Garden View Care Center

Inspectors wroteBased on clinical record review, family interviews, staff interviews, and policy review the facility failed to hold Care Conferences for 4 of 4 residents reviewed (Residents #6, #11, #12, #16). The facility failed to hold and document Care Plan Conferences that included the resident and/or the resident representative. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, facility audit review, observations, resident interviews, staff interviews, and policy review the facility failed to provide professional standards of care by not providing treatments per physician orders, documenting treatments before completion, documenting provision of medications when not available, and providing medications outside of parameters for 4 of 5 residents reviewed (Residents #2, #3, #8, #20). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews, staff interviews, and facility policy review the facility failed to provide oral care for 4 of 4 residents (Residents #1, #6, #2, #12) reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on observations, resident and staff interviews, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents (Residents #10, #19, #21, #1) reviewed. The facility reported a census of 32.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access by storing medication in a resident's room for 1 of 5 residents (Resident #13) reviewed. The facility further failed to properly secure medications for 1 of 4 medication carts. The facility reported a census of 32 residents.

Inspectors wroteBased on facility record review, staff interview, and facility policy review the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to provide quality care for residents. The facility failed to make good faith attempts to correct quality deficiencies, and maintain and implement a comprehensive QAPI program and plan, The facility identified a census of 32 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to provide infection prevention measures to ensure the use of Enhanced Barrier Precautions (EBP) when required, hand hygiene during wound care, and hand hygiene during dependent activities of daily living (ADLs) for 4 of 4 residents (Residents #15, #2, #6, #1) reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, resident interviews, staff interview, and policy review, the facility failed to provide dignity and respect to residents during interactions and care (Residents #8, #18, #20). The facility reported a census of 32 residents. Findings Include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS provided the resident did not have hallucinations, delusions, verbal/physical behaviors towards others or have rejection of care. The MDS documented diagnoses of anemia, hypertension-high blood pressure (HTN), and diabetes mellitus (DM). The MDS revealed the resident required no assistance with self care skills and ambulation. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to protect a resident from misappropriation of property when a resident's medication became missing from the facility for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, law enforcement interview, staff interviews, and policy review the facility failed to report possible abuse in a timely manner related to the misappropriation of residents medications for 1 of 1 resident's (Resident #2) reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, law enforcement interview, staff interviews, and policy review the facility failed to investigate the misappropriation of resident medications that went missing for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on observation, resident electronic health record review, staff interview, and policy review the facility failed to provide safe ambulation/transfer techniques by not using a gait belt to ambulate a resident that required assistance for 1 of 3 (Resident #14) residents reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to meet professional standards for ostomy care by not releasing the build up of gas in the ostomy bag, which caused the appliance to spill the contents for 1 of 1 (Resident #13) reviewed. The facility reported a census 32.

Inspectors wroteBased on observation, resident interview, electronic health record review, policy review, and staff interview the facility failed to provide a respiratory treatment timely for 1 (Resident #17) of 1 residents reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to provide appropriate treatment and services to meet a resident's highest practicable physical, mental, and psychosocial well-being for residents diagnosed with dementia for 2 of 2 residents reviewed (Resident #6, #11). The facility had a census of 32.

Inspectors wroteBased on clinical record reviews, resident interviews, staff interview, and policy review the facility failed to order and dispense medications per physician orders for 3 of 7 residents reviewed (Residents #1, #16, #19). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, staff interviews, resident interview and policy review the facility failed to regulate a resident's medication to treat the resident's medical condition for 1 of 3 residents (Resident #16) reviewed. The facility failed to provide a current diagnosis for a narcotic medication. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to provide snacks to 3 of 4 residents (Residents #8, #19, #20) who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 32 residents.

Inspectors wroteBased on review of previous Centers of Medicare and Medicaid Services (CMS) form 2567, staff interviews, and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 31 residents.

Inspectors wroteBased on observations, and staff interviews the facility failed to ensure maintain a clean, safe, and sanitary homelike environment. The facility reported a census of 31 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to secure resident's medical records. The facility also failed to ensure 1 of 3 resident's (Resident #2) medical file was complete and accurate. The facility reported a census of 31 residents.

