Franklin Heights Nursing & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment of each resident's needs, strengths, goals, life history, and preferences wasn't completed within the required 14-day timeframe following or 1 of 1 the quarterly assessment for resident reviewed (Resident #1). The facility failed to ensure the DOR completed Resident #1's BIMS assessment in a timely manner. The failure could place residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #2) reviewed for call light placement. The facility failed to ensure call lights were in reach for Resident #2 on 03/27/2026. This failure could place residents by not having access to call for assistance resulting in needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences for 1 of 6 residents (Resident #1) reviewed for oxygen management. The facility failed to post an Oxygen sign that documented Resident # 1 received oxygen in her room on 03/27/2026. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health and risk of fire hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 5 (Resident # 2, Resident # 5, Resident # 6, Resident #7 and Resident #8) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Residents #2, #5, #6, #7 and #8, had their call lights within reach. This failure could place residents at risk for not having their needs/preferences met.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 7 of 10 employees (DON, CNA P, SW B, LVN D, LVN N, CNA L and RN O) reviewed for employee misconduct registry and nurse aide registry screenings; the facility failed to complete Criminal Check for 2 (LVN N and RN O) of 10 employees reviewed for criminal checks. The facility had failed to have copies of previous annual employee misconduct registry and annual nurse aide registry screenings for DON, CNA P, LVN D, LVN N, CNA L and RN O in their personnel files. The facility failed to have a dated initial EMR/NAR check for Social Worker B upon hire on 09/18/25. The facility failed to complete the annual EMR/NAR screenings on LVN Charge Nurse on 01/09/26 according to facility's policy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services. The facility, which was licensed for 132 beds, failed to employ a qualified social worker on a full-time basis since 08/05/2025. This failure could place residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience for two (Resident #4 and Resident #5) of three residents reviewed for freedom from physical restraints. The facility failed to ensure Residents #4, and Resident #5 did not have pillows under their mattresses which restricted his movement from getting off the bed and were not required to treat his medical symptoms. This failure could put residents at risk of unnecessary restriction of their movements. Resident #4 Record review of Resident #4's face sheet dated 10/24/2025, revealed, admission on [DATE] to the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to implement Resident #1's comprehensive person-centered care plan on 11/11/2025, for medication administration. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent significant medication errors for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow physician's order by administering Amiodarone (a heart medication used to control dangerous irregular heartbeats) to Resident #1 when he was not prescribed this medication. This failure placed the residents at risk of not receiving their medications as ordered by the physician, which could cause a serious allergic reaction and side effects.

Inspectors wroteBased on interview and record review, the facility to ensure resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 3 (Resident #13, Resident #57, and Resident #111) of four residents reviewed for notification of room change. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency and the State Long-Term Care Ombudsman program in a language understood for 7 of 7 residents (Confidential Group). The facility failed to ensure the Ombudsman information was reviewed with residents in the facility and ensure the information was discussed on how to file a complaint with the State agency when residents interviewed in a confidential group meeting were unaware, they had a Long-Term Care Ombudsman Program, contact information for the Ombudsman or how to file a complaint with the State agency. This failure could affect the residents who reside in the facility, to not be aware of resources that were available to them.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL care for 3 of 16 residents (Resident #56, # 94 and #107) reviewed for ADLs.-The facility failed to ensure Resident #56, # 94 and #107's fingernails were clean and free from debris on 07/21/2025.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. -The facility failed on 07/21/2025 to seal a container with marinara sauce inside of refrigerator #1. -The facility failed on 07/21/2025 to maintain 1 strawberry ice cream container free from drippings in refrigerator # 3.-The facility failed on 07/21/2025 to close or seal a bag containing frozen egg omelets inside of refrigerator #4. -The facility failed on 07/21/2025 to dispose of rotting and moldy onions and potatoes in the pantry. These failures could place all residents who received meals from the main kitchen at risk of food borne illnesses. [...]

Inspectors wroteBased on interview and record review the facility failed to have complete and accurately documented medical records for two (Resident #13 and #111) of five residents whose clinical records were reviewed for accuracy.-The facility failed to document room transfers and the reason for transfers for Resident #13 on 03/19/25 (Hall 4) and 06/27/25 (Hall 4 to Hall 1).-The facility failed to document room transfer and the reason for transfer for Resident #111's on 04/13/25 and 04/22/25. These failures could affect the residents in the facility at risk of inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen. -The facility failed on 07/21/2025 to effectively remain free of cockroaches in the only kitchen in the facility. These findings placed residents at risk of ill effects of pest infestation. During observation and interview on 07/21/2025 at 8:15 AM with the Director of Food and Nutrition, two dead cockroaches were observed on the kitchen floor in between cooking stations near a water drain. They were in near proximity to cooking utensils, pots and pans. The Director of Food and Nutrition stated that it was likely that cockroaches were present in the kitchen because it had been raining in the area and that made the insects crawl into the kitchen. [...]

