Garden Village

Inspectors wroteBased on observation, interview and record review the facility failed to protect a resident's right to be free from verbal and physical abuse for 1 of 8 residents (Resident 2) reviewed for abuse investigations. This failure placed residents at risk for further abuse, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) for 1 of 5 sampled residents (Resident 2) reviewed for ADLs. Failure to provide assistance with bathing to residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, impaired skin integrity, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, 1) proper temperatures were consistently monitored accurately and legible for 3 of 4 months reviewed for meals temperatures and 2) equipment surfaces were cleaned and sanitized for 1 of 1 kitchen. This failed practice placed residents at risk for food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, sanitary (the conditions that affect hygiene and health) and comfortable homelike environment regarding, A) the cleanliness of resident room Packaged Terminal Air conditioners (PTAC, a through-the-wall system that provides independent heating and cooling to a localized area) units for 3 of 7 resident rooms (301, 302 and 304), reviewed for environment cleanliness, B) soiled shower room ventilation and holes in wall tiles for 1 of 3 shower rooms (300's hallway) reviewed for environment, and C) a gouge (a hole or indentation) in a resident room flooring for 1 of 3 resident rooms (Resident 12) reviewed for a safe environment. This failure placed residents at an increased risk of injury and dissatisfaction with their living environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure components of their infection prevention/control program, to prevent the development and transmission of infections with, A) the facility's water management program Legionella (a bacteria that can cause a severe respiratory disease) testing protocols, and identification of control measures (actions or steps taken) to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) were developed/implemented for 1 of 1 water management program (WMP) reviewed for infection control, B) hand hygiene and glove change when completing resident cares for 3 of 10 staff (Staff AA, BB, K) reviewed for infection control, and C) the cleaning/disinfecting of the facility's environmental surfaces and isolation precautions room (preventative measures used to reduce the [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from interference/coercion (the use of expressed or implied pressure to compel someone to act against their will) in a manner that promoted and/or supported the resident's individual choice in respect to their quality of life, without fear of reprisal, regarding the residents choice to smoke a cigarette for 1 of 3 residents (Resident 4) reviewed for the resident rights. This failed practice placed the resident at risk of increased confusion and/or frustration with facility staff regarding their individual choice to smoke and unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the personal privacy for 2 of 4 residents (Residents 34, 72) observed for incontinent brief change and blood glucose checks (a blood test that measures the level of glucose (sugar) in the blood, the test can involve a finger prick, a nurse collects a drop of blood, the test involves a test strip and glucometer (glucose meter) with results in seconds). This failure placed the residents at risk for loss of the right to personal privacy.

Inspectors wroteBased on interview, and record review, the facility failed to monitor person-centered behaviors and obtain informed consent when they received psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 9 and 27) reviewed for unnecessary medications. This failed practice placed residents at an increased risk of receiving medications they did not want or they no longer needed and inadequate dosing of medications.

