Glasgow Hills of Journey

Inspectors wroteBased on record review and staff interview, the facility failed to comply with all applicable state laws, regulations, and codes. The facility's Infections Medical Waste Program permit was expired. This was a random opportunity for discovery. Facility census: 105.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to make prompt efforts to resolve a resident grievance. The facility failed to follow through on purchasing new pajamas for a resident after they were lost in the facility. This was a random opportunity for discovery during a complaint investigation. Census: 105. Resident identifier: #40.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a care plan for Resident #40 based on accurate diagnoses. This was a random opportunity for discovery during a complaint investigation. Resident identifier: #40. Facility census: 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for two (2) of 30 residents reviewed in the long-term care survey sample. Resident identifiers: #101 and #33. Facility census: 101.

Inspectors wroteBased on observation and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This failed practice has the potential to effect more than an isolated number of residents. Facility Census: 101. Findings Include: a) Initial tour of the Kitchen and Pantries An initial tour of the kitchen upon entrance to the facility on [DATE] at 9:15 AM found the kitchen staff had a cyclone floor fan blowing toward the food preparation area. The fan as observed to be covered in dust and was not clean. The dietary manager (DM) stated, I am getting rid of this right now. On the dementia unit in the refrigerator was two (2) bottles of ranch dressing which were open and not dated, a small carton of vitamin D milk which was open and not dated, and a small bag fiesta shredded cheese which was open and not dated. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. The medication diagnosis was inaccurate for two (2) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Additionally, a resident's psychiatric evaluation notes referred to her as a male. This was true for one (1) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #40, #101, and #102. Facility census: 101.

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure Resident #85 received the assistance he needed with eating to enable him to maintain his dignity. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. Resident Identifier: #85. Facility Census:101. Findings Include: a) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form were issued and signed in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident's legal representative at risk of not being informed of the resident's rights prior to the end of Medicare Part A covered services. Resident identifier: #102. Facility census: 101.

Inspectors wroteFACILITY Environment Based on observation and staff interview the facility failed to ensure the resident environment was clean and homelike. This was a random opportunity for discovery and as true for the bathroom shared between room [ROOM NUMBER] and 311. Facility Census: 101. Findings Include: On 06/30/25 at 11:45 am a tour with the Dementia Unit Director found the toilet seat attached to the toilet shared between room [ROOM NUMBER] and 311 was in poor repair. It appeared to be dirty at first glance, but the director indicated that the plastic coating was off and why it was discolored she stated, I have told maintenance about it. Also, in the same bathroom the baseboard trim was missing along the wall toward room [ROOM NUMBER].

Inspectors wroteBased on observation, resident interview, record review, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #59 and #88. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with a newly evident or a possible serious disorder. This was true for one (1) out of 30 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #35. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan that accurately reflected resident status and need for assistance. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #62 and #85. Facility census: 101.

Inspectors wroteBased on observation, resident interview, record review, and staff interview, the facility failed to revise the comprehensive care plan to reflect the resident's choices and when a resident's medication dosages changed. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifier: #75 and Resident #101. Facility census: 101.

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure Resident #85's care plan accurately reflected the level and type of assistance he needed for eating. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident Identifier: #85. Facility Census:101. Findings Include: a) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the resident's oxygen flow rate was set according to the physician's orders. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of oxygen. Resident Identifier: #62. Facility census: 101.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. This was a random opportunity for discovery. Resident Identifier: #59. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #108 was free of chemical restraints. This was true for one (1) of six (6) residents reviewed under the care area of abuse. Resident Identifier: #108. Facility Census: 107. Findings Include: a1) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident had a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN) on 05/18/24. The physician's order did not have a time limit. The monthly pharmacy review was completed on 05/23/24 with the recommendation to either discontinue the PRN Ativan or reorder with a specific number of days. The review was signed by the physician on 06/12/24. However, the physician's order was not changed until 07/06/24. At the time of the change, the PRN Ativan was ordered for 60 days. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop/implement the care plan for Resident #108 regarding non pharmacological interventions, restricted limb precautions for Resident #109, #15 and #91. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #108, #109, #15, and #91. Census: 107. Findings Include: a) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident did have a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders regarding restricted limb precautions for Resident #109, #15 and #91. This was true for four (3) of 13 residents reviewed during the survey process. Resident Identifiers: #109, #15, and #91. Census: 107. Findings Include: a) Resident #109 On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the physician's order was not followed. The following dates indicate the blood pressure was taken in the left arm: [...]