Inspectors wroteThe findings included:An observation and interview on 07/23/25 at 11:55 AM with Treatment LVN, revealed red dried drippings on the Betadine bottle stored in the treatment cart. Treatment LVN stated all bottles should be clean and free of dried drippings. He stated dried drippings were an infection control issue which can affect the residents. Treatment LVN stated he was responsible for the maintenance of the treatment cart. An interview on 07/24/25 at 12:25 PM with the ADON who stated the Treatment LVN was responsible for the treatment cart. She stated the Treatment LVN were to review their treatment cart daily for cleanliness including bottles being free from dried drippings. The ADON stated it was her and the DON's responsibility to monitor all carts for cleanliness on a weekly basis. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #11) of 3 residents reviewed for resident rights. -The facility failed to ensure the urinary collection bag for Resident #11's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #10) of 6 residents reviewed for call light placement. -The facility failed to ensure that Residents #10's call light was within her reach. This failure placed residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #11) of 3 residents reviewed for catheter care. -The facility failed to ensure Residents #11's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #12) of 3 the residents reviewed for respiratory care. -The facility failed to ensure Residents #12 did not have an empty oxygen humidifier bottle on the oxygen concentrator dated 07/20/2024 while in use. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed to keep 1 gallon bottle of Soy sauce stored on a metal rack in the walk-in refrigerator free of dried drippings around the lid. -The facility failed to keep one plastic container with jelly stored on a metal rack in the walk-in refrigerator free of dried food residue on the lid. -The facility failed to store foods in the refrigerator in sealed containers. There was ground beef thawing inside the refrigerator and blood drippings were found on the floor where the meat was placed. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality for 4 (Resident #16, #54, #58, and #89) of 10 reviewed for dignity and 2 (the DON and CNA A) of 7 staff reviewed for Resident dignity. The facility failed to ensure staff were not standing up and feeding the residents in the main dining room. The facility failed to ensure that Resident #54 was offered a clothing protector resulting in his clothing being soiled during meals. The facility failed to ensure that Resident #58's privacy was respected by not covering his Foley bag with a privacy bag. The facility failed to provide personal hygiene for Resident #89 by not removing her facial hair. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #88 and Resident #196) of 5 residents observed for oxygen management. Resident #88 and Resident #196 were on oxygen and did not have oxygen signs posted outside their bedrooms (room [ROOM NUMBER] and room [ROOM NUMBER]). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for thirty-two of fifty-two days reviewed for nurse staffing information. The facility failed to post the required staffing information for [NAME] & East Wings- East Wing - 10/07/23, 10/21/23, 10/22/23. West Wing - 10/07/23, 10/21/23, 10/22/23. East Wing - 11/04/23, 11/18/23, 11/25/23, 11/26/23. West Wing - 11/04/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23 East Wing - 12/01/23, 12/02/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. West Wing - 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/23/23, 12/24/23, 12/30/23, 12/31/23. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 (Resident #10) of 6 residents reviewed for medication administration; and 1 of 3 medications carts (used in Zone 4 & Zone 5) reviewed for medication storage. -The facility failed to administer medication to Resident #10, according to physician ' s order. -The facility failed to follow the facility ' s policy and procedure on drug destruction by not providing the administrator copies of Individual Control Drug Records for 21 of 31 controlled substances to reconcile with the pharmacist at time of drug destruction. -The facility failed to keep medication drawers free of dust and paper particles in medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals in accordance with manufacturer ' s specifications for of 3 medication carts (Zone 4 /Zone 5) reviewed for medication storage and handling of medications. -The facility failed to date Glucometer Normal/High Control Solutions when opened according to manufacturer specifications in Zone 4/Zone 5. These failures could affect diabetic residents that received medications from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #58) of 12 residents reviewed for infection control; and 2 of 6 linen carts observed for infection control; 2 of 2 crash carts observed for infection control. The facility failed to ensure Resident #58's foley bag was not hanging from the trash can near the floor. The facility failed to keep linen cart covers in the laundry room free of tears. The facility failed to keep linen cart covers used to store clean linen free of stains. The facility failed to ensure staff were not storing clean eating utensils in linen cart. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment; failed to maintain 1 of 6 linen carts in safe operating condition. The facility failed to maintain the oven in operational condition. The facility failed to maintain a working trash can next to the hand washing sink in the kitchen. The facility failed to correctly wash cookware using the three-compartment sink. The facility failed to maintain 1 of 6 clean linen carts in safe operating conditions. This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition.

