Grace Pointe Wellness Center

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services. The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 02/09/2026. This failure could place residents at risk of not having their psychosocial or discharge planning needs met. Record Review on 06/16/2026 at 02:27 PM, of an email sent to SW on May 27, 2026, from The Association of Social Work Boards (ASWB) revealed a passing score on the ASWB master's examination. [...]

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge for 1 (Resident #3) of 1 resident reviewed for transfer/discharge. The facility failed to ensure Resident #3 was provided a proper 30-day discharge letter from the facility after an incident with LVN R. This failure could place residents at risk of being discharged inappropriately causing a disruption in their care and services and potential decline in health. Record review of Resident #3's face sheet dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and still currently a resident at the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 8 residents (Residents #2 and Resident #15) reviewed for dignity. -The facility failed on 03/10/2026 to assist Resident #2 to shave her facial hair.-The facility failed on 03/10/2026 and 03/11/2026 to cover Resident #15's genitals and anus. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional for 1 of 1 (activities staff) reviewed for staff qualifications. The facility failed to ensure the activities staff had completed State approved training to direct facility activities. This failure could place residents who participated in facility activities at risk of physiological, psychological, social, and spiritual harm by receiving services from unlicensed personnel.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed to ensure dietary staff followed proper food safety practices for cooling and storing prepared food on 03/10/2026. This failure had the potential to place all residents who received meals from the main kitchen at risk for foodborne illness due to, improper food storage practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 dryers reviewed. The facility failed to ensure the furthest right dryer was operational. This failure placed residents at risk for delay in having their clothes and bedding returned without delay. During an observation on 3/11/2026 at 3:09 PM of the laundry room revealed Laundry Aide I was utilizing 2 of 3 dryers in the laundromat. The furthest right Dryer was rusted, had dust, and was missing its operational panel that covered the top portion of the dryer. The dryer was non-responsive despite moving the knobs and checking for power to the machine. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 5 residents (Resident #10) reviewed for call lights. The facility failed to ensure Resident #10's call light was within reach on 03/10/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of eight residents ( Resident #2) reviewed for ADL care. The facility failed on 03/10/2026 to ensure Resident #2's fingernails were clean and trimmed. This failure could place residents who required assistance with ADLs at risk for unmet care needs.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #18) of 5 residents observed for oxygen management. The facility failed to ensure Resident #18's nasal canula was properly stored while oxygen was not in use. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 dining rooms reviewed.- 1 living cockroach was in the dining room.-The facility failed to dispose of 1 dead cockroach in the dining room.-The facility failed to dispose of 5 dead cockroaches in the Air Conditioning unit room. This failure placed residents at risk for a facility wide infestation of cockroaches.

