Four Seasons Living Center

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when Registered Nurse (RN) A did not verify admission physician's orders, which resulted in staff not administering diabetic medications and resident hospitalization with Diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body lacks enough insulin to use blood sugar). The facility census was 224. The administrator was notified on 06/12/26 of Past Non-Compliance which occurred on 06/08/26. The Director of Nursing (DON) investigated, notified the residents' responsible party, counseled RN A, and in-serviced staff regarding medication administration, transcribing physician's orders, medication reconciliation, and the admission process. Staff corrected the deficient practice on 06/08/26. [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 239.1. Review of the facility's Facility Assessment Policy and Tools policy, dated 10/31/24, showed the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to update two resident's (Resident #1 and Resident #2) plan of care after the residents consistently pulled the fire alarm. The facility census was 235. 1. Review of the facility's Comprehensive Care Plan, dated 10/31/24, showed the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy showed it did not contain direction for staff regarding updating the resident's plan of care with new interventions after a new or increased behavior.2. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to report an allegation of sexual abuse for one resident's (Resident #4) within the required two hours to the state agency Department of Health and Senior Services (DHSS). The facility census was 228. 1. Review of the facility's Abuse and Neglect Policy, dated 06/12/24, showed it is the policy of this facility to report all allegations of abuse and are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames. The facility must ensure that all the alleged violations involving abuse or sexual assault are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency. 2. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did not accurately code a psychiatric/mood disorder diagnosis for three residents (Resident #1, Resident #2 and Resident #3) out of four sampled residents. Facility census was 232.1. Review of the facility's MDS 3.0, Care Assessment Summary and Individualized Care Plans policy, dated 11/06/23, showed to understand the changes presented by Centers of Medicare and Medicaid Services (CMS) for the MDS 3.0 to define the intent of each section of the MDS 3.0 and to ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties. 2. Review of the resident's diagnosis report, dated 04/30/23, showed staff documented a diagnosis of bipolar disorder. [...]

