Greendale Park Nursing and Rehab

Inspectors wroteBased on interviews and observation, the facility failed to ensure a qualified individual was designated to serve as the director of food and nutrition services with the potential to affect 65 of 76 residents consuming food in the dietary department. This failure had the potential to contribute to improper kitchen sanitation practices.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure facial hair was properly restrained while serving food with the potential to affect 65 out of 76 residents consuming food in the dietary department. This had the potential for physical contamination of the food being served.

Inspectors wroteBased on staff interviews, document review, and policy review, the facility failed to maintain a comprehensive water management program, including hot and cold-water temperature monitoring, a water system risk assessment, and a water distribution flow diagram. Additionally, the facility failed to provide an infection surveillance system to identify, track, trend, analyze, and respond to infectious illnesses within the facility. These deficient practices had the potential to contribute to the transmission of infectious diseases and adversely affect all 76 residents residing in the facility.

Inspectors wroteBased on interviews, and record review, the facility failed to provide a contract that they provided Medicaid services as required for one of one resident (Resident (R) 9) reviewed for admission contract of 18 sample residents. The facility's contract, signed by residents and/or their representatives, stated The Facility does NOT participate in the Medicaid program. This failure had the potential to affect payor source.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to notify the physician that medication (Arikayce - an antimicrobial) was not administered as ordered for one out of three residents (Resident (R) 1) reviewed for physician notification of 18 sample residents. This failure had the potential to delay physician evaluation and intervention and placed R1 at risk for worsening or progression of the underlying infection. (Cross Reference F755)

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were available and administered as ordered for two of three residents (Residents (R) 2 and R1) reviewed for medication availability from a total sample of 18 residents. This failure had the potential to result in adverse health outcomes which could lead to ineffective treatment.

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error for 1 (R1) of 18 sampled residents reviewed for medications. R1 was prescribed the medication Arikayce, an antimicrobial medication related to a diagnosis of mycobacterium avium complex (a chronic, non-contagious infection caused by bacteria naturally found in soil and water - causing a pulmonary infection). R1 did not receive the medication as ordered on 6 different dates.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 (R41, R2, R60, and R10) of 6 residents reviewed for pressure injuries. R41 developed an avoidable left heel deep tissue injury that was not comprehensively assessed or measured since September 2025. [...]

Inspectors wroteBased on interview and record review the facility did not ensure the Payroll Based Journal (PBJ) was accurately submitted to the Centers for Medicare and Medicaid (CMS). The facility's fourth quarter (July 1st-September 30th) PBJ data triggered for excessively low weekend staffing. This deficient practice has the possibility of affecting all 74 residents residing at the facility.

Inspectors wroteThe facility did not 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 deficient practice had the potential to affect all residents residing in the facility. The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems. R11 was documented as having loose stools and had a physician's order to check stool for Clostridium Difficile (C-diff). Transmission Based Precautions (TBP) was not implemented. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement policies and procedures to ensure that when Covid (Coronavirus)-19 vaccine is available to the facility, each resident is offered the vaccine unless the immunization is medically contraindicated or the resident has already been immunized for 4 of 5 (R2, R9, R35 and R54) residents reviewed for immunizations.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure 1 (R2) of 1 residents reviewed for self-administration of medications had a physician order to self-administer and for the medication.*R2 was observed with Melatonin 5mg at the bedside and did not have a physician order for Melatonin 5mg or an order to self-administer medication.

Inspectors wroteBased on observation and interview the facility did not ensure a clean environment for 1 (R67) of 1 Resident.*Food and debris were observed alongside and under the wheelchair cushion on 1/20/26, 1/21/26, & 1/22/26.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R25) of 5 residents were free from chemical restraints. R25 was prescribed Seroquel 25 mg (milligrams) twice daily, an antipsychotic medication, on 11/5/25 after R25's family voiced concerns about R25 yelling and swearing. The facility did not attempt any nonpharmacological interventions and did not rule out any underlying medical conditions.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R2, R35, and R34) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the facility bed hold notice did not contain the required information for appeal rights. *R2 was discharged to the hospital on 8/6/25, 10/21/25, and 12/7/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. The facility bed hold notice does not contain the email address for all 3 agencies listed and the ombudsman information does not include an address. The facility was not able to provide documentation that bed hold/transfer notice was provided to R2 and/or representative for R2's discharge on [DATE]. *R35 was discharged to the hospital on 8/19/25 and 12/2/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R2) of 4 Residents reviewed with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility.*R2 was observed not wearing a right hand splint to prevent further decrease in range of motion/mobility.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R25 & R34) of 6 residents received adequate supervision and assistance devices to prevent accidents.*R25 was observed without a fall mat and body pillow while in bed according to R25's plan of care.*R34's falls on 8/12/25, 10/24/25, 11/23/25, 12/13/25, & 1/3/26 were not thoroughly investigated and the root cause was not consistently determined to help prevent further falls.