Inspectors wroteBased on interview and record review, the facility failed to follow up on written notices of bed holds, (holding or reserving a resident's bed while the resident was absent from the facility) with resident and/or resident representatives (RR), given at the time of hospital transfers for 2 of 2 residents (Residents 27 and 82) reviewed for the discharge process. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed, any monetary charges associated with the bed hold while in the hospital and disallowed the resident and/or their representative an opportunity to fully understand the rationale/resident rights associated with the discharge.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety and supervision of 1 of 3 residents (Resident 61) reviewed for accident risks. The facility's failure to implement their missing resident protocol when Resident 61 did not return from an outing with family at their indicated time put the resident's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement interventions for 1 of 2 residents (Resident 9) reviewed for nutrition. This failure placed the resident at risk for continued significant weight loss and the loss of nutritional satisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 9) were free of unnecessary drugs due to lack of monitoring and care planning of high-risk cancer (a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body) medication. This failed practice placed the resident at risk of adverse side effects and unmet care/personal needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program ensuring that flies (an insect that can develop/breed in various environments, rapidly reproduce and known for spreading diseases) were not entering/gathering in hallways and resident rooms for 1 of 4 Hallways (Hall 3 [H3, 300's rooms]) reviewed for environment. This failure placed the resident at risk of infection, infestation (the state of being overrun by pests) and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 3 of 3 days of the survey period. This failed practice prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (a required document describing resident population, acuity, and needs to determine staff and other resources necessary to completely care for residents) was updated to include and consider specific staffing needs for each resident unit/each shift and plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information, including information for agency and contract staff, was electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for 1 of 3 quarters (3rd quarter of 2024), reviewed for Payroll Based Journal (PBJ, mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and resident representative for 1 of 4 residents (Resident 2) reviewed for falls. This failure placed the resident at risk for a delay in medical treatment and of not having a resident representative involved in health care decision making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised for 1 of 3 residents (Resident 1) reviewed for care plan revisions after a significant change. This failure placed the residents at risk for injury and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received assessments and supervision for 2 of 5 residents (Resident 84 and 143) reviewed for elopement/missing person, implement risk assessments and supervision for 1 of 3 residents (Resident 73) reviewed for hot liquids, and implement safety interventions for 1 of 2 residents (Resident 12) reviewed for smoking to prevent accidents and hazards. This failed practice placed residents at risk for accidents, injuries, and the potential risk of fire. The lack of a system to ensure the elopement process was followed timely, resulted in an Immediate Jeopardy (IJ) when Resident 84 went missing from the facility between the hours of 11:30 PM on [DATE] and 2:00 AM on [DATE], and was later located at 8:11 AM on [DATE] deceased in the community. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for change in conditions related to skin and constipation, follow hospice and physician orders, and obtain and report labs for 7 of 8 residents (Residents 83, 79, 12, 5, 4, 30, and 68) reviewed for quality of care. These failures placed all residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Resident 83 experienced harm when they obtained a facility acquired pressure injury (PI, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices). Additionally, Resident 79 experienced harm when they continued to have seizures when they did not receive medications indicated for seizures in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 5 residents (Resident 54) reviewed for hospitalization. Resident 54 experienced harm when they received an antipsychotic medication (a class of drugs used to treat symptoms of psychosis and other mental health disorders) that caused acute toxic encephalopathy (indicates brain dysfunction caused by toxic exposure in the absence of primary structural brain disease) and increased sleepiness that resulted in a four-day hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of nursing staff to provide care and services for 17 of 17 residents (Residents 293, 245, 79, 2, 11, 1,19, 49, 71, 5, 83, 18, 51, 84, 3, 244 and 54). These failures placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and properly discard foods after the expiration date for 1 of 1 dry food storage rooms and 1 of 1 walk in refrigerators reviewed for kitchen and food safety. This failure placed the residents at risk for food borne illness (fever, chills, stomach cramps, diarrhea, nausea, and vomiting caused by the ingestion of contaminated food and/or beverages).

Inspectors wroteBased on interview and record review the facility failed to provide a written notice to the resident and/or their representative of the discharge for 5 of 5 residents (Residents 5, 54, 67, 18, and 51) reviewed for hospitalization. This failure placed the residents at risk for unmet discharge needs.

Inspectors wrote<Resident 67> Review of Resident 67's medical record showed they admitted to the facility with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), and liver cirrhosis (severe scarring of the liver). The 06/30/24 comprehensive assessment showed Resident 67 was independent for activities of daily living and had severe impaired cognition. Record review showed Resident 67 had a change of condition on 10/03/2024 and was transported to the hospital emergency department followed by a six day stay at the hospital. Record review showed no bed hold information communicated to the resident or their representative at the time of the transfer to the hospital on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS, a required assessment and care planning tool) assessments within the regulatory timeframes for 6 of 6 residents (Residents 2, 11, 1, 19, 49 and 71) reviewed for timeliness of assessments. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to ensure that dependent residents received assistance with dressing, personal hygiene, and shower/bathing for 4 of 5 residents (Resident 5, 83, 18, and 51). This failure placed the residents at increased risk for skin breakdown and unmet care needs.

Inspectors wroteBased on observation and interview the facility failed to serve meals that were at a safe temperature and appetizing for 2 of 5 residents (Residents 3 and 1) reviewed for food quality. This failed practice placed the residents at risk for decreased nutritional intake and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff compliance with current infection control guidelines and standards of practice by staff not following the guidance for a sign that was posted on the transmission based precaution (TBP) rooms for donning (putting on) personal protective equipment (PPE); and not adhering to fit testing (to ensure a proper fit) guidelines for an N-95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for 3 of 5 staff (Staff AA, T, and K). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, Resident Representative (RR), or payee were notified when their personal funds account reached a balance that was below $200 of the Social Security Income (SSI, a monthly Social Security benefit for people with low incomes, limited resources and who are blind, disabled or 65 or older) resource limit of $2000, for 1 of 5 residents (Resident 64) reviewed for personal funds. This failed practice placed the resident at risk of losing their Medicaid (a federal system of health insurance for those requiring financial assistance) or SSI eligibility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Resident's Representative (RR) was fully informed of a change of condition for 2 of 4 residents (Resident 68 and 79) reviewed for nutrition. The facility failed to inform the RR of severe weight loss. This failure denied the RR the right to be involved and make decisions regarding the care and treatment of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the personal privacy for 1 of 4 residents (Resident 245) observed for incontinent care and 1 of 1 resident (Resident 293) observed after a fall. This failure placed the residents at risk for loss of the right to personal privacy.