Inspectors wroteBased on Observation, staff and resident interview the facility failed to provide a homelike environment for resident # 78. Resident ' s privacy curtain had several stains. This was true for on (1) of five (5) residents reviewed for environment. Facility Census 107.

Inspectors wroteBased on record review, staff interview the facility failed to keep resident free from verbal abuse. This was true for one (1) of eleven (11) instances of alleged verbal abuse reviewed during this investigation. Facility census 107.

Inspectors wroteBased on record review and staff interview the facility failed to report an alleged incident of abuse to the appropriate agency. This is true for one (1) of six (6) residents reviewed. Facility Census 107.

Inspectors wroteBased on record review and staff interview the facility failed to complete an investigation and five-day follow-up for an alleged incident. This is true for one (1) of six (6) instances of alleged verbal abuse that was investigated during this survey. Facility Census 107.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of four (4) residents reviewed under the care area of dialysis. Resident Identifier: #91. Facility Census: 107. Findings Include: a) Resident #91 On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. However, a physician's order dated 04/17/25 stated, dialysis: check thrill and bruit to fistula on left arm every shift. On the following dates the blood pressure was taken in the restricted limb: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #109's skin assessment. This was true for one (1) of three (3) residents reviewed during the survey. Resident Identifier: #109. Facility Census: 107. Findings Include: a) Resident #109 On 05/20/25 at 2:00 PM, a record review was completed for Resident #109. The review of the physician's orders, care plan, weekly skin assessment and progress notes did not indicate the resident had any skin concerns. However, the facility provided a document entitled, Nursing Assistant Skin Inspection and Shower sheet dated 11/11/23 that indicated the resident did have a skin concern on the bilateral areas of the buttocks. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the most recent survey was accessible to residents, family members, and legal representatives of residents. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 99.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure residents were free from neglect. Residents #13, #90 and #100 had physician orders for hourly checks for fall prevention. Due to the facility's failure to complete the hourly checks, resulting in the residents continuing to fall. Resident #2 was on 15-minute checks but was able to place himself in the room of a female resident and did not have pants on. Resident identifiers: #13, #90, #100. Facility Census: 99.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to all the proper State Authorities. This was true for one (1) resident reviewed in the care area of verbal abuse during a complaint survey. Resident identifier: #10. Facility census: 99.

Inspectors wroteBased on record review and staff interview the facility failed to ensure all residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This failed practice was true for seven (7) out of seven (7) reviewed for sexual behavior which were ordered 15-minute monitoring checks without a duration or time frame to discontinue the checks. This was depriving the residents of sense of wellbeing for quality of life. Resident identifiers: #57, #2, #95, #99, #62, #37, and #60. Facility censuses 99.

Inspectors wroteBased on medical record review, and staff interview the facility failed to give medication as ordered by the physician, failed to complete 15-minute monitoring of a resident, failed to complete neuro checks after an unwitnessed fall. These failed practices were true for six (6) out of six (6) residents reviewed for late medications, and seven (7) out of seven (7) residents reviewed for 15-minute monitoring, and one (1) out of one (1) resident reviewed for neuro checks. Resident identifiers: #33, #62, #31, #7, #43, #20, #37, #60, and #90. Facility Census:

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment over which it had control and remained as free of accident hazards as was possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents who reside at the facility. Facility census: 99.

Inspectors wroteBased on facility documents and staff interviews the facility failed to meet the requirements of the staff posting by failing to reflect the actual number of staff who worked and the actual number of hours they worked. This failed practice had the potential to affect a limited number of residents. Facility census: 99.

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. This was a random opportunity for discovery and had the potential to affect a limited number of residents who reside at the facility. Facility census: 99.

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice, and to ensure residents rights for self-determination was encouraged. This was true for two (2) residents and was a random opportunity for discovery. Resident identifiers: # 95 and #99. Facility 99.

Inspectors wroteBased on review of facility documents, staff interview, and interview via phone with the [NAME] Virginia licensing board of nursing. The facility failed to report nurses who had a disciplinary action in effect taken and/or released from their employment at the facility due to unaccounted for or missing controlled medications and not administering medications as ordered, along with falsified documentation about marking a medication as given when it was not given. Resident Identifier: # 101. Facility census: 99.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure all handwritten skin assessments were clear and accurate and contained enough information to accurately identify the resident. This failed practice had the potential to effect more than a limited number of residents. Facility census: 99.