Inspectors wroteBased on interview and record review, facility staff failed to update one resident's (Resident #2) plan of care who experienced suicidal ideation and had a history of self-harm, and facility staff failed to update three resident's (Resident #1, Resident #3 and Resident #5) plan of care after they exhibited increased behaviors. The facility census was 232. 1. Review of the facility's policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, dated 01/06/23, showed it did not contain direction for staff regarding updating the resident's plan of care with new interventions after a new or increased behavior.2. Review of Resident #1's progress notes, dated 01/27/2026, showed staff documented the resident was an aggressor in a resident-to-resident altercation and reported the holy spirit had taken over his/her body and he/she did not need medication. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe for one resident (Resident #1) of one sampled resident who reported an employee physically abused him/her. The facility's census was 227.1. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the doors on the Tiger Medical Unit, a secured unit, were monitored during a fire alarm test which resulted in one resident (Resident #27) eloping from the facility at approximate 3:00 P.M. In addition, staff failed to complete hourly face checks for the resident, did not check on the resident after he/she missed dinner and smoke breaks, and did not notice the resident was missing until 9:00 P.M. Facility staff further failed to properly complete a thorough head count to ensure all residents were in the facility after the fire drill when staff were made aware two residents (Resident #116 and #112) had left the facility when the unit doors were left unattended and unlocked. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry to prevent the growth of foodborne pathogens. Facility staff failed to ensure two ice machines, used to supply ice to residents, drained through an air gap to prevent cross-contamination. Facility staff failed to store moist cleaning clothes in sanitizing solution between uses to prevent the growth of bacteria and cross-contamination. Facility staff also failed to maintain kitchen equipment and surfaces in two of two kitchens and one kitchenette in a clean sanitary manner to prevent cross-contamination and the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 231. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staffs' failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 231 with a capacity of 239. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity, when residents were required to line up for medication administration outside of the nurse's station door, and required two residents to communicate with staff through a three-inch hole in the enclosed nurse's station glass. Additionally, residents were required to stand in line to get their meal trays and were unable to eat in the dining room due to lack of chairs. The facility census was 231. Review of the facility's policy titled, Resident Rights, dated 07/5/23, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality including privacy in treatment. Review of the facility's policy titled Promoting/Maintaining Resident Dignity, dated 09/21/25, showed every resident has a right to be treated with dignity and respect. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations for residents when they failed to provide sufficient dining room chairs in four dining rooms to ensure residents were able to sit down and eat their meals. The facility census was 231. Review of the facility's policy titled Promoting/Maintaining Resident Dignity, dated 09/21/25, showed each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. 1. Observation on 12/2/25 at 11:15 A.M., showed 17 residents residing on the Tiger Medical Unit. The dining room contained two tables and three chairs. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to clean and maintain resident room and common area walls, doors, windows, floors, toilets, air conditioning (A/C) units, bathroom vents, and furniture. Facility staff failed to ensure residents had access to clean clothes and linens in a timely manner and failed to assist residents with laundry as needed. The facility census was 231 with a capacity of 239. 1. Review of the facility policy titled Safe and Homelike Environment Policy, dated 06/5/24, showed the facility will provide a safe, clean, comfortable and homelike environment. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital and failed to send a copy of the notice of transfer and/or discharge for eight residents (Resident #4, #7, #9, #12, #91, #93, #100, and #150) out of eight sampled to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The facility census was 231. 1. Review of the facility's policy titled Bed Hold, revised 06/12/2025, showed: -Before a resident is transferred or discharged , the facility must: -Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; --Notify a representative of the Office of the State Long-Term care Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for ten residents (Resident #12, #19, #57, #58, #76, #82, #91, #117, #185, and #211) out of 45 sampled residents with changes in the resident's needs. The facility census was 231.1. Review of the facility policy titled Comprehensive Care Plans, dated 10/31/24, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences and will be prepared by an interdisciplinary team. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to provide care, to maintain personal hygiene, grooming, bathing and nail care for four residents (Residents #211, #233, #149, and #77) out of a sample of 45 residents. The facility census was 231. Review of the facility's policy titled Activities of Daily Living (ADLs), dated 05/18/24, showed a resident who is unable to carry out ADLs will receive the necessary services, to maintain good nutrition, grooming and personal hygiene. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on comprehensive assessment. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure nine Nurse Aides (NA) (NA D, NA I, NA P, NA V, NA W, NA X, NA Y, NA Z, and NA AA) out of nineteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The facility census was 233.1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications.2. Review of NA D's CNA report showed a hire date of 04/28/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.3. Review of NA I's CNA report showed a hire date of 08/26/24. Review showed the file did not contain documentation the NA completed a nurse aide training program.4. Review of NA P's CNA report showed a hire date of 07/15/25. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed train their staff on how to adequately care for residents behavioral health needs and two residents, with behavioral health needs, were involved in a resident to resident altercation (Resident #22 and #44) and failed to educate staff on resident specific behaviors and interventions for seven residents (Resident #170, #19, #27, #116, #129, #163, and #211) of 35 sampled residents on two units, the women's behavioral health unit and Tiger Lane. The facility census was 231. 1. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed it is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document the administration of controlled substance medications in the facility's Control Drug Record book (used to reconcile narcotic medications) at time of administration for three residents (Resident #166, #189 and #116) out of 45 sampled residents. The facility census was 231. 1. Review of the facility's Controlled Substance Administration and Accountability Policy, dated 05/14/24, showed the following:-It is the policy of this facility to promote safe, high quality patient care, complaint with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure;-All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles when unpackaged, loose medications were found in five of seven medication carts observed. The facility census was 231.1. Review of the facility's, Medication Storage Policy, dated 05/18/24, showed the policy did not provide guidance regarding loose medications in the medication carts. Observation on 12/01/2025 at 9:55 A.M., showed the 200 hall medical unit medication cart with one crushed pill and one blue and yellow capsule loose in the cart. Observation on 12/01/2025 at 10:19 A.M., showed the 100 hall medical unit medication cart with two white tablets, one pink tablet, and one white tablet in the narcotic box all loose in the cart. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure prepared food items were served at a safe and appetizing temperature to residents who ate in the Main Street and 400 hall dining rooms. Facility staff failed to ensure the internal temperature of hot food held in the steam table measured at least 140 degrees Fahrenheit (dF) and failed to ensure the internal temperature of hot food measured at least 120 dF upon service to the residents. The facility census was 231. 1. [...]