Inspectors wroteBased on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for misappropriation of property for 1 (alleged allegation of unknown resident) of 1 alleged allegation reviewed for abuse. The facility failed to implement their abuse policy when they failed to report, investigate, and protect residents from further potential abuse when it was reported on 05/30/24 to the DON by LVN D that LVN K was stealing resident (unknown who the resident(s) were) medications. This placed residents at risk for misappropriation of property and other abuses by not immediately following the facility abuse policy and procedure manual of recognizing, reporting, investigating, and allegations of misappropriation and other abuses.

Inspectors wroteBased on interviews and record review the facility failed to ensure alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (DON) of 1 DON reviewed for reporting. [...]

Inspectors wroteBased on interviews, and record review the facility failed to ensure violations were thoroughly investigated with results of the investigations presented to the administrator and to other officials in accordance with state law including to state survey agency, within 5 working days of the incident and if the alleged violation was verified appropriate corrective action must be taken for 1 (stealing of medications) of 1 facility medication reviewed for incidents. The facility failed to thoroughly investigate the stealing of medications reported on 05/30/24 to the DON. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that resident assessments were accurate for 3 (Resident #88, Resident #196, and Resident #198) of 5 residents reviewed for accuracy of resident assessments. The facility failed to accurately identify the need for oxygen therapy for Resident #88 admission MDS dated [DATE] and Resident #196 ' s admission MDS dated [DATE]. The facility failed to accurately identify the need for intervenors therapy for Resident #198 ' s admission MDS dated [DATE]. This deficient practice could place residents at risk of not receiving a completed initial assessment which could result in necessary care and services based on their individually assessed needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #16, #49, and #89) of 18 residents assessed for comprehensive person-centered care plans. The facility failed to ensure that Resident #16's Care plan reflected interventions in place to address his frequent falls. The facility failed to ensure that Resident #49 had a care plan in place to address chronic pain. The facility failed to ensure that Resident #89 did not have a care plan in place to address potential trauma from use of a urinary catheter. These failures could put residents at increased risk of not having their care needs met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 residents (Residents #89 and #77) out of 12 reviewed for services to maintain good grooming and hygiene. The facility failed to provide Resident #89 with removal of facial hair. The facility failed to provide personal hygiene for Resident #77 by not trimming his fingernails. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #198) of 3 residents reviewed for pressure ulcers. LVN E failed to notify the Wound Care Nurse that Resident #198 ' s dressing for his right heel and calf was not placed according to physician orders exposing the unstageable right heel. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on observations, interviews, record review the facility failed to ensure that a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence was not possible to maintain for 1of 5 (Resident #89) residents reviewed for urinary catheter. The facility failed to ensure Resident #89's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #198) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. Resident #78 midline (intravenous catheter) dated 05/20/2024, the dressing edges where loose and coming off, dressing had dried blood towards the bottom of the dressing, and was dated 05/20/24. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the residents' goals and preferences for one (Resident #49) of 12 residents reviewed for pain control . The facility failed to ensure that Resident #49's request, and physician's order to administer Tylenol 4 (Acetaminophen-Codeine Oral Tablet 300-60 MG) were carried out in a timely manner. This failure could put residents at increased risk for pain and decreased quality of life.

Inspectors wroteBased on interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1alleged allegation of stealing of medications reviewed for allegations of misappropriation of property. The facility failed to ensure the DON followed the internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents in one of six zones (Zone 1 Rooms 1 -12) reviewed for effective pest control. The facility failed to ensure that two live cockroaches were not found in Zone 1 (Rooms 1 -12) of the facility. This failure put residents at increased risk of transmission of vermin-borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs for one out of seven Residents (Resident #6) reviewed for resident rights. On two occasions 05/11/2024 and 05/13/2024 Resident #6 was left alone in her room on the bed without being able to reach her call light. This deficiency could put other residents who are unable to use their call lights at risk of not having their care needs met by not having access to call lights to communicate their needs. Findings Included: [...]