Inspectors wroteBased on observation and staff interview the facility failed to ensure they maintained a clean and sanitary environment for all residents. Observations were made of torn pillows and a room with an foul odor. These were random opportunities for discovery. Resident identifiers: #67 and #75. Census: 94.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure three (3) residents who were random opportunities of discovery had Activities of Daily living (ADL) provided for them in the form of grooming (nail care). Resident identifiers: #29, #41, and #76. Facility census: 94.

Inspectors wroteBased on record review and staff interview the facility failed to have Quality Assurance Assessment (QAA) Committee meetings that consist of the Infection Preventionist (IP) attendance. This had the potential to affect all residents currently residing in the facility. Facility Census: 93.

Inspectors wroteBased on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the laundry room and water management. This practice had the potential to affect all residents that resided in the facility. Facility census: 93.

Inspectors wroteBased on medical record review, policy review and staff interview the facility failed to notify the physician and/or resident representative in a timely manner when a resident had a change in condition. Resident #73 perpetrated sexual abuse on Resident #47, #60, and #17 on several occasions. The facility staff failed to notify the physician and/or responsible parties of these incidents. Resident identifiers: #74, #47, #60 and #17. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to implement their abuse prohibition policy regarding reporting of allegations of sexual abuse. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: Resident #47 and #60 . Facility Census: 93. Findings Included: During a review of the facility policy titled Freedom from Abuse and Neglect Policy not dated read as follows. .Identification: 1. Staff will immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation, or misappropriation to the Executive Director. .3. The facility will report the allegation to the State Agency in accordance with state law. a) Resident #47 During a record review on 12/04/23 at 12:56 PM, Resident #10's medical records revealed the following notes: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an allegation of abuse was reported to all the proper State Authorities. This was true for two (2) of three (3) resident reviewed in the care area of Abuse during the Long Term Care Survey Process . Resident identifier: Resident #47, and Resident #60. Facility Census: 93. Findings Included: a) Resident #47 During a record review on 12/04/23 at 12:56 PM, Resident #74's medical record found the following notes: -11/09/23 at 11:00 AM Resident to Resident encounter of verbal sexual abuse to Resident #47. -11/09/23 at 3:55 PM Resident to Resident encounter of verbal sexual abuse to Resident #47. -11/12/23 at 11:39 AM Resident to Resident encounter of verbal sexual abuse to Resident #47. b) Resident #60 During a record review on 12/04/23 at 12:56 PM, Resident #74's medical records revealed a note dated on 11/23/23 at 11: [...]

Inspectors wroteBased on record review and staff interview the facility failed to revise the person-centered care plan, after a change in the resident's care or preference for care, for three (3) of 20 residents reviewed during the Long-term Care Survey Process (LTSP). Resident identifiers: Resident # 44, #26, and #46. Census: 93.

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of the Residents. This was true for four (4) of five (5) Residents reviewed in care area of Activities during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #74, Resident #65, Resident #35 and Resident #82. Facility Census: 93. Findings Included: a) Resident #74 During a record review on 12/06/23 at 10:51 AM, Resident # 74's medical record revealed monthly activity participation record. The participation records were void documentation of any involvement in group or individual activities. [...]

Inspectors wroteBased on record review, and staff interview the facility failed to follow Physician orders for Resident #46. Resident #46 was not getting his morning time medications as ordered by the physician on days he went to dialysis. Resident #46 also was not served food in the correct form to meet his needs and as ordered by the physician. This was true for one (1) of 20 sampled residents. Resident Identifier: #46. Facility Census: 93. Findings Include: a-1) Resident #46's meal service On 12/11/23 at 10:58 AM, a review of Resident #46's medical record found a physician order for a Dysphagia Advanced diet, with thin liquids. and a peanut butter and jelly sandwich with each meal. An observation of the noontime meal on 12/11/23 beginning at 12:10 PM, revealed Certified Nursing Assistant (NA) #13 delivered Resident #46 his roommates tray. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure performance reviews of Nurse Aide (NA) at least once every 12 months. This was true for two (2) of five (5) employee files reviewed for the Sufficient Nurse Staff care area. This had the potential to affect more than a limited number of residents currently residing in the facility. Employee identifiers: #23, and #46. Facility census: 93.

