagia (difficulty swallowing) was served food in the proper consistency to prevent choking. Staff reported the resident was routinely served a whole, hardboiled egg for breakfast. On 12/17/23, the resident was found unresponsive in the first-floor dining room. Cardio Pulmonary Resuscitation (CPR, a lifesaving technique used when breathing or heartbeat has stopped) was started and a piece of hard boiled egg, approximately 2 inches in diameter, was removed from the resident's mouth. The resident expired at the facility. The census was 97. The Administrator was notified on 12/21/23 at 4:00 P. M., of an Immediate Jeopardy (IJ) past noncompliance which began on 12/17/23. [...]

Inspectors wroteSee the deficiency cited at Event J2L412. Based on observation, interview and record review, the facility failed to protect one resident (Resident #400) from misappropriation of property when a staff member took a resident's baseball cap, which he/she received during a trip to the baseball game. The resident said he/she wanted his/her baseball cap back, and not having it made him/her feel bad and sad. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc; -Definitions: -Misappropriation of Resident Property (Includes but is not limited to): [...]

Inspectors wroteSee the deficiency cited at Event J2L412. Based on observation, interview and record review, the facility failed to ensure an allegation of misappropriation was reported to the facility Administrator and the state agency in a timely manner, when a staff member, Housekeeper B, removed a resident's baseball cap from the resident's room without his/her knowledge or consent (Resident #400). Another staff member, Housekeeper D, saw Housekeeper B with the resident's baseball cap but did not report the allegation to management until a week later when management asked him/her about the incident. The incident of misappropriation occurred on 11/8/23. The incident was reported to the Administrator on 11/14/23 and to the state agency on 11/15/23. The sample size was 14. The census was 94. [...]

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility failed to staff a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week and failed to ensure the Director of Nursing (DON) worked as a charge nurse only when the facility had a census of 60 or less. The census upon the entrance of the survey team was 102.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were securely locked, failed to ensure medication rooms were securely locked, failed to ensure medications contained opened and expiration dates, failed to ensure medication refrigerators were free from spills, and failed to ensure temperature monitoring was documented.

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to store and prepare food in accordance with professional standards for food service safety for one of one main kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the dumpster area in a manner to keep the area clean and free of waste. This affected two of two dumpsters used to serve the facility.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to protect the dignity of three of six residents reviewed for urinary catheters [Resident (R) #9, R #18, and R #24].

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to provide the residents with a safe, sanitary, and comfortable homelike environment for two of three units observed during the survey.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to establish and maintain an effective infection control program by: 1. Failing to ensure one Certified Medication Technician (CMT) performed hand hygiene during administration of medications; and one CMT and one Licensed Practical Nurse (LPN) cleaned a portable blood pressure cuff before or after using it on different residents; and 2. Failing to develop and implement written policies and procedures in accordance with accepted national standards and guidelines for the use of personal protective equipment (PPE) when suctioning during tracheostomy care.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one resident (Resident #400) from misappropriation of property when a staff member took a resident's baseball cap, which he/she received during a trip to the baseball game. The resident said he/she wanted his/her baseball cap back, and not having it made him/her feel bad and sad. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: -Prevention and Reporting: -The facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc; -Definitions: -Misappropriation of Resident Property (Includes but is not limited to): [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an allegation of misappropriation was reported to the facility Administrator and the state agency in a timely manner, when a staff member, Housekeeper B, removed a resident's baseball cap from the resident's room without his/her knowledge or consent (Resident #400). Another staff member, Housekeeper D, saw Housekeeper B with the resident's baseball cap but did not report the allegation to management until a week later when management asked him/her about the incident. The incident of misappropriation occurred on 11/8/23. The incident was reported to the Administrator on 11/14/23 and to the state agency on 11/15/23. The sample size was 14. The census was 94. Review of the Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin Policy, revised August 1, 2022, included the following: [...]

Inspectors wroteBased on interviews, record review, and review of the facility policy, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed in a timely manner after a significant change in status was identified for one of 20 residents [Resident (R) #64] reviewed.