Inspectors wroteBased on interviews and record review the facility failed to communicate with hospice representatives for 1 of 7 (Resident #1) residents reviewed for hospice services. The facility failed to notify Hospice of Resident #1's acute glucose level increase on 05/04/24. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility care givers.

Inspectors wroteBased on interview and record review the facility failed to ensure alleged violations involving neglect or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #6) of 4 residents reviewed for reporting. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for wound care. Resident #3 was not given wound care as prescribed to left and right heel to cleanse with normal saline cleanser, pat dry, apply foam heel protector or abdominal pad and wrap with roll gauze dressing every Monday, Wednesday, and Friday for protection as ordered as there was no wound care performed on 03/13/24. This failure could affect residents by placing them at risk of deterioration of the wound.

Inspectors wroteBased on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for one (Resident #2) of four residents reviewed for abuse The facility failed to implement their abuse policy when they failed to report, investigate and protect residents from further potential abuse when Resident #2 made an allegation of sexual abuse An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor its plan for effectiveness. [...]

Inspectors wroteBased on interview and record review the facility failed ensure alleged violations involving abuse, including sexual abuse/exploitation are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 4 residents reviewed for reporting. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure violations are thoroughly investigated with results of the investigations presented to the administrator and to other officials in accordance with state law including to state survey agency, within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for incidents. The facility failed did not thoroughly investigate Resident #2's sexual abuse/exploitation in which Resident #2 claimed CNA H had touched in her private parts and when wiping would stick his fingers inside her when he showered her to the Administrator, to other officials, and to State Survey Agency. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. [...]

