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Inspectors wroteBased on observation, review of a cleaning checklist, staff interview, and policy review, the facility failed to ensure the kitchen was properly cleaned and maintained in a sanitary manner, and failed to ensure food items were stored in a manner to prevent contamination. This deficient practice had the potential to affect all 39 residents who received food prepared in the kitchen. The facility census was 39.

Inspectors wroteBased on medical record review, observations, staff and Poison Control Center Representative interviews, and review of a Material Safety Data Sheet (MSDS), the facility failed to ensure medications were appropriately secured/stored resulting in a cognitively impaired resident ingesting an undetermined amount of antifungal powder. This affected one (#10) of three residents reviewed for medication storage. The facility census was 38.

Inspectors wroteBased on observation, staff interview, review of facility policy, and review of the Food and Drug Administration (FDA) guidelines, the facility failed to label refrigerated foods and practice proper hand hygiene during food service. This had the potential to affect all residents. The facility census was 39.

Inspectors wroteBased on medical record review, resident and staff interview, review of the facility submitted Self-Reported Incident (SRI), review of the facility investigation, and review of facility policy, the facility failed to ensure a complete and thorough investigation of alleged resident abuse. This affected one (#17) of four residents reviewed for abuse. The facility census was 39.

Inspectors wroteBased on observation, resident representative interview, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with shaving. This affected one (#41) of two residents reviewed for activities of daily living (ADLs). The facility census was 39.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place. This affected one (#10) of one residents reviewed for falls. The facility census was 39.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure recommended nutritional supplements were implemented. This affected one (#4) of three residents reviewed for nutrition. The facility census was 39.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure accurate resident medical records. This affected one (#10) of two residents residents reviewed for accurate medical records. The facility census was 39.

Inspectors wroteBased on medical record review, observation, staff interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned prior to providing care for a resident who required Enhanced Barrier Precautions (EBP). This affected one (#17) of one resident reviewed for EBP. The facility census was 39.

Inspectors wroteBased on record review, staff interview, observation, and policy review, the facility failed to follow infection control policy and procedures when providing incontinence cares. This affected one (#7) out of three residents reviewed for incontinence care. The facility census was 43.

Inspectors wroteBased on observation, staff interviews, and review of the policy, the facility failed to maintain a functioning call light system to alert staff of a resident's need. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Inspectors wroteBased on observation, medical record review, staff interviews, and policy review, the facility failed to ensure an incontinent resident was provided with resident specific and timely incontinence assistance. This affected one (#3) of three residents reviewed for the provision of incontinence care and The facility census was 34.

Inspectors wroteBased on medical record review, family and staff interviews, observations, review of hospital records and review of the facility policy, the facility failed to ensure Resident #35 was properly monitored and interventions were applied to address constipation. This resulted in actual harm when Resident #35 went multiple days with no recorded bowel movements, went to the local hospital emergency room (ER) and was subsequently admitted to the hospital for a small bowel obstruction. This affected one resident (#35) of three residents reviewed for constipation. The facility also failed to ensure an order for a wound dressing treatment was in place prior to the application of wound dressing. This affected one resident (#11) of four residents reviewed for skin conditions. The Facility census was 39. Findings Include: 1. [...]

Inspectors wroteBased on observations, resident interview, staff interviews, and review of facility policy, the facility failed to ensure residents who required staff assistance with activities of daily living (ADLs), received adequate and timely care to maintain good personal hygiene including shaving and nail care and timely repositioning. This affected four residents (#4, #26, #9, and #190) of five residents reviewed for ADLs. The facility census was 39. Findings Include: 1. Review of Resident #4's medical record revealed an admission date of 02/21/21. Diagnoses included history of Coronavirus (COVID-19), need for assistance with personal care, cognitive communication deficit, major depressive disorder, and bipolar disorder. [...]

Inspectors wrote2. Observation on 04/18/23 from 8:01 A.M. to 8:12 A.M. of breakfast trays being delivered to the resident's room, revealed State Tested Nursing Assistants (STNAs) (#341 and #344) were noted to touch personal items of residents as well as the residents while delivering the breakfast trays. Continued observations revealed neither STNA performed any hand hygiene after assisting the residents and before delivering the next breakfast tray. Interview on 04/18/23 at 8:13 A.M. with STNAs (#341 and #344) verified they did not perform the appropriate hand hygiene between the resident's trays being delivered. 3. Review of the medical record for resident #9 revealed an admission date of 03/22/17 with a diagnosis of hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #9 had impaired cognition and required limited assistance of one staff for eating. [...]