Inspectors wroteBased on observation and interview, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, daily in an area readily accessible to all residents and visitors. The facility census was 233. Review of the facility's policy titled Nurse Staffing Posting Information Policy, reviewed 06/26/24, showed the nurse Staffing Sheet will be posted on a daily basis and will contain: -Facility Name;-Current date;-Facility current resident census;-The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directedly responsible for resident care per shift:-Registered nurses;-Licensed Practical Nurses (LPN)/Licensed Vocational Nurses (LVN);-Certified nurse aides (CNAs). [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three residents (Resident #5, #6, and #7) out of seven sampled residents remained free from physical abuse when Resident #8 who had a history of physical aggression towards other residents willfully hit the residents in the head. The facility's census was 234.1. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physician condition, cause physical harm, pain or mental anguish. Physical abuse is purposefully beating, striking, wounding, or injuring any resident in any manner whatsoever. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1's) responsible party after the resident had a change in condition. Facility staff failed to notify one resident's (Resident #3's) physician out of two sampled residents when staff did not administer the resident's medications. The facility census 231.1. Review of the facility's Notification of Change policy, dated 05/14/24, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for two residents (Resident #1 and #2) out of three sampled residents. Facility staff also failed to update the plan of care with behavioral interventions for one resident (Resident #8) out of one sampled resident. The facility census was 231. 1. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to ensure prescribed medications were available and administered for one resident (Resident #3) out of two sampled residents. The facility's census was 230.1. Review of the facility's Medication Administration policy, dated 06/26/24, showed medications are administered by a licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 2. Review of the facility's Transcription of Orders/Following Physician's Orders policy, dated 05/18/24, showed staff are directed as follows:-The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. [...]

Inspectors wroteBased on interview and record review, facility staff failed to contact one resident's (Resident #1's) responsible party after the resident had a change in condition. The facility census 231. 1. Review of the facility's, Notification of Change policy, dated 05/14/24, showed:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring Notification include accidents, resulting in injury or potential to require physician intervention.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for two residents (Resident #1 and #2) out of three sampled residents. The facility census was 231. 1. Review of the facility's policy, MDS 3.0, Care Assessment Summary and Individual Care Plans, dated 11/06/23, showed:-The Plan of Care should address improvements where possible and maintenance and prevention of avoidable declines and all Care Area Triggers;-There are twenty (20) areas that can become triggered areas for concern and must be addressed with individualized interventions on the plan of care for resident;-The policy did not address timeframes for revising a resident's care plan after a change in condition.2. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to ensure prescribed medications were available and administered after admission from 07/18/25 to 07/21/25 to one resident (Resident #3) out of two sampled residents and failed to notify the physician to obtain further orders. The facility's census was 230.1. Review of the facility's policy titled, Medication Administration, dated 06/26/24, showed medications are administered by a licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 2. Review of the facility's policy titled, Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed: [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. This had the potential to affect all residents. The facility census was 232. 1. Review of the Facility Assessment, dated 08/01/24, showed staff are directed as follows: -Direct care staff required to care for their facility census for a twenty-four hour period should include: Six Licensed Practical Nurses (LPN); Nine Certified Medication Technician (CMT); Twelve Certified Nurse Aides (CNA); Eight Nurse Aides (NA); and One Resident Care Coordinator (RCC). -The assessment is based on the resident population and their needs for care and support; -The last quarter average number of occupied beds was 235. Review of the employee staffing schedule from 01/19/25 through 02/04/25, with an average daily census of 235, showed: -Thursday, 01/30/25; [...]

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to complete and document wound care treatments for two resident's (Resident #2 and #3) out of three sampled residents. The facility census was 232. 1. Review of the facility's Documentation of Wound Treatments policy, dated 05/18/24, showed wound treatments are documented at the time of each treatment. If treatment is not due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include, but is not limited to: Date and time of the wound management treatments; weekly progress towards healing and effectiveness of current intervention; Any treatment for pain; Modification of treatments or interventions; Notifications to physician and/or responsible party regarding wound or treatment change. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of bacteria and food contamination. Facility staff failed to maintain kitchen equipment and surfaces in two of two kitchens and one kitchenette in a clean sanitary manner to prevent cross-contamination and the growth of food-borne pathogens. The facility census was 233. 1. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation policy, revised on 02/02/24, showed the policy directed staff to air dry dishes by racking or putting on single trays lined with mesh after they are washed and sanitized. Observation on 10/21/24 at 10:31 A.M., showed 14 metal food service pans stacked together wet in the kitchen. Observation showed eight of the 14 wet stacked pans contained food debris inside them. [...]

Inspectors wroteBased on record review and interview, facility staff failed to prevent the commingling of 12 resident's (Resident #53, #85, #69, #102, #20, #181, #128, #98, #125, #216, #116, and #204) personal funds with the facility operating funds out of 79 sampled. The sampled resident's resided in the facility. The facility census was 233. 1. Review of the facility's policy titled Resident Rights, revised 07/05/23, showed the facility must establish and maintain a system that assures a full and complete separate accounting of resident's personal funds, the system must preclude any commingling of resident funds with facility funds. Review of the facility's policy titled Resident Trust, revised 11/08/23, showed the facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. [...]