Inspectors wroteBased on observation and interview the facility failed to ensure the residents had the right to examine the results of the most recent survey of the facility and the facility failed to post the results of the most recent survey in a place that is readily accessible to residents, family members, legal representatives of residents, and the public for 1 of 1 survey results binder reviewed. The facility failed to ensure the annual survey results binder was accessible for residents, family members, and staff on 03/11/2026This failure placed residents, family members, and legal representatives of the residents at risk of not being informed the facility's survey and investigation results.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to document accurately on Resident #1's EMAR for Acetaminophen with Codeine 300-30 MG tablet, 1 tablet. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 08/14/2025. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for one (Resident #1) of four resident reviewed for grievance resolution. The facility did not issue a written decision to Resident #2 who filed a grievance on 09/05/25 and 09/09/25. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 10 employees (LVN A) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete the annual employee misconduct registry and annual nurse aide registry screenings for LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on interview and record review the facility failed to provide to send a copy of notice to the Office of the State Long-Term Care Ombudsman at least 30 days prior to the discharge or as soon as possible for 1 (Resident #2) of two residents reviewed for facility-initiated discharges, in that: The facility failed to send a copy of the Discharge Notice at the same time notice was provided to Resident #2 on 09/03/25 to the Local Office of the State-Long Term Care Ombudsman. This failure could place residents at risk of not providing added protection to residents from being inappropriately transferred or discharged and provide residents with access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on interview and record review the facility failed to ensure that information is comprehensive, timely and properly signed for 1 of 9 residents (Resident #3) reviewed for accuracy and completeness. The facility failed to document when Resident #3 complained of pain to the right lower extremity. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in treatment, or a potential decline in the resident's health.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Residents #1) reviewed for abuse. The facility failed to ensure residents right to be free from abuse when Resident #1 reported sexual abuse by CNA O to staff in January 2025 and the alleged perpetrator was not suspended, the allegation was not investigated, and the facility did not report the suspected crime to local law enforcement and the State Agency, resulting in failure to protect residents from further potential criminal activity by an alleged perpetrator. An Immediate Jeopardy (IJ) situation was identified on 04/09/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #2) reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 7 residents (Residents #1) reviewed for abuse/neglect. 1. The facility failed to investigate an allegation of sexual abuse of Resident #1. 2. The facility failed to prevent further potential abuse and mistreatment by allowing the alleged perpetrator to remain in the facility and to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified 04/09/25. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding information found in a Social Services Quarterly Assessment that no male CNAs should be in Resident #1's room. This deficient practice could place residents at risk of not receiving the necessary care or services.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) reviewed for accuracy and completeness. The facility failed to document an allegation of sexual abuse was made by Resident #1's. This deficient practice could place residents at risk for abuse, neglect, exploitation.

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 3 of 22 (Residents #17, #34 and #40 ) residents reviewed for telephone use. The facility failed to provide a place for Resident #17, #34, and #40 to make telephone calls without privacy or being overheard. This failure could place all residents that use the telephone at risk of conversations being overheard and privacy rights not being respected .

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 22 residents (Resident #39, Resident # 33) reviewed for care plans. 1. The facility failed to implement the resident 's care and Resident #39 was not seen by the podiatrist, and her toenails were long . 2. The facility failed to develop a care plan that addressed Resident #33's wandering behavior. This failure could place residents increased risk of being unable to maintain their highest practicable physical well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 2 of 22 residents (Resident #39, Resident #62) reviewed for foot care. --The facility failed to provide access to podiatrist for Resident #39. -The facility failed to provide access to podiatrist for Resident #62. This failure could place residents at risk of poor foot hygiene and a decline in residents' physical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #26 and Resident #39) of 2 residents observed for oxygen management. -The facility failed to keep the oxygen concentrator filter clean for Resident #26. --The facility failed to keep the oxygen concentrator filter clean for Resident #39. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; and failed to have an established system in place for accurate reconciliation of controlled substances for 2 of 4 medication carts that had controlled substances and safe and secure storage of medications for of 2 of 3 medication carts reviewed for medication storage. -The facility failed to ensure Licensed staff signed the Controlled Substance Medication Count Record after counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming and off-going nurses. [...]

Inspectors wroteBased on observation, and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing of medications. -The facility failed to ensure opened bottles of Acidophilus Probiotic Dietary Supplement was refrigerated after opening in the 400 Hall medication cart. These failures could place residents at risk for not having their medications available or at decrease efficacy of medications by not following manufacturer's specifications, and cross contamination.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage -The facility failed to store foods in the refrigerator in sealed containers. -The facility failed to keep 1 of 23 spice bottles stored on metal storage rack completely sealed. The facility failed to keep the kitchen ceiling tiles free of dried brown water stains throughout kitchen. -The facility failed to keep ceiling vents free of lint that were directly above food preparation area. - The facility failed to replace missing ceiling tiles in room between the kitchen and Dishwashing Room and in the Dry Storage Room. - The facility failed to maintain Vegetable sink in operational condition. [...]

