Fulton Nursing & Rehab

Inspectors wroteBased on interviews and record review, facility staff failed to complete weekly skin assessments ordered by the physician for three residents (Resident #1, Resident #2, Resident and #3) out of five sampled residents. The facility census was 69.the purpose is prevent and treat further break down of skin or pressure ulcers. Treatment and prevention of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 10/31/25, showed staff assessed the resident as severely cognitively impaired and at risk for developing pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to address and update care plans to address behaviors for three resident (Resident #1, #2 and #3) of three sampled residents and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set (MDS) a federally mandated assessment instrument), to provide interventions to meet individual needs for two residents (Resident #2 and #3) out of three sampled residents. The facility census was 68.1. [...]

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 the potential spread of Covid-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for Covid-19. The facility failed to separate five residents (Resident #1, #3, #7, #10 and #12) who tested positive for COVID-19 from five residents (Resident #2, #4, #8, #9, and #11) who had tested negative for COVID-19, which placed the Covid-19 negative residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 68. 1. Review of the facility's Outbreak Management: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility's census was 67.1. Review showed the facility did not provide a policy in regard to RN services. Review of the Facility Assessment, revised 08/27/25, showed the facility should staff at least one RN for eight hours per day, seven days a week. Review of the facility's RN Staffing assignments, dated 09/01/25 through 09/30/25, did not contain documentation of RN coverage for eight consecutive hours per day on 09/01/25, 09/05/25, 09/06/25, and 09/21/25. Review of the facility's RN Staffing assignments, dated 10/01/25 through 10/21/25, did not contain documentation of RN coverage for eight consecutive hours per day on 10/04/25, 10/05/25, 10/18/25, and 10/19/25. [...]

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 (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear Personal Protective Equipment (PPE) (gowns, gloves and/or eye protection) and/or failed to have EBP signs posted for 5 residents (Resident #18, #45, #52, #53, and #71), and failed to review Infection Prevention and Control policies annually. The facility census was 62 with a capacity of 100. 1. [...]

Inspectors wroteBased on record review and interviews, facility staff failed to maintain an Antibiotic Stewardship Program (the monitoring for appropriate antibiotic use and effectiveness to improve outcomes and prevent development of antibiotic resistance). The facility census was 62.1. Review of the facility's policy titled, Antibiotic Stewardship Program, undated, showed:-The Infection Preventionist (IP) will be the hub of the program and have the knowledge and expertise to develop, implement and monitor the Antibiotic Stewardship Program;-The IP/Designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription;-The IP/Designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy and indication;-The IP/Designee will track C. [...]

Inspectors wroteBased on interview and record review, facility staff failed to delegate an Infection Preventionist (IP) with qualifications by education, training, experience or certification to perform the role. The facility census was 62.1. Review of the facility's policy titled Infection Prevention and Control Program, undated, showed the IP is qualified to conduct infection control and prevention activities as a result of education, training and experience. He/She will complete the Centers for Disease Control (CDC) Long Term Care Infection Preventionist training module. Review Registered Nurse (RN) W's, personnel records showed he/she completed two of 19 continuing education units of the CDC Long Term Care Infection Preventionist training module on 05/15/24. [...]

