Garden View Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) with a history of falls, in a review of five sampled residents, when staff did not routinely check on the resident at least every two hours per the facility's expectations throughout the night. On the morning of 5/30/26, staff found the resident on the floor in his/her room with the door closed for an undetermined amount of time with dried blood on his/her hair, face, and hands. The resident was admitted to the hospital following evaluation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four residents (Resident #7, Resident #2, Resident #5 and Resident #10), in a review of eleven sampled residents, were free from sexual abuse. Resident #11 demonstrated a pattern of sexual behaviors with residents without the capacity to consent to sexual activity. Staff found Resident #11 in Resident #7's room with his/her hands down Resident #7's pants and in the resident's perineal area, Resident #11 touched and rubbed Resident #2's breasts, kissed Resident #5 on the mouth twice, and grabbed Resident #10 by his/her hands, pulled the resident to him/her and groped his/her breast. The facility census was 70. Review of the undated facility policy, Abuse Prevention Program, showed the following:-Policy Statement: Residents have the right to be free from abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of sexual abuse to the state agency for three residents (Resident #2, Resident #5, and Resident #10), in a review of 11 sampled residents when staff witnessed and documented sexual abuse. Resident #11 demonstrated a pattern of sexual abuse behaviors with residents without the capacity to consent to sexual activity. Staff witnessed Resident #11 rub Resident #2's breasts, kiss Resident #5 on the mouth twice, and grab Resident #10 by his/her hands, pull the resident to him/her and grope the resident's breast. Further review showed the facility did not report these incidents to the resident representatives for Resident #2, #5 or #10 as facility policy directed. The facility census was 70. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately report allegations of physical abuse of one resident (Resident #1), to the state agency in a review of four sampled residents. The facility census was 73. Review of the facility policy for Freedom from Abuse, Neglect and Exploitation - Investigation and Reported dated 11/2024 showed the following: -At the facility all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -The facility will not condone any form of resident abuse or neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely and thorough investigation when one resident (Resident #1), in the review of four sampled residents, made an allegation of physical abuse. The resident said he/she was being hit by a young person (specified gender). The facility identified a staff member, Certified Nurse Aide (CNA) A, who met the general description that the resident provided. The facility failed to protect the resident when CNA A continued to work after the allegation of physical abuse was made. The facility census was 73 . Review of the facility policy for Freedom from Abuse, Neglect and Exploitation - Investigation and Reported dated 11/2024 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), with diagnosis of major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder and panic disorder, in a review of four sampled residents, who had a significant history of past trauma, received care planned interventions to address the resident's trauma to ensure the resident attained the highest practicable mental and psychosocial well-being, when the resident began to exhibit increased paranoia and saying someone had been hitting him/her. The facility census was 73 Review of the facility policy for Behavioral Assessment, Intervention and Monitoring with a revision date of 3/2024 showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained areas throughout the kitchen in a clean and sanitary manner, failed to ensure ice machines in the kitchen and nourishment centers were clean and in good repair, failed to ensure staff properly wore hair and beard restraints while in the kitchen, and failed to cover food/drink items when transporting meal trays to residents' rooms. The facility census was 48. 1. Review of the facility policy, Sanitation, dated November 2024, showed the following: -All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair; -Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Residents #1, #4, #6, and #11), in a review of 14 sampled residents. The facility failed to complete Tuberculin Skin Tests (TST) and/or annual evaluations as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for three of ten new employees reviewed (Registered Nurse I, Laundry Staff J and Dietary Staff K). The facility failed to monitor cold water temperatures as part of their water management program to prevent the growth of water borne pathogens including Legionella. The facility census was 48. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for incontinence care for one resident (Resident #1) and failed to provide oral care for one resident (Resident #29), in a review of 14 sampled residents, who required assistance to perform activities of daily living. The facility census was 48. Review of the facility's policy, Oral Care, dated October 2024, showed the purpose of the procedure was to clean and freshen the resident's mouth, to prevent infections of the mouth, to maintain the teeth and gums in a healthy condition, to stimulate the gums, and to remove food particles from between the teeth. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety by failure to transfer one resident (Resident #1) as directed in his/her plan of care and failed to follow facility fall policy and procedure following one resident's fall (Resident #12) or implement interventions in the resident's plan of care to prevent further falls in a review of 15 sampled residents. The facility census was 48. Review of the facility's policy, Gait Belt Use/Transfers, dated November 2024, showed the following: -The facility will take all measures to ensure resident safety; -Transfers are performed based upon resident transfer status and the facility's policy; -Gait belts should be placed around the resident's waist, above the pelvic bone and below the rib cage over top of clothing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store, change and date respiratory equipment (oxygen tubing) for two residents (Residents #4 and #39), in a review of 14 sampled residents. The facility census was 48. During an interview on 01/23/25 at 10:59 A.M., the administrator said the facility did not have a policy for changing and dating oxygen (O2) tubing. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/10/24, showed the following: -Cognitively intact; -Used oxygen. Review of the resident's care plan, dated 10/17/24 showed the following: -Oxygen for for chronic obstructive pulmonary disease (COPD) (lung disorder that blocks airflow), history of pneumonia and respiratory failure; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired testing supplies and medications not in use by two residents including one current resident Resident #10) and one discharged resident (Residents #100), were destroyed or returned as directed by facility policy. The facility census was 48. Review of the facility's policy, Storage of Medications, last revised [DATE], showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure staff responded timely to reports of pests in the building. The facility census was 48. Review of the facility's policy, Pest Control, revised May 2024, showed the following: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services are provided by the pest control service/vendor; -Maintenance services assist, when appropriate and necessary, in providing pest control services. Review of the facility's policy, Sanitation, revised November 2024, showed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment prior to placement of bed rails, document alternatives attempted prior to bed rail placement, complete entrapment zone measurements, or obtain written consent from the residents and/or their guardians prior to use for one resident (Residents #11), who used side rails, in a review of 14 sampled residents. The census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment for one resident (Resident #11), in a review of 14 sampled who used bed rails/assist bars. The facility census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July, 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary; -To try to prevent injuries from the use of bed rails and related equipment, the facility should promote the following approaches: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative when six residents (Residents #11, #12, #16, #29, #35, and #251), in a review of 14 sampled residents, were transferred to the hospital. The facility census was 48. Review of the facility's Transfer or Discharge Notice policy, last revised December 2024, showed the following: -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge when an immediate transfer or discharge is required by the resident's urgent medical needs; -The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the bed hold policy with required information to the resident and/or resident representative within 24 hours of transfer to the hospital for four residents (Residents #11, #16, #35, and #251), in a review of 14 sampled residents. The facility census was 48. Review of the facility's undated policy, Bed Hold, showed the following: -If the resident is discharged to the hospital, the bed is considered empty. The facility can do one of two things: -1. Hold the bed for the resident who is in the hospital or on leave from the facility for any reason; -2. Release the bed, allowing the facility to admit a new resident; -During the absence of resident for any reason, the regular charge herein shall apply until the room is released and all belongings are removed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #22), in a review of fifteen sampled residents, remained free from verbal abuse, when Certified Nurse Aide (CNA) U used curse words directed toward and within hearing distance of the resident. CNA U's language made the resident feel hurt and abused. The resident was tearful after the incident. The facility census was 29. The facility learned of the allegation of staff to resident abuse when staff reported the concern on 06/14/23. Administration suspended CNA U pending the investigation. The facility reported the incident to DHSS timely and conducted a thorough investigation, speaking with residents and staff and later terminated CNA U's employment. All staff were in-serviced regarding abuse, neglect and professionalism on 06/14/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals employed by the facility did not have a federal indicator for misconduct. Review of Licensed Practical Nurse (LPN) B's employee file showed he/she had a federal indicator for misconduct. LPN B was employed by the facility as a charge nurse with access to all residents. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a policy and procedure to address reviewing the state Certified Nurse Aide (CNA) Registry for all new employees. This has the potential to affect all residents of the facility. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -For any individual applying for a position as a Certified Nursing Assistant (CNA), the state nurse aide registry will be contract to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of the facility policy showed it did not include that all individuals employed by the facility will be checked against the state nurse aide registry. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when it failed to appropriately store and handle food products to maintain quality and free from potential contaminants, and label and date opened food items. The facility also failed to ensure dietary equipment was free of an accumulation of grease, dust and debris. The total facility census was 60 and the certified census was 29. Review of the facility's policy, Preventing Foodborne Illness, Employee Hygiene and Sanitary Practices, revised October 2017, showed the following: -Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 29. Review of the facility policy, Antibiotic Stewardship, dated December 2018, showed the following: -The facility would educate and train staff and practitioners about the antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. Antibiotic usage and outcome data would be collected and documented using a facility approved antibiotic surveillance tracking form. The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual(s) onsite who was responsible for implementing programs and activities to prevent and control infections. The facility census was 29. Review of the facility's Infection Preventionist policy, dated 12/2018, showed the following: -The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection and prevention and control policies and procedures; -The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection prevention and control practices. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease. The facility failed to offer and vaccinate nine eligible residents (Resident #24, #5, #8, #18, #19, #13, #17, #3, and #4), in a review of 15 sampled residents, and 10 additional residents (Resident #501, #21, #504, #6, #2, #15, #16, #12, #20 and #503) with the recommended doses of the pneumococcal vaccine as indicated by the Centers for Disease Control and Prevention (CDC) recommendations. The facility also failed to ensure the facility policy followed current CDC guidelines for pneumococcal vaccine administration. The facility census was 29. Review of the undated facility policy for Influenza/Pneumococcal Vaccines showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity for four residents (Resident #1, #9 #13, and #24), in a review of 15 sampled residents. Staff stood while assisting three residents (Residents #1, #9, and #13) to eat in the dining room, and did not answer one resident's (Resident #24's) call light promptly, causing the resident to be incontinent. The facility census was 29. Review of the facility policy, Answering the Call Light, revised October 2010, showed the policy directed staff to answer a resident's call light as soon as possible. Review of the facility's Assistance with Meals policy, dated December 2018, showed residents who cannot feed themselves shall be fed with attention to safety, comfort and dignity. This includes not not standing over resident while assisting them with meals. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #3 and #24) in a review of 15 sampled residents, when staff woke residents according to staff preference or based off of a get up list. The facility census was 29. Review of the facility's admission agreement form, residents' rights and responsibilities, dated 4/20/21, showed the following: -Rights to freedom from control; -Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility. 1. Review of Resident #24's care plan, dated 01/25/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice of code status was consistent throughout the resident's medical record and the Outside The Hospital Do-Not-Resuscitate (OHDNR) Order form was completed for three residents (Resident #1, #13, and #16), in a review of 15 sampled residents. Also, staff responsible for the care of one resident (Resident #11) did not accurately review the resident's chart to ensure the proper code status and two other care staff did not know where a resident's code status would be located. The facility census was 29. Review of the facility policy, Advanced Directives, dated 12/2018, showed the following: -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for incontinence care for three residents (Resident #3, #4, and #17), in a review of 15 sampled residents, who required assistance to perform activities of daily living. The facility census was 29. Review of the facility policy, Perineal Care, dated 12/2018, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Review the resident's care plan for any special needs of the resident. 1. Review of Resident #17's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/22/23, showed the following: -The resident had short and long term memory loss; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reposition three residents (Resident #3, #4, and #17), in a review of 15 sampled residents, who were at risk for developing pressure ulcers. The facility's census was 29. Review of the facility's repositioning policy, dated May 2013 showed the following: -The purpose was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair-bound residents and prevent skin breakdown, promote circulation, and provide pressure relief for residents; -Review the resident's care plan to evaluate for any special needs; -Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs including toileting, meal assistance and supervision for five residents (Resident #2, #24, #1, #13, and #17), in a review of 15 sampled residents on a secured dementia unit. The facility census was 29. Review of the facility policy, Staffing, revised April 2007 showed the following: -Our facility provides adequate staffing to meet needed care and services for our resident population; -Our facility maintains adequate staffing on each shift to ensure that our residents' need and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts and treatment cart were secured when unattended. The facility census was 29. Review of the facility policy, Storage of Medications, dated 12/2018 showed the following: -The facility shall store all drugs and biologicals in a safe, secure and orderly manner; -Nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Observation on 06/23/23 at 8:22 A.M., at the C wing nurses station, showed the following: -The medication cart sat at the nurses station unlocked; -The treatment cart sat across from the nurses station unlocked. The cart contained multiple tubes of prescription ointments/creams/medications; -A housekeeper walked by the medication cart; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for three residents (Resident #1, #2, and #4) in a review of 15 sampled residents. The facility census was 29. Review of the facility policy, Handwashing/Hand Hygiene, dated 08/2015, showed the following: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents; b. Before performing any non-surgical invasive procedures; c. Before moving from a contaminated body site to a clean body site during resident care; d. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 29. Review of the facility assessment dated [DATE] showed the following: -Required in-service training for certified nurse assistants CNAs must be sufficient to ensure that continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and other individuals with cognitive impairments; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. During an interview on 6/23/23 at 9:05 A.M., Activity Aide N said the following: -He/She worked at the facility for four years; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of a gait belt for two residents (Resident #1 and #13), in a sample of 15 residents, when staff pivot transferred the residents. The facility census was 29. The facility did not provide a policy for gait belt use or resident transfers. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/05/23, showed the following: -The resident had short and long term memory problems; -He/She required extensive assistance of two staff members for transfers; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name, resident census and total 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 29. Review of the facility policy, Posting Direct Care Daily Staffing Numbers, revised July 2016 showed the following: -The facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; [...]