Inspectors wroteBased on record review and interview, facility staff failed to provide refunds of personal funds to the residents from the facility operating account within 30 days for three residents (Resident #587, #588, and #585) out of five sampled who were discharged from the facility. The facility census was 233. 1. Review of the facility's policy titled Resident Rights, revised 07/05/23, showed upon the death of a resident the facility must convey within 30 days resident funds, and financial accounting of those funds to the individual or probate jurisdiction administering the resident estate. Within five days of the discharge of a resident, the facility will provide the resident or resident designee/guardian with an up-to-date accounting of resident funds. [...]

Inspectors wroteBased on observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain resident rooms, furniture in common areas, and ensure resident rooms did not contain piles of laundry. Staff failed to clean and maintain wheelchairs for three residents (Resident #137, #98, and #115) of 35 sampled residents. The facility census was 233 with a capacity of 239. 1. Review of facility policy titled, Housekeeping - Deep Cleaning, dated 06/29/23, show staff were directed as follows: -Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, floors at closets and doorways are to be free from wax/dirt build up; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing activity program designed to meet the residents' interest, mental, and psychosocial well-being on the weekends for six residents (Resident #10, #73, #140, #141, #186, and #212) out of 35 sampled residents. The facility staff failed to post an activities calendar with accurate events for residents to view on Tiger Lane. The facility census was 233. 1. Review of the facility's policy titled Activity, dated 07/19/23, showed the purpose is to ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (dF) or higher upon service to residents who resided on the 400 and 500 halls. The facility census was 233. 1. Review of the facility's Dietary Food Preparation policy, revised on 07/05/23, showed the policy directed staff to check the internal temperature of food items before service and the acceptable serving temperatures for hot foods were greater than 135 dF but preferably 160 dF to 170 dF. Review showed the policy directed staff to reheat food products to the proper temperature if temperatures do not meet acceptable serving temperatures. 2. Observation on 10/21/24 from 12:17 P.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to screen four employees (Dietary Aide S, [NAME] Y, Housekeeper N, and Activity Aide K) out of ten new employees prior to employment to determine if the employees had a federal indicator with the Employee Disqualification List (EDL) and/or the Family Care Safety Registry (FCSR). The facility census was 233. 1. Review of the Facility's policy titled Pre-Employment Screening, undated, showed the Human Resources department will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and if applicable, is duly licensed or certified to perform the duties of the position for which they applied. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document they administered three residents (Residents #115, #132 and #219) of 35 sampled residents medications and treatments. The facility census was 233. 1. Review of the facility's policy titled Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed the nurse or Certified Medication Technician (CMT) in charge of medication administration must review all of their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physicians' order and that all necessary interventions were taken in the event of an omission Review of the facility's policy titled Documentation of Wound Treatments, dated 05/18/24, showed wound treatments are documented at the time of each treatment. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide supervision of one resident (Resident #1) who has a history of inserting foreign objects into his/her colostomy bag (a bag that collects stool) and stoma (an opening in the body) which resulted in the resident being transfered to the hospital. The facility census was 232. 1. Review of the facility's policy titled, Incidents and Accidents Policy, dated 05/18/24, showed staff were directed to assure appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/18/24, showed staff assessed the resident as cognitively intact and used a colostomy bag. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to document and update care plans to include the use of a colostomy bag (a bag that collects stool) for one (Resident #2) and new interventions for one resident (Resident #1) with a behavior of inserting foreign objects into his/her colostomy bag and stoma (opening in the body) out of four sampled residents. The facility census was 232. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated 6/26/24, showed staff were directed to: -Develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, facility staff failed to contact one resident's (Resident #1's) responsible party when the resident was transported to the hospital. The facility census was 236. 1. Review of the facility's Notification of Changes policy, dated 5/14/24, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident ' s physician, and notifies the resident's representative when there is a change that requires notification. Circumstances which requires notification are significant changes in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status which may include life threatening conditions or clinical complications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, staff failed to protect residents in the facility when they did not follow acceptable infection control practices for COVID-19. The facility failed to separate residents who tested positive for Covid-19 from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for residents (Resident #40, #43, #21, #22, #27 and #9) at an increased risk of contracting Covid-19 due to prolonged exposure. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete 72-hour neurological checks and fall follow up documentation for two residents (Resident #1 and #2) of four sampled residents, who had un-witnessed falls. The facility census was 233. 1. Review of the facility's Post Fall Protocol, revised 6/30/23, showed the purpose of the policy is to ensure all residents who have had a fall have accurate assessment and follow through to prevent further injury and recurrence of falls. Review showed neurological assessments include assessment of level of consciousness, movement of extremities, hand grasps, pupil size, pupil reaction, and speech. [...]