Inspectors wroteBased observations, interviews, and record review, the facility failed to 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 during laundry room observation, and 1 of 1 treatment cart observed for Infection Control. -The facility failed to ensure staff performed hand hygiene when passing out food trays. -The facility failed to ensure opened packages of gauze non-sterile sponges were stored in sealed plastic bags. -The facility failed to ensure facility staff did not store personal belongings on a clean linen table shelf. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 3 facility floors reviewed for environment and 1 of 1 kitchen reviewed for safe operating equipment. -Resident rooms had loose closet doors in need of repair. This failure could affect residents, placing them at risk of living in an unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility interior and exterior; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 resident (Resident #41) of 22 residents reviewed for call light placement. -The facility failed to ensure that Residents #41 call lights were within their reach on 12/09/2024. This failure places the resident at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents had the right to be treated with respect and dignity and to be cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 (Resident #8) of 11 residents reviewed for being treated with dignity and respect. The facility failed to ensure that an unidentified nurse staff did not enter Resident #8's room at an unidentified time and date without permission after knocking, leaving him without time to put on clothing. This failure put residents at risk of embarrassment, decreased self-esteem, and loss of a sense of independence and control.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents had the right to receive unopened mail and other letters, packages and other materials delivered to the facility for the resident for one (Resident #8) of 11 residents reviewed for receiving unopened mail and other materials delivered to the facility for the resident. The facility failed to ensure that Resident #8 received an unopened personal correspondence. This failure places residents at risk of violations of their right to privacy due to their letters and packages being opened before they are delivered to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse when an altercation occurred on 2/26/24 between two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. 1. The facility failed to investigate an altercation on 2/26/2024 at 9:29 AM between Resident #1 and #2. 2. The facility failed to protect Resident #1 from Resident #2 resulting in a resident-to-resident physical altercation on 02/26/2024 at 1:00 PM. This failure puts residents at risk of physical altercations that could result in injury.

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation of residents for two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. 1. The facility failed to investigate altercation on 2/26/2024 at 9:29 AM between Resident #1 and #2. 2. The facility failed to protect Resident #1 from Resident #2 resulting in a resident-to-resident physical altercation on 02/26/2024 at 1:00 PM. This failure puts residents at risk of physical altercations that could result in injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for two residents (Resident #1 and Resident #2) of 11 reviewed for implementation of policies that prevent abuse. LVN C failed to report an alterction between Resident #1 and #2 that took place the morning of 02/23/2024 to the Administrator. This failure puts residents at risk of physical altercations that could result in injury.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one resident (Resident #1) of 3 reviewed for appropriate treatment and services to attain or maintain their highest practicable well-being. 1. The facility failed to track resident's ongoing wandering behaviors which placed him at risk of not having these behaviors identified and addressed. 2. The facility failed to identify and establish a care plan to address Resident #1's wandering behavior which placed him at risk of verbal and physical abuse from other residents. This failure puts residents with dementia at increased risk of not having their dementia-related needs met.

Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) residents reviewed for change in condition. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for 4 (Resident #22, Resident #30, Resident #11 and Resident #237) of 23 residents reviewed for PASARR coordination. -The facility failed to ensure that Resident #22 ' s PASARR status was reviewed when he was given a new psychiatric diagnosis and prescribed antipsychotic medication -The facility failed to ensure that Resident #30 ' s PASARR status was reviewed when he received a new diagnosis and began receiving psychological services -The facility failed to submit a request for specialized services for Resident #11 in order for him to continue his therapy. -The facility failed to submit a request for initial specialized services for Resident #237. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 27 residents (Resident #13 and Resident #237) reviewed for care plans in that: - The facility failed to include Resident #13 ' s smoking on his care plan. - The facility failed to include in Resident #237 ' s comprehensive care plan that he was PASSAR positive (had mental illness diagnosis and/or intellectual/developmental disability qualifying him for specialized PASSAR Services). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #62) of 4 reviewed for medication orders. The facility failed to re-order pain medication for Resident # 62 after the blister pack had been completed. The facility failed to remove insulin from medication on the second floor for a resident that was moved to the third floor on 10/12/23. The facility failed to remove medications from medication carts when residents were discharged to the hospital. This deficient practice could result in a decline in health if medication was not ordered for residents when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked storage area and to limit access to authorized personnel for 3 of 3 rooms reviewed for medication storage. -The facility failed to ensure all drugs and biologicals were stored in locked storage area and limited access to authorized personnel. -The facility failed to permanently attach metal box containing controlled substances to the refrigerator rack for 2 of 3 medication refrigerators. The facility's failure could place residents at risk for not receiving prescribed medications as ordered and risk for drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep floor in the dry storage room free of black grease built up. -The facility failed to keep wall in the dry storage room free of Scraped paint. -The facility failed to keep bottles of vinegar stored on metal storage racks in the dry storage room free of white powder residual on caps. -The facility failed to keep floor in the dry storage room clean, and free of food and paper particles. -The facility failed to keep refrigerator storage racks free of rust. -The facility failed to store foods in refrigerator in sealed containers; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 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 disease and infection in 1 of 3 (2nd floor) dining rooms and for 2 of 27 residents (Resident #16 and Resident #57) reviewed for infection control. -The facility failed to ensure staff followed infection control practices when passing out meal trays during dining service. -The facility failed to ensure that Resident #57 ' s catheter tubing did not drag on the floor. -The facility failed to ensure LVN I washed her hands and put on gloves prior to checking for G-Tube Placement. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on Observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment. The oven thermostats did not properly set the temperature in the four ovens. Vegetable sink has not been operable in over 3 months. These failures could place residents at risk of foodborne illnesses and injury.

Inspectors wroteBased on observation, interview, and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 8 (Resident #10) residents reviewed for resident rights in that: The facility failed to respect Resident #10 ' s Next of Kin ' s decisions regarding refusing DNR and attempted to seek legal guardianship to obtain DNR consents. This failure could place residents at risk of receiving services without their or their representative ' s consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident ' s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 (Resident # 44) reviewed for resident rights. The facility failed to ensure an investigation was initiated promptly for Resident #44 ' s grievance of missing money and debit card. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 8 (Resident # 44) reviewed for misappropriation of property. The facility failed to report an allegation of misappropriation of property (money, old coin and debit card) to the State Survey Agency within 24 hours of being made by Resident #44. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident ' s status for 2 (Residents #7 and #22) of 23 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #7 ' s MDS accurately reflected her refusal of care. - The facility failed to ensure that Resident #22 ' s MDS accurately reflected use of restraints. These failures could put residents at risk of not having their need for help with removal of facial hair or the use of bedrails assessed accurately .

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (Resident #7) of 23 residents reviewed for quality of life. The facility failed to ensure that Resident #7 did not have facial hair on her chin and upper lip. This failure put residents at risk of embarrassment and a negative self-image.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are continent of bladder receives services and assistance to maintain continence for one (Residents # 19) of 23 residents reviewed for bladder incontinence. The facility failed to ensure that Resident #19 ' s oxygen tubing was long enough for her to walk to the bathroom, resulting in increased instances of urinary incontinence. This failure put residents at increased risk of urinary tract infections, urinary incontinence, embarrassment, and a negative self-image.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice for 3 (Residents #4, #19, and #22) of 9 Residents reviewed for oxygen usage. The facility failed to ensure that Residents #4, #19, and #22 ' s oxygen concentrators had clean filters. This failure could put residents at increased risk of breathing in dust and allergens and of decreased effectiveness of oxygen concentrators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free from any physical restraints that are not required to treat the resident's medical symptoms for 1 (Resident #22) of 23 residents reviewed for restraints. The facility failed to ensure Resident #22 had an evaluation, consent, and correct orders for the bed rails that were on his bed. This failure put residents at risk of unnecessary restraints on their movement.