Inspectors wroteBased on record review, and staff interview, the facility failed to have a pharmacist review each resident's medication regimen monthly to identify irregularities and maintain record of the identified irregularities. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #70, #66 and #46. Facility census: 93.

Inspectors wroteBased on observation and staff interview the facility failed to keep the nourishment room on the dementia unit clean and sanitary. This failed practice had the potential to affect more than isolated number of residents. Facility Census: 93.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure three (3) of 20 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per direction and one (1) of 20 residents Physician 0rders were accurate. Resident identifiers: #72, #40, #74 and #99. Facility census: 93. Findings Included: a) Resident #72 Record review on 12/06/23 at 9:43 AM found, a POST form on Resident #72's chart was unsigned by the Resident or Medical Power of Attorney (MPOA). The POST form was dated 06/09/22. During an interview on 12/06/23 at 2:04 PM with the Director of Nursing, she confirmed Resident #72's POST form was incomplete without a Resident or MPOA signature. b) Resident #40 Record review on 12/05/23 at 2:30 PM found, a POST form on Resident #40's chart was unsigned by the Resident or MPOA. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to treat each resident with dignity and respect. This was true for one (1) of one (1) resident reviewed for the dignity care area and one (1) random opportunity for discovery . Resident Identifiers: #66, #74. Facility Census: 93.

Inspectors wroteBased on resident and staff interview, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, by failing to ensure residents were provided with the proper sized undergarments. This was true for one (1) of one (1) resident reviewed for the accommodation of needs care area. Resident identifiers: 43. Facility Census: 93. Findings Include: a) On 12/5/2023 at approximately 12:54 PM, during an interview, Resident #22 stated the facility will frequently run out of bariatric incontinence supplies and the Nurse Aides will have to put them in a smaller size, which cuts into their sides. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to provide the resident and/or representative with the bed hold policy at the time of discharge. This was true for one (1) of two (2) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifiers: #46. Facility Census: 93. Findings Included: a) Resident #46 On 12/11/23 at 11:00 AM, during a record review of Resident #46 for hospitalizations, one (1) of four (4) bedhold notifications was not available. During an interview on 12/11/23 at 11:30 AM, Staff # 68 was unable to provide the requested behold notification dated 6/23/23. Staff #75 followed up on 12/11/23 at 2:40 PM to confirm the behold document was not found. Staff #75 stated they could not speak to why but they would do better next time. .

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed to reflect the residents new diagnosis bipolar disorder and major depression. This was true for one (1) of two (2) residents reviewed in the PASARR care area. Resident Identifiers: Resident #45. Facility Census: 93. Findings Included: a) Resident #45 During a record review on 12/06/23 09:42 AM, Resident # 45's PASARR dated 09/07/21 was void of the diagnosis of affective bipolar disorder and Major depression. Further record review revealed the following diagnosis included: -Schizoaffective Disorder 06/04/21 -Affective Bipolar Disorder 06/04/21 -Major Depression 03/15/23 During an interview on 12/07/23 at 8:43, AM the Social Worker (SW) stated I was unaware we needed to do a new PASARR with a new diagnosis. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier #40. Census 93. Findings Included: a) Resident #40 On 12/07/23, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated No current diagnosis. The record also revealed indicated the resident had a psych diagnosis of Major Depression on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 12/07/23 at 2:23 PM the Director of Nursing verified, Resident #40's PAS did not reveal his diagnosis of Major Depression. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for Resident #47 and Resident #40. This was true for two (2) of 20 residents sampled during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #47 and Resident #40. Facility Census: 93.

