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Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to obtain consent prior to searching a resident's personal possessions for one of three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, observations, and staff interview, it was determined that the facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure the resident has a right to personal privacy and confidentiality, including the right to privacy in his or her oral communications, for one of 20 Residents reviewed (Resident 13).

Inspectors wroteBased on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of two nursing units (second floor).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a significant change assessment after a significant change in health status was identified in one of 20 residents reviewed (Resident 80).

Inspectors wroteBased on clinical record review, review of Centers for Medicare and Medicaid RAI manual, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 20 resident records reviewed (Residents 19 and 86).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure one of two medication storage areas observed were secure and access was limited to authorized personnel via a key (Second floor medication storage room).

Inspectors wroteBased on review of facility meal assessment form, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and a beverage that were at a palatable and appealing temperatures at one of one meal observed.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to administer medications in a safe and sanitary manner for two of three residents observed during medication administration observation (Residents 7 and 24).

Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior, and failed to ensure that bath linens were in good condition on two of two nursing units observed (first and second floor).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of four residents reviewed (Resident 11).

Inspectors wroteBased on policy review, document review, and staff interviews, it was determined that the facility failed to protect the resident's right to be free from physical abuse by Employee 7 for one of six residents reviewed (Resident 4). Findings Include: A review of the facility's policy, titled Preventing Resident Abuse, revised November 28, 2016, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment that results in physical harm, pain or mental anguish. A review of Resident 4's clinical record revealed diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times. Cycles of severe symptoms are often followed by periods of improvement. [...]

Inspectors wroteBased on document review and staff interviews, it was determined that the facility failed to ensure sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing related services to assure resident safety and care for residents with mental and psychosocial disorders and a history of trauma to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident 4). Findings Include: Review of the facility's Registered Nurse Job Description dated December 11, 2023 and signed by Employee 7 read, Purpose of Your Job Description- Supervise day to day nursing activities of the facility. [...]

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and failed to ensure staff follow professional standards of infection control practices during medication administration for two of five residents observed for medication administration (Residents 34 and 78).

Inspectors wroteBased on clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to ensure one of one residents reviewed were provided the right to self-determination in regard to a room change (Resident 10).

Inspectors wroteBased on a review of resident council meeting minutes, policy review, and resident and staff interviews, it was determined that the facility failed to have evidence to support that resident council grievances were acted upon.

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents access to grievance forms in a manner that honors the right to file grievances anonymously for one of two resident areas observed (first floor), as well as five of five residents in attendance at the group interview (Residents 3, 17, 46, 71, and 87); and failed to make prompt efforts to resolve a grievance for one of six residents reviewed (Resident 85).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care accurately reflected the needs of the resident for three of 21 residents reviewed (Residents 20, 60, and 72).

Inspectors wroteBased on facility policy review, record review, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care and ensure the residents right to participate in the care planning process for seven of 27 residents reviewed (Resident 3, 34, 56, 58, 71, 73, and 81).

Inspectors wroteBased on facility policy review, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for two of 21 residents reviewed (Residents 25 and 85). Findings Include: Facility policy, titled Pacemaker, Care of a Resident, with a last reviewed July 25, 2024, read, in part, Monitoring. 3. The pacemaker battery will be monitored remotely through the telephone or an internet connection. 4. The resident will have an EKG (electrocardiogram) annually, or as ordered, to monitor for changes in the heart's electrical activity. 5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. Documentation. 1. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication irregularity for one of five residents reviewed for unnecessary medications (Resident 29).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on review of the sign-in sheets for the facility's Quality Assurance (QA) Committee and staff interview, it was determined that the required members failed to attend a meeting at least quarterly for two of three quarters over the past year.

Inspectors wroteBased on a review of the facility's infection prevention and control policy and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage.

Inspectors wroteBased on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) stated, The facility must designate one or more individual(s) as the infection Preventionist(s) (IP)(s) who are responsible for the facility ' s IPCP. The IP must: Work at least part-time at the facility. The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility. [...]

Inspectors wroteBased on review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10), and failed to provide annual training that included resident abuse prevention for one of five nurse aide employee records reviewed (Employee 6). Findings Include: Review of personnel information revealed Employee 6's hire date was November 18, 1992; Employee 7's hire date was October 16, 2000; Employee 8's hire date was November 15, 2004; Employee 9's hire date was October 15, 2007; and Employee 10's hire date was December 19, 2022. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to include a resident in the development of their baseline care plan to establish the initial goals of the resident, and failed to provide the resident or their representative a written summary of their baseline care plan for two of two residents reviewed (Residents 6 and 30).

Inspectors wroteBased on facility policy, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents' dependent on staff for assistance with these activities of daily living for two of three residents reviewed (Residents 36 and 53). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, with a review date of July 25, 2024, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly, and sanitary conditions were maintained in the garbage storage area for one of one dumpster observed.

Inspectors wroteBased on observations, facility document review, clinical record review, and staff interviews, it was determined that the facility failed to provide beverages for a resident in a form to meet the resident's individual need for one of four residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (COPD- a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident 1's current physician orders revealed a diet order dated May 14, 2024, for a regular diet, mechanical soft texture, nectar consistency liquids. [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide care and services regarding showering for one of five residents reviewed (Resident 2).

Inspectors wroteBased on observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide beverages that were palatable temperatures for one of one meals tested.

Inspectors wroteBased on review of the pharmacy contract, medication guide review, clinical record review, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident, which resulted in one resident not receiving their seizure medication and suffering from a seizure, for one of 24 residents reviewed (Resident 240).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 24 residents reviewed (Residents 8 and 59).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 24 residents reviewed (Residents 52 and 62).

Inspectors wroteBased on resident observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident comprehensive plan of care was reviewed and revised for three of 24 residents reviewed (Residents 45, 62, and 292).

Inspectors wroteBased on review of facility documentation, observation, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents for two of two nursing floors (First and Second floor nursing units).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 24 residents reviewed (Resident 81).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure a medication reconciliation of medications, record of disposition of medications, and documentation of medications dispensed was conducted upon discharge for one of three discharged residents reviewed (Resident 88).

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 24 residents reviewed (Resident 47).

Inspectors wroteBased on observation, policy review, staff interview, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of 24 Residents reviewed (Resident 50).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that the physician documented a rationale for declination of a pharmacy review recommendation for two of 24 residents reviewed (Resident 28 and Resident 81).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed compartment for one of one medication rooms reviewed (second floor medication room).