Inspectors wroteBased on observations, staff interviews, previous Centers of Medicare and Medicaid Services (CMS) form 2567, and policy review the facility failed to provide appropriate infection prevention and control for residents in the facility. The facility failed to resolve water intrusion and black substance in the basement and back substance in the laundry room. The facility reported a census of 31 residents. Observation on 4/2/2026 at 1:12 PM revealed the wall between the washers and driers in the laundry to have various areas of cracks in the paint. Behind an area close to the floor board revealed a black fuzzy substance. Behind the water heater stagnate water present as well as to the left of the first washer once inside the dirty side of the laundry room. The Maintenance Director stated at times the drainage hoses become clogged and the water runs over the water compartment. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review the facility failed to treat 1 of 3 residents (Resident #1) with dignity when assisting with Activities of Daily Living (ADLs). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to ensure 1 of 3 residents reviewed (Resident #2) were provided transportation services for their out-of-town appointment. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to report an allegation of abuse within 2 hours of the alleged incident. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff and resident interviews the facility failed to provide Activities of Daily Living (ADLs) care for 1 of 3 residents reviewed (Resident #1) for ADL care. The facility reported a census of 31 residents.

Inspectors wroteBased on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to prevent neglect when Staff A refused to provide or delayed providing suctioning for Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck). Resident #34 stated Staff A, Licensed Practical Nurse (LPN) refused to suction him nearly nightly when he worked at the facility. The resident experienced psychosocial harm as evident by severe anxiety, fear of being unable to breath and dying. Staff A worked at the facility 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. Schedule documented Staff A was the only nurse when working the overnight shift when scheduled. [...]

Inspectors wroteBased on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to investigate the allegation of neglect, failed to separate Staff A, Licensed Practical Nurse (LPN) from Resident #34 and failed to take corrective actions to prevent further abuse/neglect of Resident #34. Resident #34 stated Staff A would refuse to provide or delayed providing suctioning to Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck) frequently. Resident #34 explained he would have to call the Certified Nursing Assistants (CNA's) with the call light 3 or 4 times before his tracheostomy would be suctioned by Staff A. Staff A worked at the facility from 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. [...]

Inspectors wroteBased on staff interviews, provider interview, hospital reports and clinical record review the facility failed to ensure that residents received accurate and timely assessment and intervention for 1 of 2 residents reviewed (Resident #1). Early in November 2025, Resident #1 was found to have a Urinary Tract Infection (UTI) and was put on an antibiotic. He continued to be febrile (elevated temperature) off and on throughout the month. Staff failed to provide timely and consistent assessments to include vital signs, and failed to contact the doctor with continued fever. On December 1, 2025, Resident #1 was admitted to the hospital with urosepsis (severe life threatening infection in the blood that originated from a UTI). The facility reported a census of 37 residents.

Inspectors wroteBased on observations, electronic medical record (EMR) reviews, staff interviews, and facility policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents (Resident #22) reviewed, requiring the use of oxygen and nebulizer treatments. The facility reported a census of 37 residents.

Inspectors wroteBased on facility record review, legal record review, resident and staff interviews, and facility policy review, the facility failed to provide a licensed nurse on a 24-hour basis. The facility failed to have a licensed nurse on premises on the overnight shift from 11/11/25-11/12/25. The facility reported a census of 37 residents.

Inspectors wroteBased on staff interviews, personal record review, and facility policy review, the facility failed to ensure that nursing staff were adequately orientated and trained before they were scheduled to work independently with the residents for 2 of 2 nurse files reviewed. The facility reported a census of 37 residents.

Inspectors wroteBased on staff interviews, staff file review and policy review, the facility administration failed to conduct annual staff evaluations for 3 of 3 personnel files reviewed. The facility reported a census of 37 residents.

Inspectors wroteBased on government record review, facility record review, resident interview, staff interview, policy review, and current survey results, the facility administration failed to provide effective administrative oversight. The facility failed to conduct further research on a national nurse license verification that documented a revoked nursing license in another state in 08/2025, failed to conduct reference checks prior to hire, and failed to investigate reported performance concerns for 1 of 1 employee records reviewed (Staff A, Licensed Practical Nurse [LPN]). The facility also failed to ensure quality improvement measures were taking place after being designated a Special Focus Facility in 07/2025. The facility reported a census of 37 residents.

Inspectors wroteBased on document review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 12 areas over the last year and monitoring / tracking of performance improvement plans that remained incomplete in a reasonable time frame. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, clinical record review, facility document review, policy review and staff interviews, the facility failed to follow the menu and prepare food to meet the nutritional needs for 7 of 37 residents reviewed (#9, #12, #17, #21, #23, #26 and #30). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, observations, document review, policy review and staff interviews the facility failed to prepare food in a form designed to meet individual needs by processing an incorrect consistency for modified diet ordered for 7 of 7 residents reviewed (Resident #9, #12, #17, #21, #23, #26 and #30). The facility reported a census of 37 residents.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, not dating open food items and not disposing of expired food items. The facility reported a census of 37 residents.