Inspectors wroteBased on observation, family interview, staff interview and medical record review the facility failed to ensure Resident #66 maintained acceptable parameters of hydration status. This was true for one (1) of one (1) resident reviewed for the Nutrition/Hydration Status area of care. Resident Identifiers: 66. Facility Census: 93. Findings Include: a) Resident #66 On 12/05/23 at approximately 12:34 PM, during a tour of the facility, it was observed that no water was placed within reach of Resident #66. Upon further observation, it was discovered there was no water in Resident #66's room. On 12/06/23 at approximately 2:20 PM, a family interview was conducted in Resident #66's room. The family member stated Resident #66 is not able to reach for or hold things up well enough to eat or drink. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medically-related social services were maintained to ensure the highest practicable well-being of one (1) of 20 residents reviewed during the Long-term Care Survey Process (LTCSP). Resident #44 was identified as having grief and there was lack of evidence the resident was monitored and or interventions implemented during the grief process. Resident identifier: Resident #44. Census: 93.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored, and labeled in accordance with current accepted professional practices. This was true for medications stored in one (1) of two (2) medication carts inspected. The facility failed to ensure medications were dated when opened and put in to use or was found to be expired and still being stored for use. This practice had the potential to effect more than a limited number of residents. Resident identifiers: Resident #7, and Resident #50. Facility census:

Inspectors wroteBased on medical record review and staff interview the facility failed to provide a COVID-19 booster vaccination for one (1) of five (5) residents reviewed for compliance with Covid -19 vaccinations. Resident identifier: #72. Facility Census: 93.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards. There was an unlocked medication room that contained medicaitons on the dementia care unit. This was a random opportunity for discovery. The deficient practice put all 23 residents currently residing on the dementia care unit at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #56, #88, #59, #67 #33, #87, #43, #37, #13, #66, #68, #14, #86, #70, #8, #81, #54, #78, #19, #48, #1, #52, and #6. Facility Census: 91.

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to protect Resident #34 from sexual abuse resulting in actual psychosocial harm. The facility failed to ensure Resident #34 was safe and not exposed to continued sexual abuse from Resident #10. This was a random opportunity of discovery. Resident identifier: #34, #10. Facility Census: 91.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident, and to establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights . This has the potential to affect more than a limited number of residents . Resident Identifiers: Resident Council, 22, 28. Room numbers: #117, #126, #129, #130, #131, #133, #201. Facility Census: 91.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike This has the potential to affect more than a limited number of residents . Resident identifiers: #45, #48, #86, and #92. Room numbers: #117, #126, #129, #130, #131, #133, #201, #302, #304, #312, #311, #31, and #303. Facility Census: 91. Findings Include: a) Hallways On 12/04/23 at approximately 10:34 AM, Excessive debris in the floor in front of the storage closet on the East Front hallway was observed. On 12/04/23 at approximately 10:39 AM, observation of the floors in the East Back hallway found excessive debris in the floor, in front of resident rooms, and thick layers of dirt and debris in the corners of the hallway. On 12/04/23 at approximately 10:44 AM, Environmental Services Manager (EVSM) #118, witnessed the condition of the hallways. [...]

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice of staff failing to properly don Personal Protection Equipment (PPE) when indicated by signage on door and had the potential to affect all residents who currently reside at the facility. Facility census 96.

Inspectors wroteBased on record review and interview the facility failed to provide pharmaceutical services , including procedures that assure the accurate dispensing and administering of all drugs. This was found for five (5) of five (5) resident records reviewed. Resident Identifiers: Resident #25, #38, #44, #52 and #85. Facility Census 96. Findings Include: a) Medication administration - interviews On 09/18/23 at 1:00 PM, the surveyor spoke with Assistant Director of Nursing (ADON) regarding reconciliation of narcotics. He said he runs a daily report and compares what was removed from the Pixis (automated drug dispenser), compared to the Medication Administration Record (MAR). He said there are often minor discrepancies and he gets the nurse that dispensed the medication to fix it on the MAR. He said it is usually just a matter of changing the date or the time. [...]

Inspectors wroteBased on observation and interview the facility failed to serve food within professional standards for food safety. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Facility census: 96.

Inspectors wroteBased on Record review and staff interview the facility failed to ensure all medical records were accurate. This was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifiers: #37, #24, and #83. Facility census 96.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. Window curtains were not present or did not close properly to allow for privacy. Vents in the ceiling were covered with dust and the ceiling on 300 hallway was in need of repair. This was a random opportunity for discovery and had the potential to affect more than a limited number of Residents at the facility. Facility census: 96. a) Observations of curtains At 10:15 AM on 09/18/23, a tour of the facility with the housekeeping supervisor #88 found the following rooms had no window curtains and no blinds allowing resident care to be visible from outside the facility. Rooms 214, 216, 313, 301, 113, 133, 105, and 106. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #97. Facility census: 96.