Inspectors wroteBased on observations, staff interview and review of facility policy, the facility failed to ensure residents who required assistance with eating were provided with a dignified dining experience. This affected one resident (#26) of one resident observed in the dining room who required assistance with eating. There were twelve residents in the dining room. In addition, the facility failed to ensure residents in the dining room received meals timely in relation to other residents. This affected one resident (#90) of eleven residents observed to be eating in the dining room. The facility census was 39. Findings Include: 1. Review of Resident #26's medical record revealed an admission date of 01/21/21. Diagnoses included dysphagia, cerebrovascular disease, speech and language deficit, need for assistance with personal care, cerebral palsy, epilepsy, and aphasia. [...]

Inspectors wroteBased on medical record review, observations, resident interview, staff interview and review of the facility policy, the facility failed to ensure a resident's physician was notified of changes in skin conditions. This affected one resident (#11) of the three residents reviewed for notifications. The facility also failed to ensure the physician was notified when a resident's blood sample for testing was not able to be completed. This affected one resident (#17) of the three-residents reviewed for notification. The Facility census was 39. 1. Review of Resident #11's medical record revealed an admission date of 06/02/20. Diagnoses included type II diabetes, urinary incontinence, uterine cancer, dysphagia, major depressive disorder, anxiety disorder, epilepsy, and obesity. [...]

Inspectors wroteBased on observations, resident interview, and staff interview, the facility failed to ensure resident's rooms were maintained in a clean and homelike manner. This affected one resident (#13) of 39 residents reviewed for their environment. The facility census was 39.

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to ensure resident's baseline care plans were accurate and complete. This affected two residents (#91 and #190) of three reviewed for baseline care plans. The facility census was 39.

Inspectors wroteBased on staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure comprehensive care plans were individualized for each resident. This affected two residents (#22 and #34) of 14 residents reviewed for comprehensive care plans. The Facility census was 39.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to provide pressure ulcer care for residents. This affected one resident (#91) of two reviewed for pressure ulcers. The facility census was 39.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure fluids were monitored for residents. This affected one resident (#17) of one resident reviewed for dialysis. The facility census was 39.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a physician ordered abdominal binder was applied to secure a resident's feeding tube. This affected one resident (#35) of one reviewed for tube feeding. The facility identified two residents who received tube feeding. The facility census was 39. Findings Include: Review of Resident #35's medical record revealed an admission date of 01/26/23. Diagnoses included epilepsy, dysphagia, cerebral palsy, mild intellectual disabilities, and autistic disorder. Review of Resident #35's Minimum Data Set (MDS) assessment dated [DATE], and 03/14/23 revealed a Brief Interview for Mental Status (BIMS) was not assessed. Review of Resident #35's 03/14/23 MDS revealed he required limited assistance with bed mobility, and extensive assistance for transfer. [...]

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure a peripherally inserted central catheter (PICC) was maintained appropriately. This affected one resident (#29) of one resident reviewed for intravenous (IV) therapy services. The facility census was 39.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the physician responded in a timely manner to the pharmacist's recommendation during a monthly medication review. This affected one resident (#13) of five residents reviewed for unnecessary medications. The facility census was 39.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents prescribed medications had appropriate indications for their use. This affected one resident (#91) of five reviewed for unnecessary medications. The facility census was 39.

Inspectors wroteBased on observation, staff interview, review of the kitchen cleaning schedule, and review of facility policy, the facility failed to maintain a clean kitchen. This affected 40 of 40 residents who receive food from the kitchen.

Inspectors wroteBased on observation, resident and staff interview, record review and review of facility policy, the facility failed to provide a hoyer lift to accommodate the resident's needs. This affected one resident (#25) of one resident review for accommodation of needs. The facility census was 40.

Inspectors wroteBased on medical record review, review of facility policy, observation and staff and resident interview, the facility failed to provide invitations to care conferences to two residents (#10 and #25). Additionally, the facility failed to update a resident's plan of care with for one resident (#1). This affected three residents (Resident #1, #10 and #25) of twelve residents who had care plans reviewed. The facility census was 40.

Inspectors wroteBased on medical record review, review of facility policy and staff interview, the facility failed to obtain an ordered laboratory test timely for one resident. This affected one (Resident #34) of 12 residents reviewed during the annual survey for laboratory tests. The facility identified 23 residents who had orders for laboratory tests in the last 90 days. The facility census was 40.

Inspectors wroteBased on resident and staff interview, record review and review of facility policy, the facility failed to ensure residents received dental services. This affected one resident (#25) of one resident review for ancillary services. The facility census was 40.