Inspectors wroteBased on document review, staff interview, and policy review the facility failed to properly monitor and measure its success and track performance to ensure that improvements are realized and sustained for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 37 residents.

Inspectors wroteBased on staff interviews, policy review and clinical record review the facility failed to ensure that the residents had rational for continued use of psychotropic medications and attempted Gradual Dose Reduction (GDR) of psychotropic medications for 3 of 5 resident reviewed (Residents #4, #6, #32). The facility reported a census of 37 residents.

Inspectors wroteBased on record review, resident interview, staff interviews, and policy review the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 assessment for 1 out of 14 residents reviewed (Resident #10). The facility census was 37.

Inspectors wroteBased on observation, staff interviews, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 1 of 14 residents (Resident #22) reviewed. The Care Plans failed to identify resident centered interventions for a resident who used continuous oxygen. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and facility policy review the facility failed to revise a Comprehensive Care Plan for 1 of 14 residents (Resident #10) reviewed. The facility failed to revise the interventions and goals for a resident who was not receiving a Restorative Nursing Program. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to follow physician orders for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 37 residents.

Inspectors wroteBased on observation, staff interview and record review the facility failed to provide wound treatments as ordered for 2 of 2 residents reviewed with pressure ulcers. Resident's #2 and #34 were admitted with a history of severe skin breakdown and required consistent treatments. The clinical record showed that in September and October 2025, staff failed to document the treatments had been administered as ordered, and failed to document why the resident refused the treatments and that the doctor had been notified. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 1 of 14 residents reviewed (Resident #10). The facility reported a census of 37.

Inspectors wroteBased on clinical record review, observations, staff interview, and facility policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 1 residents reviewed (Resident #10). The facility reported a census of 37 residents.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility failed to ensure they did not store unnecessary narcotics and failed to maintain accurate accounting for narcotics for 1 of 3 residents reviewed (Resident #38). The facility reported a census of 37 residents.

Inspectors wroteBased on observations, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 3 of 14 residents reviewed (Resident #28, #31 and #35). The facility reported a census of 37 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, staff interviews, and document review the facility failed to provide complete and accurately documented records when a resident inventory list was not completed upon admission for 1 of 5 resident reviewed (Resident #19). The facility reported a census of 37 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, resident interviews, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower to 3 of 4 residents reviewed (Resident #1, #2 and #4). The facility reported a census of 37 residents.

Inspectors wroteBased on personnel file review, facility policy review, and staff interviews the facility failed to complete a background check related to abuse and criminal history in a timely manner for one staff member. The facility reported a census of 41 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, and resident and staff interviews, the facility failed to provide food at an appetizing temperature for 4 of 5 residents ( Residents #7, #17, #26, and #27) reviewed. The facility reported a census of 41 residents.

Inspectors wroteBased on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review, the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 41 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview the facility failed to use Enhanced Barrier Precautions (EBP) when providing ileostomy care for 1 of 3 residents (Resident #26), and complete an annual review of the facility Infection Prevention and Control Program (IPCP). The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview the facility failed to offer residents a COVID-19 immunization in 2024 for 4 of 5 residents reviewed (Residents #30, #32, #22 and #38.) The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews the facility failed to provide a bed hold notification upon hospitalization for 1 of 3 residents (Residents #10) reviewed. The facility reported a census of 41 residents. Findings Include: Review of the clinical record revealed, Resident #10 transferred to the hospital on 1/24/25 and returned to the facility on 1/31/25. Review of the clinical record revealed a bed hold notification signed on 4/3/23. During an interview on 4/10/25 at 10:07 AM, the Director of Nursing stated the facility had the resident sign a bed hold form during admission for future bed hold purposes and that was the bed hold utilized for all future bed hold needs. During an interview on 4/10/25 at 10:15 AM, the Administrator stated a bed hold notification was required at the time the transfer occurred. [...]

Inspectors wroteBased on clinical record review, facility policy review, family and staff interviews, the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 41 residents.

Inspectors wroteBased on record, policy review, and interview the facility failed to complete a discharge summary with a recapitulation of the residents stay, arrangements for support and follow up appointments, and medication reconciliation for 1 of 1 resident reviewed (Resident #42.) The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, observations, facility policy review and staff interviews,the facility failed to apply a hand splint in an attempt to prevent further decrease in range of motion for 1 of 3 residents (Resident #19) reviewed. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, Shift Change Controlled Substance Inventory Log review, facility policy review and staff interviews, the facility failed to ensure medications for a bowel program to treat constipation were available when needed for 1 of 1 resident (Resident #32). And the facility failed to consistently complete shift to shift inventory counts for controlled medications. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to ensure a resident received insulin as prescribed by a physician resulting in a significant medication error for 1 of 6 residents reviewed (Resident #20). The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and policy review the facility failed to follow physician order's for 2 of 4 residents (Resident #2 and #3) reviewed. The facility also failed to obtain an order to discontinue a medication prior to destroying it for 1 of 4 residents (Resident #6) reviewed. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to complete a full assessment, initiate neuros, and have a licensed nurse assess Resident #5 after she sustained an unwitnessed fall. The facility also failed to complete assessments for 6 residents (Resident #1, #8, #11, #12, #13, and #14) that tested positive for COVID-19 and 1 resident (Resident #9) that tested positive for influenza A. The facility reported a census of 37 residents.