Inspectors wroteBased on record review, observation and staff interview the facility failed to implement the care plan for two (2) of three (3) residents reviewed for the care area of falls. Resident identifiers: # 58 and #3. Facility census: Facility census: 96.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to treat pain to the extent possible in accordance with professional standards of practice. This caused harm to the resident by causing uncontrolled pain and an emergency room visit for this uncontrolled pain. This was true for one (1) of two (2) residents reviewed for the care area of pain. Resident identifier: #22. Facility census: 90.

Inspectors wroteBased on resident interview, resident observation, record review and staff interview the facility failed to provide the necessary behavioral health care and services to assist the resident in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being for Resident #85 following the death of his son. Observations of the resident found him to be very tearful and suffering from mental anguish. The facility had provided no grief counseling or any mental health services to help Resident #85 deal with the passing of his his son. This failure resulted in actual psychosocial harm for Resident #85 who was suffering grief on his own without any assistance from facility staff to help lessen the effects of his grief. Resident Identifier: #85 Facility Census:

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #54 received the necessary dental services to ensure he was pain free and able to attain his highest practicable physical well-being. Resident #54 was to have teeth extracted the facility has failed to make the arrangements for Resident #54 to have his teeth extracted. This failure has resulted in actual harm for Resident #54 because he has continued pain from the teeth which are in poor condition. This was true for one (1) of two (2) residents reviewed for the care area of dental status. Resident identifier: #54. Facility census: 90.

Inspectors wroteBased on observations and staff interview the facility failed to ensure the Resident's environment was clean, safe, sanitary, and homelike. A privacy curtain in Resident room [ROOM NUMBER] was visibly soiled. Resident room [ROOM NUMBER] and 303 had doors which were in poor repair, and the wardrobe door was broken off lying in the floor of resident room [ROOM NUMBER].

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a representative from the Office of the State Long-Term Care Ombudsman was notified of transfers and/or discharges as required. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations and true for one (1) of two (2) residents reviewed for discharge during the long term care survey process (LTCSP). Resident Identifiers: Residents #442, #342 and #42. Census: 90.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility census: 90. Findings Included: a) Unlocked Nourishment Room During the initial tour on 11/14/22 at 11:50 AM an observation found the nourishment room door was unlocked on the Life Engagement Alzheimer's Unit (ACU). The nourishment room contained a coffee maker with a hot pot of coffee on the counter, accessible to residents living on the ACU. On 11/14/22 at 11:50 AM the Director of Nursing (DON) verified the door was sticking and not closing all the way and there was a coffee maker with a hot pot of coffee in reach of residents. She stated the nourishment room should always be locked. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was held prior to food service at appropriate temperatures, cold food should be held at 41 degrees or below. This failed practice had the potential to affect more than an isolated number of residents. Facility census:

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 90 Findings Included: a) Dining Observation On 11/15/22 at 12:06 PM an observation of tray pass on the 100-hall found, the holding tray cart open on both sides throughout the tray pass. On 11/15/22 at 12:19 PM the Dietary Manager in Training took temperatures of the last resident tray on the 100-hall cart the following temperatures were obtained: --Ham - 95 degrees Fahrenheit (F) --Glazed Carrots -107 degrees F. --Egg Noodles - 96 degrees F. --Spiced Peaches -54 degrees F. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to complete labeling and date stored food items in the refrigerator and freezer on the Life Engagement Alzheimer's Unit (ACU) resident kitchen. The facility also failed to the monitor the temperature of Resident #85's personal refrigerator in his resident room. This has the ability to affect more than a limited number of residents that reside on the ACU. In addition to Resident #85 who was a random opportunity for discovery. Resident Identifiers: #85. Facility Census: 90. Findings Included: a) ACU Resident Kitchen A review of the facility's policy titled Food Receiving and Storage, with revised date October 2017, revealed the following: Food items and snacks kept on the nursing units be maintained as indicated below. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure each medical record was complete and accurate this was true for 12 of 27 sampled residents during the Long Term Care Survey Process. Resident Identifiers: #62, #33, #56, #84, #89, #22, #91, #35, #342, # 55, #66, and #54. Facility Census: 90. Findings Included: a) Resident #33 A review of Resident #33's shower/bed bath documentation from the point of care system in the medical record indicated Resident #33 received the following showers and/or bed baths. -- [DATE] - Bed Bath at 6:59 pm. -- [DATE] - a shower at 5:58 pm. -- [DATE] - a shower at 9:03 am. -- [DATE] - a bed bath at 6:59 pm. Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System: -- [DATE] the shower sheet indicated Resident #33 received a bed bath. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure documentation in the residents medical record of the information/education provided regarding the benefits and risks of immunizations and the administration or the refusal of /or medical contraindications to the vaccines. This was true for three (3) of five (5) residents reviewed for immunizations during the Long- Term Care Survey Process (LTCSP). This failed practice had the potential to affect all residents residing in the facility eligible for immunizations. Resident identifiers: Residents #47, #33 and #44. Census:

Inspectors wroteBased on observation, resident interview, and record review the facility failed to ensure Resident #18's call light was always within reach. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 90.

Inspectors wroteBased on resident interview, resident observation, record review and staff interview the facility failed to allow the resident the right to choose his preference in relation to his personal care. This was true for one (1) of two (2) residents reviewed for the care area of choices. Resident #77. Facility Census: 90 Findings Included: a) Resident #77 On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed to be shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and he hasn't had a shower in over a week. He would like a hair cut and shaved. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a notice of the behold policy was given to each resident and/or representative upon discharge from the facility. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Residents #342 and #42. Census: 90.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure three (3) of 27 residents Minimum Data Set (MDS) assessments were coded to accurately reflect the resident's status. Resident identifiers: #18, #35, and #22. Facility census: 90. a) Resident #18 Record review of the Resident's MDS with and ARD target date of 10/22/22 indicated seven (7) days of antibiotic use. Review of the Resident's orders and Medication Administration Record showed no record of antibiotics being ordered or administered in the month of October 2022. During an interview on 11/15/22 at 2:30 PM the Director of Nursing (DON) stated, I have looked everywhere and asked all the departments, we can't find where she got any antibiotics in October, so it must be coded wrong. [...]

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to provide Resident #4 with advance notice of care planning conferences to enable resident's participation. This was true for one (1) of 27 Residents reviewed in the sample. Resident identifier #4. Facility census: 90.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliations of all pre- and post - discharge medications. Also, the facility failed to ensure the discharge instructions were signed by the staff member completing the discharge and by the resident or the resident's representative. This was true for one (1) of one (1) residents reviewed for the care area of discharge. Resident identifier: #90. Facility census: 90.

Inspectors wroteBased on observation, resident interview, and record review the facility failed to ensure that residents who are dependent for Activities of Daily Living (ADL) care receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for two (2) of three (3) residents reviewed for the care area of ADL care. Resident Identifiers: #77 and #89. Facility Census: 90. Findings Included: a) Resident #77 On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and reported he had not had a shower in over a week. He also indicated he would like a hair cut and shave. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89. [...]

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to follow the Physician's orders as written. This was true for two (2) of twenty-seven (27) sampled residents. Resident Identifier: #55 and #85. Facility Census: 90 Findings Included: a) Resident #55 On 11/14/22 at 1:51 PM it was observed that Resident #55 had an oxygen concentrator at bedside. He was not wearing oxygen at this time. He stated he is suppose to have it on, but since he was moved to his current room on 10/17/22, the staff has not set it up nor put it on him. It was confirmed with Licensed Practical Nurse #89 on 11/14/22 at 2:04 PM that Resident #55 had been without his oxygen for twenty-eight (28) days. A review of the medical record found a current order dated 9/04/22 for two (2) Liters of oxygen via nasal cannula. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure an indwelling urinary catheter was maintained within professional standards of practice. The facility failed to ensure the catheter was anchored. The facility also failed to clarify and initiate bladder training ordered by the physician. The facility also failed to provide appropriate catheter care. This was true for one (1) of two (2) residents reviewed for catheter care. Resident identifier: #22. Facility census: 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor meal intakes for a resident with significant weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #75. Facility census: 90.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored in accordance with currently accepted professional principles. A multi-use medication vial stored in the medication preparation room had not been discarded in the time frame recommended by the manufacturer after opening . Additionally, two (2) bags of intravenous fluids were past the manufacturer's expiration date. These were discoveries made during the facility task of medication storage. Facility census: 90.

Inspectors wroteBased on record review and staff interview, the facility to ensure the residents care plan contained descriptions of care and services provided by hospice. This was true for one (1) of one (1) residents reviewed for the care area of hospice services. Resident identifier: 13. Facility census: 90.