Inspectors wroteBased on interviews, record review, and review of the facility policy, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one of 20 residents [Resident (R) #64] reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the plan of care was reviewed and revised after a fall for one of 20 residents whose care plans were reviewed (Resident (R) #7).

Inspectors wroteBased on interviews, record review, and review of the facility policy, the facility failed to ensure one of three residents reviewed received a final summary of the resident's status prior to being discharged from the facility [Resident (R) #99].

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure emergency equipment was available at the bedside for immediate access in the event of an unplanned decannulation for one of three residents reviewed for tracheostomy care [Resident (R) #90].

Inspectors wroteBased on interview and record review, the facility failed to document in the medical record the circumstances leading up to a resident's transfer to the hospital and details of the resident's return to the facility, for one of four residents reviewed for rehospitalizations [Resident (R) #18].

Inspectors wroteBased on staff interview, interview with the Regional Ombudsman, and record review, the facility failed to provide a notice of transfer/discharge to one of four residents reviewed for rehospitalization [Resident (R) #87]. The facility also failed to provide copies of transfer/discharge notices to the Regional Ombudsman for all four residents reviewed for rehospitalization (R #18, R #87, R #90, and R #97), as well as 131 additional residents who were transferred/discharged between 5/1/23 and 10/12/23.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide a notice of the facility's Bedhold Policy at the time of transfer to four of four residents reviewed for rehospitalization [Resident (R) #18, R #87, R #90, and R #97].