Inspectors wroteBased on interviews and record review the facility failed to report an incident involving a missing resident in a timely manner to local law enforcement (LLE) and the State Agency (SA) as required for 1 of 5 residents (Resident 143) reviewed for missing persons. This failure disallowed an opportunity for LLE to assist in the search of Resident 143 and placed the residents at risk for harm related to unrecognized and uninvestigated abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse, for one of five sampled residents (Resident 4), reviewed for abuse. The failure to complete a thorough investigation placed the resident at risk for potential abuse and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident admission Minimum Data Sets (MDS, a required assessment and care planning tool) were completed within the required timeframes for 2 of 3 residents (Residents 293 and 245) reviewed for admission assessments. Failure to complete admission within the required timeframes placed residents at risk for a delay in identification of care needs and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a significant change assessment had been completed for 1 of 2 residents (Resident 79) reviewed for hospice and end of life care. This failed practice placed the resident at risk for unmet care needs due to their imminent decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive resident centered care plans for 2 of 3 residents (Residents 73 and 18) reviewed for care planning in the areas of accident prevention and edema (extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease). This failed practice put residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer (PU, localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer and may be painful) for 1 of 3 residents (Resident 293) reviewed for pressure ulcers. This failure placed the resident at risk for worsening of the wound, increased discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided for 1 of 2 residents (Resident 51), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for a decrease in mobility, developing/worsening of contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor or implement interventions per Registered Dietician (RD) recommendations for 2 of 4 residents (Residents 79 and 83) reviewed for nutrition. This failure placed the residents at risk for continued significant weight loss and the loss of nutritional satisfaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services met professional standards of care for 1 of 1 resident (Resident 193) reviewed for dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream). This failure placed residents receiving dialysis at risk for unmet care needs and medical complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and discarded when expired on one of two medication carts (Halls 1 and 2) and one of two medication rooms (Main Nurse's station), reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's medical record was complete and accurately documented their Physician Orders for Self-Sustaining Treatment (POLST, a form that communicates a person's wishes for health care treatments during a medical emergency) for 2 of 3 residents (Resident 67, 73) reviewed for advanced directives. This failure put residents at risk for staff not knowing if they want cardiopulmonary resuscitation, (CPR, an emergency, lifesaving procedure) or do not resuscitate, (DNR, an order that a person had decided not to have CPR if their breathing and heart stopped.)