Inspectors wroteBased on interview and record review, the facility did not ensure ongoing communication with the dialysis center and monitoring for complications before and after dialysis treatment for 2 (R34 & R11) of 2 residents reviewed for hemodialysis.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practical mental and psychosocial well being in accordance with a comprehensive assessment and plan of care for 1 (R69) of 1 resident received for mood concerns. R69 has a long history of suicidal ideations. On 9/3/25 and 1/19/26, R69 voiced suicidal ideations while in the dining room. R69 was not placed on a one to one according to R69's plan of care, R69's physician and/or psychological services were not notified, and social service staff was unaware of these suicidal ideations.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period and each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 2 of 5 (R9 and R35) residents reviewed for immunizations.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to report an incident of resident-to-resident abuse to the state survey agency within the required timeframe for 1 of 3 allegations of abuse reviewed. Specifically, the facility failed to report an incident of physical abuse between R1 and R2 within two hours of the witnessed incident.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to complete a thorough investigation for 1 of 3 allegations of abuse reviewed. Specifically, the facility failed to obtain interviews or retain documentation of interviews from witnesses to an incident of resident-to-resident abuse involving R1 and R2.

Inspectors wroteBased on record review and interview, the facility did not complete and transmit a discharge assessment as required for 1 (R1) of 2 residents reviewed for Minimum Data Set (MDS) assessments and transmission. R1 did not have a discharge assessment completed or transmitted after discharging from the facility on 9/1/2025.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure a resident with a gastrostomy tube received the appropriate care and services for 1 (R3) of 3 residents reviewed with gastrostomy tubes. R3 had an enteral feed order for: Jevity 1.5, 65mL/hour X 20 hours. Off at 10:00AM and restart at 1400 (2:00PM). Surveyor had observations of R3's tube feed running between 10:00AM -2:00PM and was not turned off. R3 did not have monitoring, treatment, or care interventions in place for R3's G-tube site.

Inspectors wroteBased on observation, interview and record, the facility did not ensure 1 (R7) of 1 residents were assessed by the interdisciplinary team to determine it was clinically appropriate to self-administer medication. On 8/12/25, LPN-C was observed leaving R7's medication on the over bed table without observing R7 take her medication. R7 did not have an assessment to self-administer medications.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 3 resident's reviewed for hospitalization were allowed to the facility after they were hospitalized .*R1 was hospitalized on [DATE] and was denied readmission to facility. The facility did not effectively implement a discharge plan for R1 to include the timely and appropriate 30-day discharge notice providing the basis for R1's discharge nor did the facility provide coordination to find a safe transfer.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R1 and R2) of 3 resident's reviewed for hospitalization received the proper notice of transfer and bed-hold to include; date and reason for transfer, location of transfer, duration of bed hold, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman. * R1 was transferred to the hospital on 5/3/25, 6/6/25 and 6/9/25 and transfer and bed-hold notice was not given to R1 and/or R1's representative. *R2 was transferred to the hospital on 7/20/25 and transfer and bed-hold notice was not given to R2 and/or R2’s representative.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop a comprehensive person-centered care plan to include measurable objectives and timeframes to meet the nursing needs for 2 (R4, R6) of 7 residents reviewed. *R4 did not have a comprehensive person-centered care plan developed to address R4’s urinary incontinence *R6 did not have a comprehensive person-centered care plan developed to include timeframes for how staff will meet R6’s urinary incontinence needs