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all staff, including agency staff, were adequately trained and informed of facility policies and expectations per acceptable nursing standards. In addition, key management staff in the facility failed to be knowledgeable about the location of and process for medical record documentation. This failure has the potential to affect all resident in the facility. The census was 85. 1. Review of the State Operations Manual appendix PP, section 483.70(e) revised 11/22/17, Facility Assessment showed: -An assessment of the resident population is the foundation of the facility assessment and determination of the level of sufficient staff needed; -The assessment of the resident population should drive staffing decisions; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nurse aides received the required 12 hours of training per year and have a system to track the hours for eight of nine employees reviewed who worked at the facility for over a year. The census was 85. Review of the training records provided by the facility, showed: -Nine certified nurse aides (CNAs) worked at the facility for over a year; -CNA D hired 4/19/11, with 1 hour and 30 minutes of in-service education in the past year; -CNA I hired 9/26/12, with 1 hour of in-service education in the past year; -CNA G hired 9/4/15, with 8 hours and 30 minutes of in-service education in the past year; -CNA F hired 9/5/15, with 8 hours and 15 minutes of in-service education in the past year; -CNA H hired 5/31/17, with 4 hours and 45 minutes of in-service education in the past year; [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to label and date food. The facility failed to check and record refrigerator temperatures and dishwasher chemical levels. In addition, the facility failed to ensure the ice machine had an air gap, to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. These deficient practices had the potential to affect all residents. The census was 85. Observations of the kitchen, showed: -On 9/14/20 at 10:31 A.M.: -Fifteen health shakes in the refrigerator, undated. Dietary Aide Z, said the heath shakes come in frozen and were thawed in the fridge, they should be dated; -A package of hamburger patties, opened and undated; -Two pitchers of tea uncovered; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Facility Assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and in emergencies, as required. The lack of a Facility Assessment has the potential to affect the entire resident population. The facility census was 85. Review of the State Operations Manual appendix PP, section 483.70(e) revised 11/22/17, Facility Assessment, showed: -An assessment of the resident population is the foundation of the facility assessment and determination of the level of sufficient staff needed; -It must include the number of residents and the facility's resident capacity; -It must include an evaluation of: -Diseases; -Conditions; -Physical, functional or cognitive limitations of the resident population's; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow general acceptable accounting principles by not knowing where the money for closed resident accounts were dispersed to (Residents #301 and #302) and by having negative balances in resident's accounts (Residents #108, #303 and #304). In addition, the facility did not provide quarterly statements to residents (Residents #107, #153, #152, #106 and #207). The facility held funds for at least 44 residents. The census was 85. 1. Record review of Resident #301's trust account, showed he/she expired on [DATE]. The balance in his/her account at that time was $2685.41. During an interview on [DATE] at 1:32 P.M., the business office manager (BOM) said he was not sure where the resident's money went. The balance showed zero. There was no record to show where it went. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or their parties when a resident's fund reached within $200 of the SSI limit ($4,800), for one resident (Resident #308) and failed to ensure a third party liability (TPL), forms were completed for the final accounting for residents who expired. This affected five residents who expired and had money in their account (Resident's #301, #302, #305, #306 and #307). The census was 85. 1. Review of Resident #308's trust account, showed the following: -[DATE], a balance of $7105.24; -[DATE], a balance of $7105.71. During an interview on [DATE] at 10:54 A.M., the Business Office Manager (BOM) said he knew the resident was over the limit. He gave the resident a letter but did not keep a copy. He did this the first week he was given the responsibility of overseeing the resident funds in [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the resident's code status listed on the current physician order sheet (POS) matched the advance directive wishes for 12 of 31 residents sampled (Residents #113, #155, #203, #204, #207, #104, #107, #108, #109, #110, #253, and #151). The census was 85. 1. Review of the facilities Advanced Directives policy, revised [DATE], showed: -Advanced Care Directive Policy Statement: Subject to our overall philosophy, the facility will comply with a resident's advanced care directives in pre-determining their health care future, whenever possible, should they become terminally ill and unable to communicate, be in a permanently unconscious state and/or in an emergency situation. The facility will actively seek to obtain information regarding Advanced Directive wishes from each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for two of three sampled residents, one who remained in the facility (Resident #118) and one who went home (Resident #117) after discharge from Medicare Part A rehabilitation services. The facility census was 85. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident rooms, walls, floors, and shower rooms in good repair to ensure a safe, clean, comfortable and homelike environment. In addition, the facility failed to provide effective pest control and eliminate offensive odors in a resident use elevator. The census was 85. 1. Observation on all days of survey, from 9/14/20 through 9/18/20, 9/21/20 and 9/22/20, of the resident use elevator located closest to the facility entrance, showed it smelled strongly of mold and gnats were observed on the ceiling. During an interview on 9/16/20 at 8:20 A.M., Resident #151 said the elevator smelled so bad, like you could die taking it. He/she believed the smell was sewage. He/she said the smell is really bad and the elevator shouldn't be used, especially by people with breathing problems. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an admission policy or implement an admission protocol to ensure accurate accounting of resident's personal belongings to prevent resident liability for possessions if items were missing or stolen, when the facility failed complete and update an inventory list for eight of 31 sampled residents (Residents #104, #110, #201, #204, #251, #256, #253, and #254). The census was 85. 