Inspectors wrotePlease refer to Event ID 2UWO12 Based on interview and record review, facility staff failed to ensure five residents (Resident #1, #4, #2, #3 and #5) of five sampled residents had the opportunity to make and receive phone calls in a private setting. The facility census was 234.

Inspectors wrotePlease refer to Event ID 2UWO12 Based on observation, interview and record review, the facility staff failed to ensure five residents (Residents' #1, #2, #3,#4 and #5) are able to communicate freely with the state Abuse Hotline and Emergency Services. The facility census was 234.

Inspectors wroteBased on observation, interviews, and record reviews, facility staff failed to store and label food in a manner as to prevent spoilage and outdated use. Facility staff failed to maintain the main kitchen and three kitchenettes in a clean and sanitary manner. This failure had the potential to affect all residents. The census was 236. 1. Facility staff did not provide a policy to address food storage. Observation on 07/24/2023 at 9:58 A.M., of the main kitchen, showed the backsplash of the gas range had a build-up of black grease. Further observation showed food debris and paper products under the gas range. Observation on 07/24/2023 at 10:00 A.M., of the main kitchen, showed all five double door stainless steel refrigerators contained dried food splatter on the front of the doors. Observation on 07/24/2023 at 10:02 A.M., of the main kitchen, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff failed to cover two residents' (Resident #95 and #108) catheter drainage bags (bag that collects urine from the bladder), failed to keep the privacy curtain pulled for three residents (Resident #83, #159, and #687) when the lack of sheets/blankets left them exposed to the hallway, and failed to ensure three residents (Resident #112, #205, and #217) were dressed in clothing free from holes, stains, wrinkles, and facing the right direction. The facility census was 236. 1. Review of the facility's policy titled, Resident Rights, dated 07/05/23, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality including privacy in treatment and in care for his/her personal needs. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure five residents (Resident #1, #4, #2, #3 and #5) of five sampled residents had the opportunity to make and receive phone calls in a private setting. The facility census was 234. 1. Review of the facility's policy titled, Resident's Rights, dated 07/05/23, showed staff were directed as follows: -Privacy must include written and telephone communications; -Resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. Review of the facility's, Phone Times schedule, undated, showed the following call times: -9:00 A.M. to 11:30 A.M. phone can be used; -11:30 A.M. to 1:00 P.M. no phone; -1:00 P.M. to 5:00 P.M. phone can be used; -5:00 P.M. to 7:00 P.M. no phone; -7:00 P.M. to 9:30 P.M. phone can be used. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff did not maintain a safe, clean, comfortable and homelike environment, when staff failed to ensure a comfortable sound level for residents by allowing the 400 and 500 hall entrance and exit doors to slam shut, failed to maintain one resident's (Resident #64) wheelchair, and failed to adequately clean and properly maintain residents' rooms, bed linens, furniture, bathrooms, windows and window coverings in good repair. Facility staff failed clean and maintain walls, trim and doors in community areas of the facility, used by residents. The facility census was 236. 1. Review of the facility's policy titled Maintenance Work Order, dated 12/21/22, showed a work order should be submitted for any issues that an employee observes which need the attention of facility maintenance. [...]