Inspectors wroteBased on observation and interview, the facility failed to follow proper sanitation and food handling practices in the kitchen. The total facility census was 73. 1. Observation on 9/10/19 at 10:42 A.M. showed the external thermometer of the three-door freezer showed a temperature of 0 degrees Fahrenheit (F) while the interior thermometer showed a temperature of +10 degrees F. Observations on 9/10/19 between 2:49 P.M. and 3:22 P.M. showed the three-door freezer had not been opened. At 3:22 P.M., the exterior thermometer read 0 degrees F and a calibrated thermometer was placed inside the freezer. Observations on 9/10/19 between 3:22 P.M. and 3:32 P.M. showed the freezer door had not been opened. At 3:32 P.M. the external thermometer of the freezer read 0 degrees F and the calibrated thermometer inside the freezer showed +10 degrees F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #3, #10 and #16), who were unable to perform their own activities of daily living, in a review of 12 sampled, the necessary care and services to maintain good personal hygiene and prevent body odor. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Perineal Care, dated December 2018, showed the following: -The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition; -For a female resident: wet washcloth and apply soap or skin cleansing agent. Separate labia and wash area downward from front to back. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all medications in locked compartments when staff left the medication carts unlocked and left the medication keys unattended on top of the medication cart. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Security of Medication Cart, dated December 2018, showed the following: -The medication cart shall be secured during medication passes to ensure medications are kept in a controlled environment, to restrict access by unauthorized personnel/residents, and to maintain resident safety; -The nurse must secure the medication cart during the medication pass to prevent unauthorized entry; -Medication carts are to be kept locked when not in use, or when not in direct line of sight of staff members; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff served meals to meet residents' needs by not serving correct portion sizes of protein to residents on a mechanical soft diet. The total facility census was 73. Review of a list of residents and their physician-ordered diets, provided by the facility, showed 12 residents had physician orders for mechanical soft diets. Review of the facility's menu for the lunch meal on 9/10/19 showed residents on a mechanical soft diet were to receive ground pork steak. During interview on 9/10/19 at 10:42 A.M., the dietary supervisor said there are no spreadsheets to show serving sizes. Observation on 9/10/19 at 12:10 P.M. showed Dietary Aide W prepared six plates for residents on a mechanical soft diet. He/she used a pair of tongs to place an unmeasured amount of ground pork steak onto each of the plates. [...]

Inspectors wroteBased on interview and record review, the facility failed to report two allegations of resident to resident physical abuse to the state survey agency for one resident (Resident #13), in a review of 12 sampled residents. The facility's total census was 73, with a certified census of 24. 1. Review of the facility policy Freedom from Abuse, Neglect, and Exploitation Reporting and Response, dated December 2018, showed the following: -Abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law; -The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of nursing practice for one resident (Resident #18), in a review of 12 sampled residents. Nursing staff mixed a prescription cream with a barrier cream, placed the cream in the resident's room for certified nursing assistants (CNAs) to apply to the resident's skin. The nursing staff documented their initials on the treatment record (indicating they had applied the medication) when the CNAs applied the cream to the resident's skin. The facility did not have a policy to direct staff on how to properly mix the medication. The facility also failed to administer liquid medication to one resident (Resident #6) in a manner that would ensure an accurate dose of the ordered medication. The facility census was 73 and the certified census was 24. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used a gait belt (special belt, used to provide assistance during transfer, ambulation, or positioning in a chair) during transfer for one resident (Resident #10), in a review of 12 sampled residents, and failed to ensure staff used proper technique when repositioning two residents (Residents #10 and #16) in the wheelchair. The total facility census was 73 with a certified census of 24. 1. Review of the facility's undated policy, Ambulate Resident Using Gait Belt, showed the following: -Purpose is to provide safety to residents and nursing staff during ambulation and transfers; -Lower bed to lowest level; assist resident to sit on edge of bed; -Assist resident in putting on nonskid shoes and socks; -Put gait belt around the resident's waist; -Assist the resident to a standing position; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (Resident #6), in a review of 12 sampled residents, sufficient fluid intake to maintain proper hydration and health. The facility census was 73, with a certified census of 24. 1. Review of the facility policy Resident Hydration and Prevention of Dehydration, approved December 2018, showed nurses aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report any change in fluid intake to nursing staff. 2. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 Revision, showed the following: -Water is essential to life. A person can live only a few days without water. It provides minerals but no other nutrients. [...]

Inspectors wroteBased on observation and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional practices during personal care for two residents (Residents #3 and #16), in a review of 12 sampled residents. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Standard Precautions, dated December 2018, showed the following: -Standards precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided the resident or resident representative with a Notice of Medicare Provider Non-Coverage (NOMNC) when all covered Medicare services were ending and Medicare days remained for two additional residents (Resident #500 and #501), in a review of three residents selected for review who remained in the facility after Medicare services ended. The total facility census was 73 with a certified census of 24. 1. Review of the Center for Medicare and Medicaid Services (CMS), Survey and Certification memo, dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-coverage (NOMNC; form CMS-10123) informs the beneficiary of his/her right to an expedited review of a service termination. [...]