Grand Manor Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to honor the rights of residents to choose their own physician when the facility discontinued services with Physician A, who provided care to 30 residents. Three of the residents were sampled and one expressed the desire to continue care with Physician A (Resident #8). The sample was 10. The census was 101. The Administrator was notified on 05/28/26 at 2:20 P.M., of the past non-compliance, which occurred on 03/25/26. The facility provided training and in-servicing for all staff regarding the facility's resident rights policies and Physician A has been reinstated to the facility as of 05/16/26. The deficiency was corrected on 05/16/26. Review of the facility's Resident Rights policy, dated 09/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to one resident (Resident #2), when the facility did not initiate a Code Purple (missing resident), per facility policy, when Resident #2 failed to return to the facility for dinner and evening medications and did not return all night. The resident signed out at 8:30 A.M. on the morning of [DATE] with an expected return time of 5:25. The resident did not return to the facility and per the facility policy, staff should have initiated a Code Purple when the resident did not return at the expected time and staff couldn't contact the resident. When the resident did not return for dinner or medications that evening, staff did not initiate a Code Purple. The resident did not return on the night shift and staff did not initiate a Code Purple or a search. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow their abuse policy when staff failed to report a resident to resident altercation to Administration, resulting in a failure to conduct a thorough investigation into the altercation, in which one resident sustained an injury underneath his/her eye (Residents #1 and #2). The sample was four. The census was 111. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definitions:-Physical Abuse: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals. The facility had eight residents on pureed meals. The sample was six. The census was 112. Review of the facility's Dietary Food Preparation Policy, dated 7/5/23, showed the following:-Standardized Recipes: Standardized recipes will be used for all product prepared;-Procedure: -Use standardized recipes provided with menu cycle; -The Dietary Manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added to the recipe file, they must be written, standardized and approved by the Registered Dietitian; -Pureed recipes are found in the recipe binder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident charged and hit him/her in the arm (Residents #1 and #2). The sample was six. The census was 112. The Administrator was notified on 10/3/25 at 10:43 A.M., of the past non-compliance, which occurred on 9/24/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on monitoring behavioral residents. The deficiency was corrected on 9/25/25. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to ensure one resident received recommended restorative therapy exercises after being discharged from skilled nursing therapy (Resident #3). The sample was six. The census was 112. Review of the facility's Restorative Nursing Program, dated 4/30/24, showed the following:-Purpose: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level;-Definition: Restorative Nursing Program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was provided with adequate supervision and staff oversight. On 9/23/25, a resident was left unsupervised in the back unsecured area during a smoking break and the resident wandered away from the facility (Resident #1). The sample was six. The census was 112. The Administrator was notified on 10/3/25 at 10:43 A.M., of the past non-compliance, which occurred on 9/23/25. The facility provided in-servicing for all staff regarding the facility's elopement and wandering policy with emphasis on monitoring residents during smoke times. The deficiency was corrected on 9/25/25. Review of the facility's Elopements and Wandering Residents policy, last reviewed on 6/12/24, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when staff failed to administer and document medications as order by the physician for three residents. (Resident #10, Resident #12 and Resident #15). The sample was 13. The census was 111. Review of the facility's Transcription of Orders/Following Physician's Order Policy, dated 5/18/24, showed the following: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders. -Procedure: A. Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section; B. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure resident rooms were free from mice (Resident #17, Resident #15 and Resident #16). The sample was 13. The census was 111. Review of the facility's Pest Control policy, last reviewed 5/14/24, showed: -Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats); -Policy: Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of transfer and discharge and failed to provide a written notice of transfer/discharge for one resident (Resident #4) when the resident was transferred to another facility. The sample was four. The census was 114. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 5/14/24, showed the following: -Purpose: -Establish policy and procedure regarding the transfer/discharge of residents; -Definitions: -Facility-initiated transfer or discharge: A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of one resident with a diagnoses of diabetes and substance abuse, who left the building unnoticed for leave of absence (LOA). Staff last saw the resident on 3/31/25 at approximately 1:00 P.M. to 2:00 P.M. It was approximately seven hours until staff realized the resident was gone. Staff did not administer ordered afternoon and evening insulin (a hormone that helps your body use blood sugar for energy) injections (Resident #2). The sample was four. The census was 114. The Administrator was notified on 4/17/25 at 9:00 A.M., of the past non-compliance, which occurred on 3/31/25. The facility provided in-servicing for all staff regarding the facility's Resident's Outside Pass Policy and Elopement and Wandering Policy. The facility also updated Resident #2's care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure residents' individual trust fund accounts were not allowed to go into a negative balance. The facility managed funds for 61 residents. A sample of eight residents were chosen and the deficient practice affected six residents (Residents #8, #30, #37, #64, #66 and #78). The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Negative Balances in Resident Accounts; -On the last day of every month the Resident Trust Clerk must confirm that all transactions for the month have been posted and then should run a Current Account Balance report from the banking system on the last day of the month to verify resident balances. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for two months. The census was 104. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Resident Trust Bank Reconciliation: A reconciliation of the bank statement module must be completed monthly. This will be completed by the facility's staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk. Review of the facility's resident trust accounts, showed no documentation of bank statement reconciliation's from January 2024 and April 2024. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility to provide one of one residents (Residents (R) 81) a Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when he completed his Medicare A therapy services. This failure to provide the CMS for SNF ABN prevented the resident from knowing he had days remaining under Medicare A.

Inspectors wroteBased on interview, record review and policy review, the facility failed to notify the Ombudsman of a transfer for one of three residents (Resident (R) 84) out of a total sample of 26 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to issue one of three residents (Resident (R) 84) or their responsible party out of a total sample of 26 residents a bed hold notice when R84 was sent to the emergency room. This failure could leave a resident to believe they would not be allowed to return when hospital ready from

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of six residents (Resident (R) 30 and R1) reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on medical record reviews, staff interviews and facility policy review, the facility failed to maintain complete and accessible medical records for three of 31 sampled residents ((R)6, R9 and R47) whose electronic medical records (EMRs) were reviewed for the recertification and complaint survey. Specifically, the EMRs for R6, R9 and R47 contained no current care plans following the facilities migration from one electronic medical record system to another. This meant the Certified Nurse Aids could not access a current Plan of Care to provide appropriate care and services. As well as failed to ensure the one out of eight residents (R95) medication prescription was accurately documented in the medical record.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure nursing staff properly stored a residents BiPAP mask when not in use for one of one sampled resident (Resident (R) 32).

Inspectors wroteBased on interview and record review, the facility failed to provide a medication to one of eight sampled residents (Resident #1) whose diagnosis included human immunodeficiency virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and progressive multifocal leukoencephalopathy (PML, a disease of the white matter of the brain, caused by a virus infection (polyomavirus JC) that targets cells that make the myelin sheath-the material that insulates nerve cells) when the resident was admitted to the facility on [DATE] and was not given their Biktarvy (contains three antiviral medications). The resident was discharged to the hospital on [DATE] when he/she was unable to respond. The resident expired at the hospital. The census was 87. The administrator was notified on [DATE] at 5:56 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's (Resident #6) right to be free from abuse was not violated, when the resident was abused by another resident (Resident #7), of eight sampled residents. Upon discovery of the abuse, a mental health aide walked away, while the victim was still on the floor with the perpetrator at his/her side, to call for a nurse. During this brief period of time, Resident #7 threw an unlit cigarette at Resident #6. The census was 87. Review of the facility's Abuse and Neglect policy, dated 7/2022, showed: -Abuse definition: The willful infliction of injury, unreasonable confinement, intimidation, exploitation, mistreatment, or punishment with resulting physical harm, pain, or mental anguish. Included is verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled with technology. [...]