Inspectors wroteBased on interview and record review, facility failed to ensure four residents (Resident #1, #4, #3 and #5) of five sampled residents had the opportunity to make anonymous phone calls to the Department of Health and Senior Services (DHSS) Abuse and Neglect hotline. The facility census was 234. 1. Review of the facility's policy titled, Resident's Rights, dated 07/05/23, showed staff were directed to the following: -Resident Rights under Social Security Act, the resident has the right to communication with and access to persons and services inside and outside the facility; -Facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to resident; -Resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, for one resident (Resident #235) who admitted to hospice services. Additionally, staff failed to accurately code MDS Assessments for three residents (Residents #112, #205 and #209) in regard to Activities of Daily Living (ADLs) needs, two residents (Residents #21 and #207), who used Continuous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep airways open while sleeping, oxygen use for one resident (Resident #116), anticoagulant use for one resident (Resident #37) and insulin use for one resident (Resident #9). The facility census was 236 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical, and nursing needs when they failed to address activity preferences for four residents (Resident #51, 76, 172, and 187), facial hair preferences for one (Resident #123), splint use for one resident (Resident #156) and hospice services for one resident (Resident #159). The facility census was 236. 1. Review of the facility's policy titled, Comprehensive Care Plans and Baseline Care plans, reviewed 01/19/22, showed staff were directed to do the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents who required assistance with activities of daily living (ADLs) (Resident #64, #95, and #168), one resident who prefers to sleep during the day (Resident #21), and one resident (Resident #123) who used bed rails. The facility census was 236. 1. Review of the facility's policy titled, Comprehensive Care Plans and Baseline Care plans, reviewed 01/19/22, showed staff were directed to do the following: -Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure thirteen residents (Residents #21, #49, #51, #64, #76, #123, #126, #152, #156, #159, #164, #168, and #187), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 236. 1. Review of the policies provided by the facility showed no ADL care, personal hygiene or shave/facial hair policy. Review of the facility's policy titled, Nail Care, dated 06/29/23, showed staff are directed to do the following: -Nail clipping or cutting must have an order from the nurse; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide daily activities for all residents in the Turning Leaf Unit and failed to provide an ongoing program of activities designed to meet the residents' interests for three sampled residents (Resident #49, #159, and #687) on the [NAME] Hawk Boulevard hall. The facility census was 236. 1. Review of the facility's policy titled, Activity, dated 07/19/23, showed staff are directed to do the following: -Ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychological well-being; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to propel four residents (Residents #83, #24, #187, and #95) in wheelchairs in a manner to prevent accidents. The facility census was 236. 1. Review of the policies provided by the facility showed no wheelchair safety policy. 2. Review of Resident #83's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/23, showed staff assessed the resident as follows: -Cognitively impaired; -Required extensive assistance from one staff member for locomotion; -Required extensive assistance from two staff members for transfers; -Had limited range of motion (ROM), joint movement, in all extremities; -Used a wheelchair. Observation on 07/25/23 at 8:35 A.M., showed Certified Nurse Aide (CNA) T propelled the resident from the dining area to his/her room without the use of foot pedals. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Residents #1 and #156), and failed to provide appropriate catheter care (a flexible tube placed in the bladder to drain urine) for two residents (#95 and #108). Additionally, facility staff failed to clean and store respiratory equipment in a manner to prevent the spread of infection for two residents (Residents #21 and #207). The facility census was 236. 1. Review of the facility's policy titled, Handwashing, dated 06/29/23, showed staff were directed to do the following: -The use of gloves does not replace handwashing; -Hands are to be washed before and after gloving; -A waterless antiseptic solution may be used as an adjunct to routine handwashing; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide proper communication forms for one resident (Resident #231) who resides on the memory care unit. The facility census was 236. 1. Review of the facility's Communications with Persons with Limited English Proficiency policy, dated 06/30/23, showed staff were directed as follows: -Identify resident and their language; -Obtain a qualified interpreter; -Use family and/or friends as interpreters; -Provide written translation; -Monitor language needs. Review of Resident #231 admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/18/23, showed the staff assessed the resident as follows: -Language marked undetermined; -Able to make self-understood; -Able to understand; -Clear speech; -Adequate vision using corrective lenses; -Adequate hearing; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #198) received a meal or a snack prior to dialysis (process for removal of waste and excess water from the blood due to kidney failure) treatment. The facility census was 236. 1. Review of the facility's policy titled, Dietary-Medical Nutrition Therapy Policy, dated 2023, showed staff were directed to do the following: -The Dietary Technician/Dietary Manager will check all residents records for Diagnosis of Renal Failure; -After assessing residents identified to be at nutrition risk, a nutrition therapy plan is developed to meet identified needs and placed in the patient's chart; -Did not contain direction for staff in regard to dialysis. 2. [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family member or representatives of residents. This has the potential to affect all residents in the facility. The facility census was 236. 1. Review of the policies provided by the facility showed no policy in regard to posted survey results. Observation on 07/27/23 at 8:34 A.M., showed a sign on the wall at the entrance to the building that read, The results of the state survey can be viewed at the nurse's desk, The reception desk has a three ring binder with the state survey results, and The locked nurse's station has a three ring binder on the desk with the state survey results. Further observation showed the state survey results binders not accessible to residents. [...]