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's right to be free from verbal and physical abuse for 1 of 6 residents (Resident 1) reviewed for abuse. This failure placed the resident at risk for further abuse, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quarter (3rd Quarter, 2023), reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure had the potential to impact resident care and services for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement effective interventions to protect a resident from physical abuse for 1 of 6 residents (Resident 2) reviewed for resident-to-resident incidents. This failed practice placed all residents in the secured unit of the facility at risk for abuse and/or further abuse, and unmet psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a process to ensure culturally competent, trauma-informed care related to assessing for a history of traumatic life events or post-traumatic stress disorder (PTSD, a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and identifying triggers in accordance with professional standards of practice for 1 of 3 residents (Residents 1) reviewed for trauma informed care. This failure placed the residents at risk for unidentified triggers, re-traumatization, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to effectively implement and evaluate line-of-site supervision to prevent abuse or mistreatment for 4 of 7 residents (Resident 2, 3, 4, and 5) reviewed for sexual abuse. The failure to consistently implement supervision interventions to potentially prevent four sexual abuse incidents in a seven-day period resulted in Resident 4 experiencing psychological harm when the sexual abuse triggered post-traumatic stress suicide ideation, and Resident 5 experiencing psychological harm when applying the reasonable person approach. Additionally, this deficient practice placed all residents at risk for sexual and psychological abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food services regarding, 1) Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) and dry goods that did not have the proper labels and dates for food safety tracking for 1 of 1 kitchen reviewed, 2) Staff implementation of standard hygienic practices with not wearing hair nets or performing proper hand washing/glove changing during food preparation for 1 of 1 meal tray serve out, and 3) sanitation of food preparation areas that were not adequately disinfected to prevent cross contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure implementation of infection prevention and control precautions in the following areas : 1) COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of that or smell, and in severe cases difficulty breathing that could result in severe impairment or death) testing of residents, for three 3 of 6 residents (Resident 89, 11, and 13) reviewed for COVID-19 testing; 2) fit testing of N95 (a National Institute for Occupational Safety and Health [NIOSH] approved respirator that has straps around the back of the head to create a tight seal that filters varying levels of particles in the air) respiratory masks for 62 of 147 staff reviewed for N95 mask fit testing; [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure a clean, comfortable living environment for 8 of 8 sampled residents (Resident 23, 78, 83, 68, 34, 86, 60 and 67), including 2 of 2 resident rooms and 2 of 3 hallways reviewed for homelike environment. The failure to 1) ensure the ambient temperature in the secure unit was safe and comfortable, 2) replaced or repaired window trim, and 3) ensure the facility was free from worn carpet and urine odors, placed the residents at risk for injury, compromised dignity, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address concerns that were voiced during resident council meetings, for 6 of 6 months (Febuary 2023 through July 2023) of resident council minutes reviewed. Additionally, Resident 1's representative stated they had not had any response from the facility concerning a greivance for Resident 1. Failure to timely address and implement interventions to address identified concerns, resulted in the Resident Council process being ineffective in improving resident quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement abuse prohibition policies and procedures related to 1) screening for 3 of 10 staff (Staff I, J, and K) for background checks, 2) providing thorough and complete training at orientation and before the new staff member had contact with residents for 10 of 15 staff (Staff G, F, Z, BB, EE, KK, LL, MM, NN and TT ), and 3) prevention and protection after a resident to resident altercation for 1 of 6 residents (Resident 89), when the lack of monitoring and implementation of appropriate interventions lead to an alleged perpetrator having access to the victim. These failures placed all residents at risk for potential and/or further abuse, neglect, misappropriation of property, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had documented competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares), and skill sets including the demonstration of competency in skills to provide care and services for each resident in accordance with professional standards and individualized resident care needs for 14 of 15 nursing staff (Staff G, F, H, Q, V, Z, BB, EE, KK, LL, MM, NN, TT, and DDD) reviewed for staff competencies. This deficient practice placed all residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve meals that were at a safe temperature and appetizing for 7 of 10 residents (Residents 9, 21, 36, 40, 44, 64 and 68) reviewed for food quality. This failed practice placed all residents at risk for decreased nutritional intake and food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing services to residents and annually, related to: 1) mandatory effective communications for 7 of 15 staff (Staff Z, BB, KK, LL, MM, NN, and TT), 2) activities that constitute abuse/neglect, procedures for reporting incidents of abuse/neglect and dementia management regarding abuse prevention for 10 of 15 staff (Staff F, G, Z, BB, EE, KK, LL, MM, NN, TT) and, 3) mandatory Quality Assurance and Performance Improvement (QAPI), for 10 of 15 staff (Staff F, G, Z, BB, EE, KK, LL, MM, NN, TT) reviewed for training requirements. This failure placed residents at increased risk for unidentified abuse/neglect, and inadequate care from unqualified staff.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of the required annual 12-hours of in-service training for 5 of 10 staff (Staff Q, Z, KK, LL, and NN), reviewed for Nursing Assistance (NA) continuing competencies training. This deficient practice placed the residents at risk of being cared for by inadequately trained staff, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified dining experience while staff were conversating with each other and not engaged with the residents during mealtime and referred to the residents as feeders for 8 of 8 residents (Residents 3, 19, 80, 41, 43, 79, 36 and 84), reviewed for dining. This failure placed residents at risk to feel diminished and embarrassed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide properly fitted mobility equipment for 1 of 2 residents (Resident 80), reviewed for accommodation of needs for comfort and positioning. This failure placed the resident at risk diminished comfort and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from physical and verbal abuse by another resident and prevent actual and potential further abuse for 1 of 6 residents (Resident 89), reviewed for allegations of abuse. The facility allowed the alleged perpetrator to continue to share a room with the alleged victim after an incident of abuse. This failure placed the resident at risk for further abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding multiple non-pressure skin wounds that were not consistently assessed, monitored, and/or had wound care treatment completed for 1 of 3 residents (Resident 244) reviewed for non-pressure related skin issues. These failures placed residents at an increased risk for unmet care needs, untreated skin impairments, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received necessary treatment and services, consistent with professional standards of practice for 1 of 3 residents (Resident 64), reviewed for pressure ulcers. The failure to thoroughly assess, consistently monitor, and/or ensure consistent and timely provision of ordered skin care and treatments placed residents at risk for deterioration in skin condition and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 1 resident (Resident 244), reviewed for urinary catheter care. This placed the residents at risk of developing medical complications, secondary to an infection in the bladder.

Inspectors wroteBased on interviews and record review, the facility failed to ensure pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections like pneumonia and blood infections) were administered to 5 of 9 residents (Resident 82, 62, 245, 86, and 64) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease, and a decreased quality of life.