1. Review of the facility's undated admission contract, showed: -The responsible party and/or resident agree as follows: -To be fully responsible for all financial obligations incurred by the Resident, including not limited to, all medical, dental, hospital, and ambulance charges, and any other miscellaneous charges incurred by the Resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for three of four sampled newly admitted residents (Residents #251, #204, and #206). The sample was 31. The census was 85. 1. Review of Resident #251's medical record, showed: -A face sheet, with an admission date of 8/13/20; -Physician progress notes, dated 9/1/20 with diagnoses that included: seizures, osteomyelitis (inflammation of bone and bone marrow) to coccyx (tail bone area) wound, multiple strokes with left hemiparesis (weakness or inability to move one side of the body), high blood pressure and urinary catheter; -No baseline care plan. During an interview on 9/15/20 at 10:40 A.M., the resident said that he/she required assistance going to bathroom and moving around in bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement, accurate and individualized care plans completed within 21 days of admission, to address the specific needs of the residents, for seven of 31 sampled residents (Residents #108, #153, #155, #154, #202, #251 and #254). The census was 85. 1. Review of Resident #108's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Cognitively intact; -Diagnoses included atrial fibrillation (irregular heart rate), high blood pressure, Alzheimer's disease, dementia, and anxiety; -No behaviors; -Independent with bed mobility; -Required supervision with transfers, dressing, eating, toileting, and hygiene; -Continent of bowel and bladder; -Anti-psychotic, anti-depressant, anti-coagulant, and antibiotics administered in the last seven days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by failing to obtain physician orders for a catheter and a colostomy. In addition, the facility failed to ensure all physician orders were followed by not obtaining weights as indicated and ensuring treatment and therapy orders were followed. For six of 31 sampled residents (Residents #202, #203, #106, #251, #253, and #254). The census was 85. 1. Review of Resident #202's medical record, showed: -admitted [DATE]; -Diagnoses included: Quadriplegia (paralysis of all four limbs), anxiety, high blood pressure, tracheostomy (tube surgically inserted into the trachea for the purpose of breathing) and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure each resident receives adequate supervision and assistance devices to prevent accidents by failing to ensure wanderguards (an electronic device used to manage residents who wander by either setting off an alarm when the person wearing the device gets too close to an exit, or locking the exit door) were functioning properly for two of four sampled residents with a wanderguard. In addition, the facility failed to ensure one resident who wandered was assessed for elopement/wandering risk (Residents #115, #108, and #155). The sample was 31. The census was 85. During an interview on 9/22/20 at 10:20 A.M., the administrator and Director of Nursing (DON) said the facility did not have a policy that addressed residents that are elopement risks and the use of the WanderGuard. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to routinely assess, monitor and document on resident's receiving dialysis (process for removing toxins from the blood for individuals with kidney failure). In addition, the facility failed to have a policy to address the care for residents who require dialysis. The facility identified two residents as receiving routine dialysis treatments, one resident was sampled (Resident #207). The sample was 31. The census was 85. Review of Resident #207's medical record, showed: -admitted : 9/28/17; -Diagnoses included chronic congestive heart failure (CHF, impaired heart function), end stage renal disease (ESRD, chronic irreversible kidney disease), diabetes and high blood pressure. During an interview on 9/14/20 at 11:15 A.M., the resident said he/she goes out for dialysis three times a week. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation, for five out of five narcotic books reviewed. The census was 85. Review of the facility's controlled drug administration policy, dated 10/2/08, showed controlled substances shall be counted every shift by two licensed personnel to ensure adequate control. When there is a discrepancy in the records, nursing administration shall be notified as soon as possible. 1. Review of the Spectrum/rehab medication cart on 9/15/20 at 9:00 A.M., showed: -A control substance shift change count sheet dated July 2020, which contained the following information: -27 out of 93 shifts with only one nurse signature of the shift change count; -26 out of 93 shifts with no count of narcotics; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medication regimen reviews (MRR) were completed by a licensed pharmacist on a monthly basis, for 4 out of 4 residents reviewed for completed MRR (Resident #104, #203, #253, and #151). In addition, the Director of Nursing (DON), who is required to receive a copy of all pharmacy recommendations, failed to have knowledge of where pharmacy recommendations were documented. The sample was 31. The census was 85. Review of facility's pharmacy review policy, revised November 2002, showed: -Purpose: To ensure that all pharmacy recommendations are forwarded to the physician for a response in a timely manner; -Policy: All pharmacy recommendations will be forwarded to the physician. A response must be documented within 30 days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen is free from unnecessary psychotropic drugs by failing to thoroughly assess, monitor and document the use of non-pharmacological approaches prior to administration of a psychotropic drug. In addition, the facility failed to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days for 5 of 5 residents reviewed for unnecessary medications (Residents #104, #108, #206, #204 and #106). The resident sample was 31. The facility census was 85. 1. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/20, showed: -Cognitively intact; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility failed to properly label medications and vaccinations once opened, ensure the medication rooms were locked and controlled medications were locked behind two locks, monitor the medication refrigerator temperature to assure it is maintained at a safe temperature and ensure employee food was not stored in a medication refrigerator for two out of three medication storage rooms and two out of five medication carts observed. The census was 85. Review of the facility's medication storage policy, dated 12/2018, showed: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations; -Procedure: [...]