Inspectors wroteBased on, facility nursing schedule review, facility staffing sheets, management call in logs, facility's Payroll Based Journal (PBJ), staff interviews and facility assessment review the facility failed to have Registered Nurse (RN) coverage daily for 8 consecutive hours, 7 days a week. The facility reported a census of 37 residents.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the nurse staffing information was posted to include accurate required information and updated daily for residents and visitors to see. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility assessment review the decisions in administering the facility contributed to deficient practice. The facility reported a census of 37 residents.

Inspectors wroteBased on previous CMS-2567 review, staff interview, and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, record review, staff and resident interviews, and facility policy reviews the facility failed to ensure all staff wore masks, and provided masks upon entry in to the facility while in outbreak status. Staff also failed to follow proper practices when obtaining a resident's blood sugar and prior to administering resident's insulin. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, record review, staff and resident interviews, and policy review the facility failed to update 2 of 7 (Resident #4 and #5) resident's care plans. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and facility policy review the facility failed to complete treatments as ordered for 1 of 2 residents (Resident #1) with pressure ulcers. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to ensure a gait belt was used for 1 of 14 residents (Resident #5) reviewed for falls. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, agency staff schedule, facility schedule, staff interviews and facility assessment the facility failed to provide nursing coverage on [DATE] from approximately 1:30 PM until approximately 4:30 PM. Staff indicated Staff A Agency LPN started her shift on [DATE] at 6:00 PM and worked until [DATE] at approximately 1:30 PM due to another staff member calling sick to work. The Administrator advised Staff A to go back to the hotel to nap and get her medications before her next shift started at 6:00 PM. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility assessment review the facility failed to ensure the appropriate licensed staff were competent to complete an assessment after Resident #5 had an unwitnessed fall. The facility also failed to ensure the appropriate certified staff assisted Resident #5 with a transfer after she sustained an unwitnessed fall. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 4 residents reviewed (Resident #7) was free from unnecessary medications. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to appropriately store six medications after they were delivered to the facility from the pharmacy. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to ensure Resident #5, #9, and #10's records were complete and accurate. Resident #5's clinical record did not contain an incident report after she sustained an unwitnessed fall nor did staff complete an assessment. Resident #9's clinical record did not contain information about his positive Influenza A status and Resident #10's clinical record did not contain information about his positive COVID-19 status. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, record review, policy, and staff interviews, the facility failed to prevent physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The investigation revealed the same CNA had a history of verbally and physically abusing Resident #2 and Resident #5 without being separated. This failure resulted in residents living at the facility exposed to the actual abuse and the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 26, 2024 on September 8, 2024 at 11:30 a.m The facility staff removed the IJ on September 8, 2024 through the following actions: [...]

Inspectors wroteBased on observation, record review, policy, and staff interviews, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The CNA stated she reported the physical abuse of Resident #2 to a nurse on 8/26/24 between 5:00 pm - 5:30 pm. Neither the CNA nor the nurse reported the physical abuse to the state agency or the administration. The investigation revealed the same CNA had history of verbally and physically abusing Resident #2 and Resident #5 and those allegations were also not reported. [...]

Inspectors wroteBased on clinical record review, facility document review, staff interviews and policy review, the facility failed to separate an alleged CNA abuser to prevent further verbal and physical abuse of Resident #2 and Resident #5 and failed to complete a comprehensive investigation immediately. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The CNA stated she reported the physical abuse of Resident #2 to a nurse on 8/26/24 between 5:00 pm - 5:30 pm. The CNA stated the nurse never assessed the area. The CNA continued to work with Resident #2 and Resident #5 after the CNA witnessed the abuse. On 8/27/24 the staff identified a bruise to the upper left side of Resident #2's chest in the shape of fingers. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (Resident #1, Resident #9) reviewed for wandering and elopement. The facility failed to change the door code after knowledge of a resident who presented as an elopement risk knew the code and failed to ensure that door alarms worked properly. On 8/25/24 at 9:00 PM. facility staff realized Resident #1 was not in the building. The resident was last seen at 8:30 PM, and the police found the resident in Walmart around 10:00 PM. Resident #1 had a history of exit seeking behaviors, could enter the code to the front door to exit without setting off the alarm, and had presented with exit seeking behaviors the day of the elopement. [...]