Inspectors wroteBased on observation and interview, the facility failed to store food appropriately by failing to label, date, cover and discard outdated items. The facility also failed to ensure kitchen equipment was clean and in working condition. In addition, staff failed to ensure a leaking pipe under the kitchen sink was repaired in a timely manner. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The census was 62. 1. Observations on 7/10/23 at 9:15 A.M., 7/11/23 at 7:30 A.M., 7/12/23 at 9:30 A.M., showed the following: -Storage room: -A bottle of Apple Ready Care drink mix with an expiration date of 4/22/23; -Six (6) packs of V8 original Vegetable Juice with expiration dates of 11/9/19. Five packs contained all 6 cans inside the packages unopened and the one package was opened with three cans remaining; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements to residents and/or their representatives (Residents #24, #44, #37 and #55). This affected 60 residents whose funds were handled by the facility. The census was 62. 1. Review of the facility's Trial Balance report, showed the facility holds funds for 60 residents, including Residents #24, #44, #37 and #55. 2. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/23, showed: -Cognitively intact; -Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 7/11/23 at 10:44 A.M., Resident #24 said the facility holds funds for him/her. Today, he/she received a quarterly statement showing transactions for his/her account. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, homelike environment for the residents. This includes the failure to keep resident floors clean and kempt, keeping resident hall bathrooms in clean and working order, and the failure to provide homelike common areas designated on resident halls. The sample was 16. The census was 62. 1. Observation on 7/10/23 at 9:16 A.M., showed white liquid and leftover food from the breakfast meal on the floor of room [ROOM NUMBER]. At 1:21 P.M., the white liquid remained on the floor. Observation of the 300 hall on 7/10/23 at 9:21 A.M. and on 7/11/23 at 7:45 A.M., showed the floor was sticky and appeared to have a gummy film across the floor tiles. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit residents' Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for 3 of 3 months reviewed. The census was 62. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; -The manual includes a submission timeframe table for MDS record types. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of four residents (Resident #11, #58, #7 and #23). The sample was 16. The census was 62. Review of the facility's Care Plan Policy, undated, showed: Policy: Care plan coordination to provide the optimum level of functioning of each resident; To assure that all residents have an accurate and updated plan of care that reflect that individual needs and correlates with the submitted Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; Procedure: Each resident's chart will be reviewed quarterly and/or with a change of condition, by a committee consisting of Care Plan Coordinator, Dietary, Wound Care Nurse, Therapy, Nursing, Activities and Social Services; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the Medical Director failed to attend the facility's QAPI meetings. The census was 62. Review of the facility's monthly QAPI sign-in sheets for the last 12 months, reviewed 7/11/23, showed the Medical Director or his designee not in attendance. During an interview on 7/13/23 at 1:56 P.M., the Administrator said the facility holds QAPI meetings on a monthly basis. The facility identifies which issues to work on during QAPI meetings. QAPI meetings should be attended by all department heads and the facility's Medical Director. The Medical Director has attended a QAPI meeting in the past 12 months, but the Administrator could not recall the date of the last meeting the Medical Director attended. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control (IPC) as the infection preventionist (IP) for the facility's infection prevention control program. The census was 62. Review of the Centers for Disease Control (CDC) and Prevention's interim infection prevention and control recommendations to prevent COVID-19 spread in nursing homes, updated 2/2/22, showed: -Development of an IPC program; -Assign one or more individuals with training in IPC to provide on-site management of the IPC program; -This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable accommodations of needs were provided for one resident (Resident #58) with diagnoses of aphasia (language impairment) and hemiplegia (paralysis on one side of the body). The sample was 16. The census was 62. Review of Resident #58's medical record, showed: -The resident listed as his/her responsible party; -Diagnoses included stroke, aphasia, hemiplegia affecting left non-dominant side, and depression, recurrent and severe. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/29/23, showed: -Resident rarely/never understood; -Short term memory ok; -Made decisions regarding tasks of daily life independent - decisions consistent/reasonable; [...]

