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Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three residents (Resident 1) sampled for resident's right was treated with dignity and respect when Resident 2 reported that Certified Nurses Assistance (CNA) A was rude and impatiently spoke to Resident 1 in a Disrespectful manner, and denied them assistance to the bathroom when requested. These actions resulted in Resident 1 experiencing feelings of upset, disrespect, and intimidation.

Inspectors wroteBased on observation, interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #47) of 2 residents reviewed for Preadmission Screening and Record Review (PASRR) requirements and 1 (Resident #16) of 3 residents reviewed for dental concerns.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure staff immediately reported an allegation of abuse for 1 of 1 incident of alleged resident-to-resident abuse. Specifically, Resident #123 alleged to a certified nursing assistant (CNA) that Resident #115 kicked them and the CNA failed to immediately report the allegation.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide toenail care for 1 (Resident #7) of 4 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free from accidents and hazards by not developing and implementing a plan of care to prevent wandering/Elopement (leaving a healthcare facility without permission or notice) for one of four sampled residents (Resident 4) when: 1. Resident 4 exited the facility unsupervised and was found on the sidewalk near the roadway outside the facility premises. The facility ' s failure to develop a plan of care to prevent leaving the facility unsupervised which resulted in Resident 4 to leave the facility and put him at risk for harm and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. 2. The Registered Dietitian (RD) did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: 1. There was no evidence training occurred for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. 2. Staff did not perform hand hygiene or change gloves between tasks. 3. Staff did not adequately restrain hair or facial hair. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries. 5. Equipment was not cleaned according to professional standards of practice. 6. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient temperature. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. Eleven of 11 kitchen staff did not perform hand hygiene and glove use according to professional standards of practice which increased the likelihood of cross contamination. 2. Two of three hand washing areas used by kitchen staff had the potential to contaminate hands during the hand washing procedure when one sink area had drying towels that were contaminated due to dispensing onto the soiled sink and the second sink areas faucet dispensed water close to the sides of the sink which caused hands to touch the sides of the sink during the hand washing process. 3. Three of five kitchen staff did not have their hair, beards and mustaches completely covered while preparing and serving food. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when a used Emergency Kit (E-Kit, a storage box that houses an emergency supply of medications) was not removed and replaced according to facility policy. This failure had the potential for an E-Kit to have an insufficient amount of an emergency supply of medication available for the facility's residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. Expired pharmaceutical products were not removed from the medication cart (a cart where resident medications are stored and dispensed from) 2. Several medications did not have open date labels This failure had the potential for the administration of expired and ineffective medications to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were in place to adhere to diet orders or meet residents needs when: 1. The facility-specific diet manual provided no indication that the Registered Dietitian responsible for nutrition care at the facility had reviewed and approved the diet manual. 2. The facility-specific diet manual did not contain guidelines and the facility did not have a consistent system in place for provision of fortified diets ordered by providers. 3. Consistent Carbohydrate Diet meals did not match the carbohydrate guidelines in the diet manual. 4. Meals planned for residents receiving Plant Based/Vegetarian diets had little variety and there was no menu posted or available for their use. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate resident food preferences/dislikes when: 1. Resident 134 complained of having too much curry (a spice, mainly associated with South Asian cuisine) with her meals (Cross Reference F803 #4). 2. Resident 23 received pies and cakes when she continually refused them due to her diagnoses. (Cross Reference F803 #3) 3. Resident 69 and 38 refused their meal trays and the facility did not provide an alternative entrée of equal nutritive value. This failure had the potential to result in resident dissatisfaction with meal service, decrease meal intakes, nutritional status, and overall health decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide regular maintenance to the facility kitchen to ensure a safe and sanitary environment when: 1. The temperature in the cold prep room was not maintained at a safe level. 2. The walls, floor trim, floor drains, and ceiling tiles were not maintained in good repair. These failures had the potential to negatively impact the food safety and sanitation of food services areas and can be a safety issue for staff. (Reference F812)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal and medical records were kept private and confidential for two of two sampled residents (Resident 122 and Resident 71) when medication blister packs (packaging that contains resident medication and a label with their personal identifying information) were left unattended on medication cart three (a cart where resident medications are stored and dispensed from) in the facility hallway on nursing station two. This failure violated the resident's right for privacy and had the potential of unauthorized release of personal information.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food in a manner to meet an individual's needs for one of one sampled resident (Resident 38) when she was served meat that was not chopped up as per her diet order. This failure had the potential for her nutritional status to decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective pest control system was in place when a live ant was found in the kitchen's coffee room, and multiple dead ants were found in a nursing unit food storage and preparation pantry for resident food. This had the potential to result in foodborne illness for residents consuming food from the kitchen and nursing unit pantry.

Inspectors wroteBased on observation and interview, this requirement was not met when the facility failed to provide a sanitary environment for 18 of 53 sampled residents who used the shower near Nursing Station 1 (NS1), when the facility failed to clean a shower room between residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for three of 60 sampled residents (Resident 3, Resident 80 and Resident 65) when Resident 118 wandered into their rooms uninvited. This resulted in uninvited touching, anxiety, and put all residents at risk for injury and altercations.

Inspectors wroteBased on interview and record review, the facility failed to report to the required agencies involving resident to resident abuse that involved Resident 118. This failure resulted in ongoing resident to resident abuse and put all residents at risk for injuries, anxiety, and abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate resident to resident abuse that involved Resident 118. This failure resulted in ongoing resident to resident abuse and put all residents at risk for injuries, anxiety, and abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and update care plan interventions for effectiveness and modify them to prevent future falls for two of three residents(Resident 26, and 66). This failure resulted in Resident 26 and Resident 66 having falls with injuries including falls with a fracture and falls with head injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaulate falls and develop new care plan interventions for four of five sampled residents (Residents 26, 66, 118 and 110) to prevent further falls and injuries. This failure resulted in Resident 26, 66, 118 and 110 to have injuries related to falls and had the potential for all residents to be at risk for accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, residents' need to obtain dental care was not met when five of five sampled residents (Residents 20, 27, 31, 64 and 276) did not receive routine dental services. This resulted in pain, potential for choking, and potential for residents remaining on therapeutic diets (e.g., nectar thin liquids) unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety when 1) one of four ice machines was not maintained in a sanitary condition, 2) expired food was available for use in a refrigerator in the kitchen, and 3) food was not covered during transport to residents. These failures put the residents at risk for food borne illness and physical contamination of food.

Inspectors wroteBased on interview, record and policy review, the facility failed to include one of two residents (Resident 101) in two quarterly care plan meetings. This failure resulted in the potential for Resident 101 to receive Cardiopulmonary Resuscitation (CPR) when her wishes were not to receive this treatment.

Inspectors wroteBased on observation and interview the facility failed to ensure two out of three certified nursing assistant (CNA) (CNA Q and CNA P), were able to locate a resident's wishes for cardiopulmonary resuscitation (CPR). This failure resulted in the potential for unnecessary or unwanted medical procedures being performed on them and violating their wishes.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a licensed vocational nurse (LVN) K perform hand hygiene while preformed wound care. This failure had the potential to spread infection from one resident to another, and cause an infection to a wound.