Inspectors wroteBased on record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. The facility failed to have a monitoring tool in place for when residents were outside in the back patio area. Resident #1 was outside in the back patio area, unsupervised by staff for approximately 34 minutes, and was found near the facility building walking without her wheelchair near a ravine and busy street. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #11) of 3 residents reviewed for urinary catheter care. Resident #11's catheter bag did not have a catheter bag cover exposing the catheter bag filled with urine This failure could have compromised residents' dignity for those who require urinary catheter care.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #14) of 16 residents reviewed for call light placement. The facility failed to ensure that Residents #14's call light was within her reach. This failure placed residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #11) of 5 residents reviewed for indwelling catheters in that: Resident #11's indwelling catheter tubing was full and cloudy and evaluated on a wedge not being able to drain downwards properly. These failures placed residents at risk of collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to ensure Resident #2's medical record accurately documented Resident #2's sexual abuse/expiation allegation. This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting inadequate treatment/care.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 2 of 10 (Resident #1 and Resident #12) residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. Staff failed to respond to the door alarm when the resident exited the facility. Resident #1 was outside, unsupervised by staff for approximately 1 hours, and suffered lacerations and abrasions. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/19/24. The IJ template was provided to the Administrator. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 2 residents (Resident #10 and Resident #11) reviewed for environment. The facility did not ensure the foot boards of Resident #10 and Resident #11 were not broken. These failures placed residents and staff at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident ' s status for 2 (Resident #4 and Resident #8) of 5 resident reviewed for accuracy of MDS assessment, in that: Resident #4 ' s annual MDS did not accurately reflect the residents ' behaviors in the annual MDS. Resident #8 ' s annual MDs did not accurately reflect the residents ' behaviors in the annual MDS. This deficient practice could affect residents at the facility who had been assessed for behaviors and could contribute to inadequate care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 (Resident # 3, #4, #5, #7, and #8 ) of 12 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #7 ' s history of falls. The facility failed to implement a comprehensive person-centered care plan to address elopement risk for Residents #3, #4, #5, #7, and #8. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 10 residents (Resident #11) reviewed for respect and dignity. The facility staff failed to honor Resident #11 ' s request to turn on her TV, instead of going to sleep. This failure could place residents at risk of diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to respect a resident's right to personal privacy during personal care for 1 of 10 residents ( Resident #12) reviewed for respect and dignity. The facility failed to close the curtain and provide privacy when changing Resident #12. This failure could place residents at risk of diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 13) of 2 residents reviewed for allegations of injury with unknown origin. The facility failed to report Resident #13 ' s injury of unknown origin related to her dislocated jaw to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of injuries of unknown origin to the proper authorities at the facility. Findings Include: Resident #13 Record review of Resident #13 ' s face sheet dated 01/18/2024 revealed an [AGE] year-old female who was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse, neglect, and exploitation and injuries of unknown origin were thoroughly investigated for 1 (Resident #13 ) of 5 residents reviewed for abuse and neglect. The facility did not thoroughly investigate Resident #13 ' s injury of unknown origins. This failure could place residents at risk for abuse, neglect, and decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care 48 hours of a resident ' s admission for 2 (Resident #2) of 5 residents reviewed for baseline care plan, in that:. Resident #2 did not have a baseline care plan that addressed his history of falls. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for 1 (Resident#10) of 2 residents reviewed for respiratory care in that: The facility failed to place Resident #10 ' s nasal cannula in a clear labeled bag while not in use. These deficient practices could place residents at risk for infection due to improper care practices. Findings Include: Record review of Resident #10 ' s face sheet dated 01/22/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Linen Carts #1, Linen #2, and #3) of 4 linen carts and 1 (Resident #1) of 2 residents reviewed for infection control in that: 1. Linen Carts #1, #2, & #3 were not covered and sealed while storing linen, towels, Hoyers (allow a person to be lifted and transferred with a minimum of physical effort) slings, gloves, gowns, and briefs to prevent the spread of infection while in [NAME] Hall High & Low and East Hall Low. 2. Resident #1's nasal cannula fell on the floor in her room and LVN A picked up the nasal cannula and placed it back on Resident #1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 & Resident #2) of 4 residents reviewed for care plans in that: 1. The facility failed to develop a comprehensive person-centered care plan for Resident #1's for oxygen use. 2. Resident #2's refusal to be evaluated in bed while eating foods and drinking liquids was not addressed in his comprehensive person-centered care plan. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #1) of 2 residents observed for oxygen management. 1. Resident #1 utilized oxygen in her room did not have an oxygen sign posted outside of the room. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services, in that: 1. Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. 2. Staff were not wearing hairnets properly. 3. Freezer was dirty. 4. Food temperatures were not taken prior to serving meals. 5. Staff did not wash hands after touching hair on the serving line. These failures could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for a resident, consistent with the residents ' rights set forth that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #26, Resident #2, and Resident #5) of 10 residents reviewed for comprehensive care plans in that: Resident #26 comprehensive care plan did not address pressure ulcers. Resident #2 comprehensive care plan did not address assisted feeding. Resident #5 was not wearing appropriate footwear as listed on comprehensive care plan. This deficient practice could affect residents by placing them at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide the necessary services to maintain good grooming and personal hygiene care for 4 (Resident #83, Resident #5, Resident #66 and Resident #18) of 5 residents reviewed for ADL care. Resident #18 did not have her brief changed on a timely basis and was not turned as needed. The facility failed to ensure facility staff provided showers, personal grooming for Resident #83, Resident #5, and Resident #14. This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. Findings Included: Resident #83 Record review of Resident #83's Face Sheet admission date was 11/21/2022 at the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 2 (Resident #2, and Resident #55) of 10 residents reviewed for repositioning. The facility failed to ensure Resident #2, and Resident #55 were repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #83) of 8 reviewed for medication administration. MA S administered Resident #83 medication prior to taking blood pressure. This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 (Resident #2 and Resident #67) of 2 meals reviewed for residents with a diet order for nectar consistency reviewed for provision of food in a form designed to meet individual needs. 1. Resident #2 and Resident #67 received liquids of the wrong consistency. 2. Residents #2 and #67 had meal tickets that had not been updated and contained old information regarding dietary orders for liquid consistency. 3. Resident #2 and Resident #67 meal tickets were not updated. This failure could place residents who received liquid consistency diets at-risk of inadequate nutrition, choking, and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, for 1 resident (Resident #64) of 21 residents reviewed for weight loss. The facility failed to monitor, document, care plan, and implementplace interventionss for Resident #64 significant weight loss. This failure could place all residents in the facility at risk for weight loss, and not maintaining their highest practicable level of health.

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 and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 6 residents (Residents #55 and #64) reviewed for dignity. The facility did not provide Resident #55 or Resident #64 personal clothing to wear instead of hospital gowns. This failure could place residents at risk of diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #26) of 5 resident reviewed for accuracy of MDS assessment, in that: Resident #26's quarterly MDS did not accurately reflect the residents' significant changes in pressure ulcers and in bathing in the quarterly MDS. This deficient practice could affect residents at the facility who had been assessed for pressure ulcers and bathing and could contribute to inadequate care.