Inspectors wroteBased on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code - Cardiopulmonary resuscitation ((CPR) an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) on the care plan, and/or Physician Order Sheet (POS) for four residents (Resident #18, #35, #47, and #53) out of 25 sampled residents. The facility census was 62. 1. Review of the facility policy titled Advance Directive, undated, showed upon admission of a resident, the social services designee (SSD) will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop a comprehensive person-centered plan of care to meet the resident's medical, nursing, mental and psychosocial needs for 10 residents (Resident #11, #18, #42, #45, #52, #53, #56, #58, #64, and #71) out of 25 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Care Plan Comprehensive, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for three resident's (Resident #15, #41, & #47) out of 25 sampled residents with changes in the resident's needs. The facility census was 62.1. Review of the facility policy titled Care Plan Comprehensive, undated, showed an individualized care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable, mental and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. Assessment of each resident is an ongoing process, and the care plan will be revised as changes occur in the resident's condition. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document the required fall documentation and neurological assessments (an assessment completed to determine if the nervous system is impaired) for five residents (Resident #11, #35, #53, #58, and #71) out of 25 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Resident Condition Change, undated, showed: -The purpose is to observe, record, and report any condition change to the physician so that proper treatment can be implemented;-After all resident falls, injuries, or changes in physical or mental function, monitor the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to educate and provide influenza immunizations for two residents (Resident #42 and #50) and pneumococcal immunizations for three residents (Resident #42, #50 and #56) of five sampled residents. The facility census was 62.1. Review of the facility policy titled Immunization Recommendations for Long Term Care Facilities, undated, showed the resident's physician will be consulted and determine the level of risk and need for the vaccinations. Influenza vaccination is recommended annually for all residents. Pneumococcal vaccination will be administered according to state guidelines when determining vaccination status. Requirements for administering vaccinations include a physician order, consent and an information sheet with general information, risks and side effects. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated resident assessment tool, for two residents (Resident #41 and #35) out of 25 sampled residents who were admitted to hospice services. The facility census was 62.1. Review of the policies provided by the facility did not show a policy for completion of a SCSA.Review of the Resident Assessment Instrument (RAI) manual version 3.0, dated October 2024, Omnibus Budget Reconciliation Act (OBRA), required Assessment Summary showed assessment time frames as follows:-A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to check and date oxygen tubing for one resident (Resident #18) and failed to provide orders for one resident (Resident #42), who received continuous positive airway pressure, (CPAP- a treatment that keeps the airway open during sleep). The facility census was 62.1. Review of the facility's policy titled Oxygen Administration, undated, showed at regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; and place cannula tubing in a plastic bag attached to the concentrator when not in use. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/07/25, showed staff assessed the resident as: -Moderate cognitive impairment; -Received oxygen; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain ongoing communication with the dialysis facility (a healthcare facility that provides dialysis treatment to individuals with kidney failure) and failed to document completion of dialysis care for one resident (Resident #18) of one sampled who received dialysis services. The census was 62. 1. Review of the facility's policy titled Dialysis, Care of a Resident Receiving, undated, showed staff were directed to: -Care for the Artery Vein shunt/fistula/graft (a surgical connection between the artery and vein): -Keep the area clean and dry; -Feel for the thrill (a vibration that can be felt when you place your fingers over the fistula site) sensation daily and document in the resident record, if no thrill, notify the physician; -Inspect access for redness, swelling, or warmth; [...]

Inspectors wroteBased on observation, interview, and record review, 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, and on a daily basis. The facility staff failed to keep the required daily staffing records for eighteen months. The facility census was 62.1. Review of the policies provided by the facility showed they did not contain a policy for the Nurse Staff posting. 2. Review of the facility's daily nurse staffing records showed the record did not contain 18 months of nurse staff posting.3. Observation on 06/24/25 at 10:43 A.M., showed a sign on the wall, next to the medication storage room behind the nurses desk read Nursing Please fill out midnight census worksheets. [...]