Inspectors wroteBased on observation, record review and staff interviews the facility failed to maintain medical records that were systematically organized and failed to safeguard the medical records from loss or destruction. The facility reported a census of 37 residents.

Inspectors wroteBased on facility record review, staff interviews, and facility policy review the facility failed to demonstrate evidence of systematic identification of reporting, investigation, analysis, and prevention of adverse events. The facility failed to demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews and policy review the facility failed to maintain a safe and comfortable environment free of possible hazards by having insufficient linens, and residents' beds not being made on a consistent basis. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to develop, implement and follow Comprehensive Care Plans for 3 of 14 residents (#1, #2, #11) reviewed. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, facility document review, resident interviews, staff interviews, and policy review the facility failed to provide adequate nursing staff to assure residents safety and well-being. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices for residents at the facility. The facility failed to prevent, investigate and identify possible infection control issues from the water intrusion and black substance in the basement. The facility reported a census of 37 residents.

Inspectors wroteBased on observations, clinical record review, hospital document review, resident and staff interviews, and facility policy review, the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (Resident #13, and #39). The facility reported a census of 40 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews, facility document review and clinical record review the facility failed to provide adequate staffing to ensure that the needs of the residents were met, and that the call lights were answered in a timely manner. The facility reported a census of 40 residents.

Inspectors wroteBased on staff interviews, facility record review and policy review, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours each day. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to revise and update the Comprehensive Care Plan for 4 of 17 residents (Resident #13, #2, #6, and #27) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food by failing to provide hand hygiene and glove use according to professional standards. The facility reported a census of 40 residents.

Inspectors wroteBased on observations,staff interviews, provider interview, clinical record review and policy review the facility failed to ensure that residents had accurate and timely assessment and interventions for 2 of 13 residents reviewed. Resident #40 and Resident #6 had chronic skin ulcers, staff failed to complete weekly skin assessments and failed to provide skin treatments as ordered. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review the facility failed to provide ongoing assessment and oversight for residents before and after dialysis for 2 of 2 residents (Resident #2, and #27) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy review the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens for 2 of 4 resident reviewed. Wound care treatments without hand hygiene for Resident #40 and #6. The facility reported a census of 40 residents.

Inspectors wroteBased on staff interview, clinical record review and policy review the facility failed to offer influenza immunization to 1 of 5 residents reviewed. Resident #16 signed the consent for the immunization, but the chart lacked evidence that she received the shot. The facility reported a census of 40 residents.

Inspectors wroteBased on facility investigative file review, staff interviews and policy review the facility failed to report a reportable event in a timely manner for 1 of 3 residents (Resident #6) reviewed for reportable events. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff interview, hospital staff interview and policy review the facility failed to allow a resident to return to the facility after a facility initiated transfer to an acute setting for 1 of 3 residents (Resident #2) reviewed for appropriate discharge. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to complete a recapitulation of stay for 2 of 3 residents (Resident #4 & #5) reviewed. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to complete discharge assessments when 3 of 3 residents (Resident #2, #4, and #4) discharged from the facility. The facility reported a census of 41 residents.

Inspectors wroteBased on clinical record review, staff interview, hospital staff interview, and policy review the facility failed to have complete and accurate medical records for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 41 residents.

Inspectors wroteBased on observations, resident and staff interviews, resident council minutes, and facility assessment, the facility failed to provide adequate staff to meet residents' needs. The facility reported a census of 43 residents.

Inspectors wroteBased on the staff roster, daily schedules, monthly schedule, payroll-based journal (PBJ), facility assessment, and staff interviews, the facility failed to have a Registered Nurse (RN) for eight consecutive hours a day, 7 days a week as required. The facility reported a census of 43 residents.

Inspectors wroteBased on record review, resident and staff interviews, and policy review the facility failed to develop a comprehensive Care Plan for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, record review, staff and resident interviews, and grievance forms review the facility failed to provide bathing opportunities for 3 of 3 residents reviewed (Residents #4, #5, and #6). The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff and resident interviews, and facility policy review the facility failed to carry out restorative programs for 2 of 2 residents reviewed (Resident #4 and #5). The facility reported a census of 43 residents.

Inspectors wroteBased on observations and staff interview the facility failed to ensure the nurse staffing information was posted to include the required information and in an accessible area for residents and visitors to see. The facility reported a census of 43 residents.