Inspectors wroteBased on interview and record review, the facility failed to verify the accurate code status due to conflicting information in the medical record for one of 16 sampled residents (Resident #7). The census was 62. Review of the facility's Advanced Directives policy, showed: Regarding: Ensure the residents' wishes are communicated; -Procedure: -Upon admission, the resident will give the facility any legal documents such as durable power of attorney, living will and trust, legal guardianship documents, and/or any surrogate delegation of rights with those rights clearly written; -Should a resident change their code status abruptly, you are to go by their wishes and document the change of the code status; [...]

Inspectors wroteBased on interview and record review, the facility failed to assure each resident received an accurate assessment, reflective of the resident's status for 3 of 16 sampled residents (Residents #7, #11 and #23). The census was 62. 1. Review of Resident #7's progress notes, dated 10/27/2022 at 11:09 A.M., showed the resident was put onto hospice on 10/26/22. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/23 showed: -admission date of 2/27/18; -Moderate cognitive impairment; -Required extensive assistance from staff for activities of daily living (ADLs) such as personal hygiene, eating, dressing, bathing, mobility and dressing. -Diagnoses of anemia (low red blood cell count), wound infection and hip fracture; -Special services received while a resident: Hospice Care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #58) received a splint as ordered for contracture management. The facility identified seven residents with splints. The census was 62. Review of Resident #58's medical record, showed: -Diagnoses included stroke, aphasia, (language impairment) and hemiplegia (paralysis on one side of the body; -A physician order, dated 10/5/22, to apply left resting hand splints as tolerated. Review of the resident's occupational therapy Discharge summary, dated [DATE], showed: -Diagnoses included contracture, left hand; -Goal, discontinued 2/1/23: Patient will achieve normal anatomical alignment of left hand and left fingers for 8 hours in order to achieve proper alignment, in order to decrease discomfort, in order to facilitate joint mobility, and in order to maintain joint integrity;. -Comments: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe transfer for one resident (Resident #11) and implement fall prevention interventions for two residents (Residents #58 and #49). In addition, the facility failed to secure soiled utility and janitors' closets on the 200 and 300 halls that contained trash, soiled linen, cleaning equipment and chemicals. The sample was 16. The census was 62. Review of the facility's Transfer policy, undated, showed: Policy: All residents shall be assessed upon admission to determine their method of transfer; Input regarding transfers shall be made by nursing services, restorative and/or the therapy department to ascertain the safest method of transfer for the resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate respiratory services were provided for one resident (Resident #18) when staff failed to ensure the oxygen related orders matched the electronic physician orders sheet (ePOS), physician order sheets (POS) in the resident's medical record and the Treatment Administration Record (TAR). Staff also failed to obtain physician orders related to changing oxygen tubing and the oxygen humidifier bottle. The sample was 16. The census was 62. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/23, showed: -Cognitively intact; -Diagnosis of chronic obstructive pulmonary disease (COPD, lung disease that prevent the lungs from working properly); -Oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rail (side rail) assessments were completed accurately and routinely in accordance with the facility's policy for three residents (Residents #58, #34 and #14) and to obtain physician orders for the use of the side rails. The facility identified six residents with side rails. The census was 62. Review of the facility's Side Rail and Bed Assessment policy, undated, showed: -Procedure: The resident's sleeping environment shall be assessed by the interdisciplinary team (IDT), considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a yearly review of code status, full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed), and failed to verify code status by having conflicting information in the medical record for six of 20 sampled residents (Residents #17, #57, #83, #67, #9 and #93). The census was 96. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/3/19, showed the following: -readmitted to the facility on [DATE]; -Diagnoses included major depression, obesity and heart disease. Review of the medical record on 12/4/19, showed a signed facility code status form in the front of the chart read full code, dated 11/7/18. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to clarify the diagnosis for administration of antibiotic medication, failed to obtain a neurology consultation in a timely manner and left medication at a resident's bedside without an order. The facility also failed to obtain orders for the use of an indwelling catheter, the use of siderails, the use of a Bi-level Positive Airway Pressure machine and failed to transcribe the size for an indwelling urinary catheter to the physician's orders sheet, for five of 20 sampled residents (Residents #93, #29, #50, #9 and #13. The census was 96. 