Inspectors wroteBased on interview and record review, facility staff failed to contact one resident's (Resident #3's) responsible party after the resident had a change in condition. The facility census 61. 1. Review of the facility's Notification of Physician policy, undated, showed staff are directed to immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is a significant change in resident's physical, mental, or psychosocial status or a decision to transfer or discharge the resident form the facility. 2. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/22/25, showed staff assessed the resident as follows: -Severe cognitive Impairment; [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep Resident #1 free from physical abuse when floor technician E aggresively pulled the residents wheelchair which resulted in the resident falling out of the wheelchair and on to the ground. The facility census was 58. The administrator was notified on 4/30/25 of past Non- Compliance, which occurred on 4/22/25, when staff reported the allegation. Staff immediately suspended floor technician E, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/30/25. 1. Review of the abuse, neglect, exploitation, and misappropriation of property fact sheet, dated 2017, showed abuse is the deliberate inflection of injury, unreasonable confinement, intimidation, or punishment, which results in physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on record review and interview, facility staff failed to ensure two residents (Resident #1 and Resident #2) remained free from sexual abuse when Resident #1 raised his/her shirt, and Resident #2 touched his/her chest inappropriately. The facility census was 34. The administrator was notified on 10/15/24 of past Non-Compliance which occurred on 9/30/24. On 9/29/24, Certified Medication Technician (CMT) B, notified Registered Nurse (RN) A he/she witnessed Resident #1 in Resident #2's room. He/She reported he/she observed Resident #1 with his/her shirt raised, and Resident #2 touched Resident #1's chest inappropriately. Staff immediately separated the residents, assessed the residents for injuries, moved Resident #1 to a secured unit, and notified the required parties and agencies. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene during medication administration for two (Resident #4 and #21) of five sampled residents. The facility staff failed to ensure all employees were screened for Tuberculosis ((TB) a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and annual PPD tests completed and documented as per policy and state law for three employees ( Dietary Aide O, Certified Nurses Aide (CNA) E , and Certified Medication Technician (CMT) P) out of 10 sampled employees . The facility census was 44. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain bathroom doorframes, sink counters, and floors in good repair. The facility census was 44. 1. Review of the facility's policies showed staff did not provide a policy regarding environment. Review of the facility's housekeeper job description, dated May, 2006, showed housekeeping staff expectations include: - Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfection, etc; - Clean, wash, sanitize, and polish bathroom fixtures, ensure that water marks are removed from fixtures. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information of the facility's bed hold policy at the time of transfer to the hospital to the resident and/or resident's representative for three residents (Residents #14, #24, and #45) out of three sampled residents who were discharged to the hospital. The facility census was 44. 1. Review of the facility's Bed Hold Guidelines, undated, showed the facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given at the time of transfer to the hospital. 2. Review of Resident #14's medical record showed: -Transferred to the hospital on [DATE] and returned on 03/28/24; -Did not contain documentation staff notified the resident or the resident's representative of the facility's bed hold policy at time of discharge. 3. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform a significant change in status Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for one (Resident #37) of one resident who elected hospice and one (Resident #14) of six sampled residents who had a decline in their ability to feed self with supervision, transfer with substantial/maximum assistance and perform toilet hygiene. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. [...]

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 resident's medical and nursing needs for four (Resident #14, #20, #35, and #37) of six sampled residents. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, showed: [...]

Inspectors wroteBased on observation, staff interview and record review, facility staff failed to meet professional standards of care when nursing staff did not obtain orders for water for one (Resident #14) out of one resident who received all hydration via gastric tube, failed to complete resident weights for three (Resident #6, #29, and #35) out of twelve sampled residents, failed to obtain wound measurements with weekly skin assessments for one resident (Resident #35) of three sampled residents with wounds. The facility staff document falls and fall follow-up for one (Resident #2) of two sampled residents. The facility census was 44. 1. Review of the facility's Enteral Nutritional Therapy (tube feeding) policy, undated, showed to follow the feeding with the prescribed amount of water. 2. Review of Resident #14's Physician Order Sheet (POS), dated 05/01/24, showed: -On 03/28/24, Nothing by mouth; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate personal hygiene for three residents (Resident #28, #35, and #251) out of 12 sampled dependent residents, The facility census was 44. 1. Review of the facility's Daily Care Needs guidelines, undated, showed after meals staff are diected to wash hands and face of the residents and remove any food particles from resident clothing. 2. Review of Resident #28's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/09/24 showed staff assessed the resident as: -Moderately cognitively impaired; -Dependent on staff for toileting hygiene, showering/bathing, and personal hygiene; -Did not reject care; -Diagnosis of debility, heart disease, lung disease, and dementia. [...]