Inspectors wroteBased observation, interview and record review, and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for COVID-19, the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. In addition, the facility failed to have a process for monitoring and tracking infections (Residents #114 and #119). The resident sample was 31. The census was 85. 1. Review of the CDC, Preparing for COVID-19 in Nursing Homes, updated June 2, 2020, showed: -Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner to protect and promote the rights of the resident when staff failed to provide assistance with a transfer to bed per the resident's request (Resident #114). The sample size was 31. The census was 85. Review of Resident #114's medical record, showed: -Newly admitted to the facility on [DATE]; -Diagnoses included stroke, high blood pressure, depression, and dysphagia (difficulty swallowing). Observation and interview on 9/21/20 at 2:00 P.M., showed the resident lay in bed. The resident said a Certified Nursing Assistant (CNA) had refused to help him/her. He/she forgot the CNA's name. That day started out well. The CNA assisted him/her with getting cleaned up and dressed. He/she did not have any issues. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer their own medications for two residents when staff left medications at the bedside (Residents #111 and #152). The sample was 31. The census was 85. 1. Review of Resident #111's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/20, showed: -Cognitively intact; -Diagnoses included anemia, high blood pressure, renal (kidney) failure, stroke, dementia, malnutrition, anxiety, and asthma; -Required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene. Review of the resident's care plan, dated 4/15/20, showed: -Focus: Dependent on staff for meeting emotional, intellectual, physical, and social needs related to impaired mobility; -Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status to prevent weight loss for one resident (Resident #154) when staff failed to follow the facility's weight protocol, dietician recommendations and physician orders for weight monitoring and administration of tube feeding. The resident was dependent on staff to be fed via gastrostomy tube. The sample was 31. The census was 85. Review of the facility's Weight Protocol, undated, last reviewed on 5/28/19, showed: -Purpose: To provide a permanent, accessible record of resident weights; -Procedure: Residents will be weighted within 24 hours upon admission/re-admission by the certified nurse assistant (CNA). Residents will be weighed weekly for four weeks and then monthly ongoing by designated staff; -Monthly weights will be completed by the 5th of the month. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory services provided were consistent with professional standards of practice when staff failed to obtain a physician order for oxygen and medication used for breathing and failed to ensure physician orders matched the medication and treatment administration records and failed to care for oxygen concentrators and supplies consistent with professional standards of practice for two residents (Residents #104 and #152). The sample was 31. The census was 85. 1. Review of Resident #104's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/20, showed: -Cognitively intact; -Diagnoses include high blood pressure, peripheral vascular disease (PVD, circulatory disorder), anxiety, depression and asthma. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternate meals for residents which accommodated resident preference and religious restrictions (Residents #151 and #153). In addition, residents were not offered or served an alternate for breakfast. This had the potential to affect all residents who had alternate preferences for the breakfast meal. The sample was 31. The census was 85. Observations of meal service during the survey, showed: -On 9/14/20 at 10:10 A.M., Dietary Aide Z said there are no breakfast alternates; -On 9/15/20 at 9:00 A.M., the breakfast main entree was biscuits and gravy: -Resident #151 was given only a biscuit, he/she said he/she had no gravy because he/she could not eat pork as part of his/her religious beliefs, no substitute was given or offered; [...]

Inspectors wroteBased on interview and record review, the facility failed to keep resident records that were complete, readily accessible and systematically organized when the facility administration failed to be aware that weights, medication regimen reviews, dietary recommendations, and assessments were included in the resident's electronic medical record (EMR). This resulted in a failure to follow-up on recommendations, failure to properly monitor weights for one resident (Resident #154) and failure to ensure assessments and pharmacy reviews were completed as indicated for all residents sampled. The sample was 31. The census was 85. 1. During an interview on 9/14/20 at 9:48 A.M., the Director of Nursing (DON) and administrator said the only information that is in the EMR were the census and resident demographics. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care. In addition, the facility failed to maintain the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, the names and contact information for hospice personnel involved in hospice care of each resident and failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for one resident not identified by the facility as receiving hospice services (Resident #155). The sample was 31. The census was 85. [...]