1. Review of Resident #93's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/19, showed the following: -Cognitively intact; -Required limited assistance with activities of daily living; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper perineal care (peri-care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for two of four observations (Residents #74 and #82) and failed to provide personal grooming to one resident by not shaving him/her (Resident #84). The sample size was 20. The census was 96. 1. Review of Resident #74's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/11/19, showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Dependent on staff for personal hygiene and toileting; -Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) and frequently incontinent of bladder; -Diagnosis of Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician's orders for dialysis (process for removal of waste and excess water from the blood due to kidney failure) care and monitoring of dialysis access sites, administer medications as ordered on dialysis days and ensure a resident's dialysis center information on the care plan and physician's order sheet (POS) were congruent, for four residents (Residents #88, #5, #68 and #32) who received dialysis. The facility identified seven residents on dialysis, four were chosen for the sample of 20 and problems were found with all four of them. The census was 96. 1. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/13/19, showed the following: -Cognitively intact; -Independent with activities of daily living (ADLs); [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were dated when placed in the walk-in refrigerator and failed to cover the stand up mixer and slicer when not in use. The census was 96. 1. Observation of the kitchen, showed the following: -On 12/3/19 at 10:10 A.M. and 4:45 P.M. and 12/4/19 at 11:23 A.M., two thawed and undated five pound rolls of ground beef, two undated, large, thawing turkey roasts and one undated, large, thawing smoked turkey roast, sat on trays on the bottom shelf of the walk-in refrigerator; -On 12/5/19 at 9:39 A.M. and 12/6/19 at 6:45 A.M., one five pound roll of thawed ground beef and one smoked turkey, dated 12/4/19, sat on trays on the bottom shelf of the walk-in refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilized acceptable infection control measures during perineal care (peri-care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for one of four residents observed (Resident #74), by allowing urinary catheter (small rubber tube inserted in to the bladder to drain urine) tubing and the privacy bag (rubber bag that holds the catheter bag to provide dignity) to lie on the floor, by feeding two residents at the same time even though one of those residents had an infectious disease (Resident #9), and by not cleansing hands between residents when passing medications. The sample size was 20. The census was 96. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' privacy and confidentiality of medical information by leaving identifying information, a physician's order sheet and a laboratory result, in the survey binder, which is accessible to all residents and the public. The census was 96. 1. Observation of the front desk on all days of the survey, from 12/3/19 through 12/6/19, showed a sign which indicated the survey results binder was located at the front desk. Further observation of the front desk, showed a binder labeled Survey Results. 2. Review of the survey results binder, showed the following: -A March 2019 physician order sheet for one resident; -A urinalysis (urine test) result, dated 2/22/18, for one resident; -An audit sheet, dated 11/4/19, identified a resident by name and his/her location; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to contact the physician and dietician when a resident experienced a significant weight loss for one of 20 sampled residents (Resident #50). The census was 96. Review of Resident #50's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal care; -Diagnoses included altered mental status and osteoporosis (brittle bones). Review of the facility face sheet, showed an additional diagnosis of dementia. Review of the care plan, dated 11/27/19 and in use during the survey, showed the following: -Problem: Nutritional status; -Goal: Regular diet. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice for transfer/discharge notice to the resident and/or resident's representative, when the resident was transferred to the hospital for various medical reasons for six sampled residents (Residents #9, #14, #83, #5, #93 and #67). The sample was 20. The census was 96. 1. Review of Resident #9's Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following: -Original admission date of 1/18/19; -discharged to the hospital on [DATE]; -admitted to the facility on [DATE]; -discharged to the hospital on [DATE]. Review of the resident's progress notes, showed the resident readmitted to the facility on [DATE]. [...]