Inspectors wroteBased on observation, interview, and record reviews, facility staff failed to ensure residents environment remained safe from hazards when staff failed to safely propel three (Resident #8, #22, and #34) out of 12 sampled residents while in wheelchairs. Facility staff failed to provide two (Resident #14 and #36) out of two sampled residents safe mechanical transfers, and facility staff failed to safely store medications in one residents room (Resident #13). The facility census was 44. 1. Review of the facility's Wheelchair, Use of policy, undated, showed staff were directed to lower footrests and place resident's feet on footrests if used and position feet and legs in good body alignment. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/30/24, showed staff assessed the resident as: -Cognitively impaired; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure all resident's drug regimens were free from unnecessary drugs when staff failed to ensure gradual dose reductions (GDR) were attempted for psychotropic medications for four (Resident #3, #12, #28, and #36) out of six sampled residents. The facility census was 44. 1. Review of the facility's Drug Review guidelines, undated, showed staff are instructed as follows: -All medication given to each resident will be reviewed on a monthly basis in order to review drug interactions, ensure adherence to stop orders, ensure accuracy in administration, and evaluate medications appropriate to diagnosis. -Problems identified shall be addressed according to need in consultation with physician. -Follow up on problems needs either the Director of Nursing's (DON's) or pharmacist's signature to show that the problem has been addressed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to monitor and store medication in a safe and effective manner when staff did not dispose of expired medications and left resident's medication on top of the cart. The facility census was 44. 1. Review of he facility's Storage of Medications policy, undated, showed facility staff were directed as follows: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medications carts; -No discontinued, out dated, or deteriorate drugs or biological may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. 2. Observation on 05/01/24 at 8:29 A.M., showed the facility medication room contained: [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate a person to serve as the Dietary Manager (DM) with the appropriate qualifications. The facility census was 44. 1. Review of facility policies showed staff did not provide a policy related to the qualifications of kitchen staff. 2. Review of the DM's personnel record showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview on 04/30/24 at 08:19 A.M., the DM said he/she was not certified yet, but was currently working on the certification and was about half way done. The Dietary Manager said he/she did not know all of the requirements. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' Electronic Health Records (EHR) open and unattended in public hallways. The facility census was 44. 1. Review of the facility's Medication Administration Guidelines, undated, showed the record did not contain direction for protection of residents' privacy. 2. Observation on 04/30/24 at 8:49 A.M., showed Certified Medical Technician (CMT) A left the EHR screen with resident information on the screen unlocked in the hallway when he/she administered to a resident in their room. Observation on 04/30/24 at 8:51 A.M., showed CMT A left the EHR screen unlocked in the hallway with resident information on the screen when he/she adminsitered medication to a resident in their room. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete the required Comprehensive Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two (Residents #1, and #3) out of two sampled residents The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete the required Quarterly Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of four (Resident #18 and #30) sampled residents. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the RAI manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: [...]

Inspectors wroteBased on interview and record review, facility staff failed to correctly assess one resident (Resident #2) who received an anticoagulant (a blood thinning medication used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation medication) and failed to assess one resident (Resident #12) for their preferences and oral/dental status. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure three most recent years of survey results were posted and readily accessible to residents, family member or representatives of residents. The facility census was 44. 1. Review of the facility's policies showed staff did not provide a policy for required postings or survey posting. 2. Observation on 04/29/24 at 9:59 P.M., showed the facility did not have a copy of the federal survey results accessible to the resident, family members, or representatives of residents. 3. Observation on 04/30/24 at 7:48 A.M., showed the facility did not have a copy of the federal survey results accessible to the resident, family members, or representatives of residents. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete neurological checks and fall follow up documentation for three (Resident #1, #2, & #3) of three residents who had a fall and failed to complete weekly skin assessments for two residents (Resident #4 and #5). The facility census was 41. 1. Review of the facility's Fall Champion Program, undated, showed the post fall follow up period is 72 hours which includes assessment and document of the resident's condition in healthcare tracking program Progress Notes and neurological checks. 2. Review of Resident # 1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/23/23, showed staff assessed the resident as: -Cognitively intact; -No falls since admission or prior assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they assessed residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every three months for seven residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). The facility census was 46. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. [...]

Inspectors wroteBased on observation and interview, facility staff failed to maintain a clean, comfortable and homelike environment. Facility staff failed to maintain resident restrooms free of floor discolorations, missing toilet bolt covers and caulk at the base of the toilet. In addition, bathroom cabinets had laminate peeled off and drawers missing. The facility staff also failed to maintain resident rooms free of discolored floor tiles. The facility census was 50. 1. Review of the facility's policies showed staff did not provide a Facility Maintenance Policy. Observation on 4/10/23 at 11:45 A.M., showed dark black/gray stains in and around the cracks in the bathroom tiles, rust colored discoloration around the toilet bowl, and missing caulk and bolts at the base of the toilet bowl in room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to meet professional standards of care when they failed to weigh two residents (#4 and #41), check Depakote (to treat seizures, bipolar disorder or migraine headaches) levels for one resident (#11), and to take a blood pressure prior to administration of blood pressure medication for one resident (Resident #303) as ordered by the physician. Additionally, staff failed to failed to provide consistent documentation in regard to a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one resident (Resident #20), and failed to ensure physician medications orders were signed for two residents (#31 and#40). The facility census was 50. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide assistance with personal hygiene for four residents (Resident #1, #2, #11, and #17) dependent on staff for care. The facility census was 50. 1. Review of the facility's policies showed the staff did not provide a bath (shower) policy. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/23, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member for bathing, dressing, personal hygiene, and toileting; -Diagnoses of hemiplegia or hemiparesis; -Does not reject care; -No behaviors towards others; -Occasionally incontinent of urine and always incontinent of bowel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure the resident's environment remained free of accident hazards when facility staff failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents. In addition, facility staff failed to maintain the hot water temperature below 120 degrees Fahrenheit in the resident rooms. The facility census was 50. 1. Review of the facility policy and procedure manual showed they did not have a policy for hazardous chemical storage, sharps storage for razors or nail clippers. Observation on 4/11/23 at 10:29 A.M., showed the 300 hall shower room unlocked and unattended with the following: -Two sharps containers, with the tops open contained uncovered disposable razors; -A can of shaving cream; -A bottle of body wash; -A mop bucket filled with dirty water and a mop; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #2, and #34), and failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #5). The facility census was 50. 1. Review of the facility's Drug Review policy, undated, showed the following: All medication given to each resident will be reviewed on a monthly basis in order to: -Review drug interactions; -Evaluate medications appropriate to diagnosis; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -The policy did not given direction for Gradual Dose Reductions. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner, additionally staff failed to ensure two medications carts were locked at all times. The facility census was 50. 1. Review of the facility's Medications, Storage of, from Nursing Guidelines Manual, undated, directed staff as follows: -Drugs must be stored in an orderly manner in cabinets, drawers, or carts; -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. 2. Observation on 4/12/23 at 11:00 A.M., showed the Certified Medication Technician (CMT)'s medication cart contained the following loose pills: -One small round yellow pill stamped with W40; [...]

Inspectors wroteBased on interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per the facility policy for three residents (#1, #11, and #34). The facility census was 50. 1. Review of the facility provided Screening for Tuberculosis in Long Term Care Facilities guideline, undated, showed the guidance directs staff as follows: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for two of two sampled residents (Resident # 20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Notice of Transfer or Discharge, if necessary -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Transferred to the hospital on 3/29/23; -Returned to the facility on 3/31/23; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two sampled residents (Resident #20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Bed Hold Forms. -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. The Guidelines did not include mention of the Bed Hold Form. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on 3/29/23; -Resident returned to the facility on 3/31/23; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), and have ongoing communication with the dialysis clinic for one resident (Resident #24) who received dialysis. The facility census was 50. 1. Review of the facility's Dialysis Care of a resident receiving policy, undated, showed staff are directed as follows: Communication between the Facility and Dialysis Unit: -The Dialysis Communication Record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; [...]

Inspectors wroteBased on interview and record review facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 50. Review of the Activity Director's (AD) employee file showed, the file did not contain an Activity Director certification, did not show completion of a state approved training course, or experience in a therapeutic activies program as required. During an interview on 4/13/23 at 3:55 P.M., the Activity Director (AD) said he/she does not have any certifications or formal training. During an interview on 4/13/23 at 5:10 P.M., the Administrator said the AD is not certified. He/She said he/she didn't know the AD had to be certified before taking the position.

Inspectors wroteBased on observation, interview, and record review, facility staffed failed to post 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, on a daily basis. The facility census was 50. 1. Review of the facility policies showed staff did not provide a policy for nurse staff posting. Observation on 4/10/23 at 10:45 A.M., showed the nurse staff posting was not visible in the facility. Observation on 4/11/23 at 8:08 A.M., showed the nurse staff posting was not visible in the facility. Observation on 4/12/23 at 9:45 A.M., showed the nurse staff posting was not visible in the facility. Observation on 4/13/23 at 10:25 A.M., showed the nurse staff posting was not visible in the facility. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 50. 1. Review of the facility's policies showed staff did not provide a policy for specialized training as Infection Preventionist. During an interview on 4/13/23 at 2:45 P.M., the Assistant Director of Nursing (ADON) said he/she has not taken the classes or test to be certified as an IP. He/She said he/she is not enrolled in the Infection Preventionist (IP) CDC training. The ADON said they were aware you must be certified to hold the position, and he/she just took the job a few months ago. [...]