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 34 observed opportunities which resulted in a medication error rate of 5.88%. Two medication errors were identified for R7. R7's Humalog insulin pen was not primed prior to dialing the amount of insulin R7's physician ordered. R7's Glargine insulin pen was not primed prior to dialing the amount of insulin R7's physician ordered, and the insulin pen was not dated when opened.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R3 & R4) of 5 residents were free of significant medication errors.*R3 was admitted to the facility on [DATE] & discharged on 7/15/25. The after visit summary & Discharge summary dated [DATE] documents bacitracin-polymyxin B ophthalmic ointment with instructions to place into R3's right eye every 12 hours. The facility did not process this physician order and R3 did not receive bacitracin-polymyxin B ophthalmic ointment. R3 missed 10 doses of this medication.*On 12/10/24, R4's Humulin R 8 units before meals and Potassium & sodium phosphates 280-150-250 mg (milligrams) two packets twice daily documented in the hospital after visit summary & discharge summary was not processed by facility staff. R4 missed 8 doses of Humulin R and 6 doses of Potassium & sodium phosphates.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services to promote healing and prevent new injuries from developing for 1 of 2 (R3) residents reviewed for pressure injuries. R3's pressure injuries were not comprehensively assessed and treatment was not implemented timely. This deficient practice resulted in R3's development of a stage 3 pressure injury.

Inspectors wroteBased in interview and record review the Facility did not ensure 1 (R2) of 3 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choice. R2 was admitted on [DATE] with a history of diverticulosis and constipation. R2 did not have a care plan initiated for bowel monitoring or interventions. R2 did not have documentation of bowel elimination until 3/10/2025 and R2 did not have a bowel movement documented until 3/12/2025 which was diarrhea and R2 had complaints of nausea. R2 was not assessed and there was no documentation regarding R2 was having nausea and diarrhea. On 3/13/2025 R2 went to the Hospital for further evaluation for complaints of nausea and abdominal cramping and a CT scan showed R2 had moderate colonic stool burden with mildly distended rectal vault. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who are incontinent of bowel and bladder receive appropriate treatment and services to prevent skin-related complications for 1 of 2 (R3) residents reviewed for bowel and bladder. R3 admitted to the facility with pressure injuries and Moisture Associated Skin Damage (MASD). A care plan was not implemented to manage R3's incontinence.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal pressure injuries. R8 developed a facility acquired, unstageable pressure injury to their right great toe despite being at risk for the development of pressure injuries. R8's skin was not assessed upon admission and an individualized care plan was not developed based upon R8's risks and care needs. Assessments by the contracted wound care provider incorrectly identified the location of the wounds. Facility wound assessments were not comprehensive.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining falls. On 12/22/24, at 6:50 am, R8 sustained an unwitnessed fall and was found by facility staff lying on the floor with his left arm stuck in his bed rail. The facility did not complete a bed rail assessment prior to R8 having bed rails (cross-reference F700). The facility did not complete a thorough fall investigation, determine a root cause for his fall, complete reassessments to determine if bed rails continue to be appropriate for R8, and create a care plan with interventions in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility did not assess the risk of entrapment and review the risks and benefits for 1 (R8) of 1 residents observed having bed rails. R8, who is dependent on staff for mobility, was observed to have a half side rail/grab bars on both sides of the bed and did not have a completed side rail risk assessment.

Inspectors wroteBased on record review and staff interview, the facility did not ensure an RN (Registered Nurse) worked at the facility for at least eight consecutive hours a day, seven days a week, on 17 of 152 days reviewed. The facility also did not ensure a charge nurse was designated for shifts. * The facility did not have an RN (Registered Nurse) working in the facility for at least eight consecutive hours on 4/14, 4/20, 4/27, 5/12, 5/18, 6/1, 6/9, 6/15, 6/29, 7/4, 7/7, 7/13, 7/14, 7/20, 7/21, 7/28 and 9/2/2024. This deficient practice had the potential to affect all of the residents residing at the facility from April 1st through July 31st, 2024, and September 1st through September 30, 2024. * The facility did not ensure a charge nurse was assigned for each shift. This has the potential to affect all 76 residents residing in the facility at the time of the survey.

Inspectors wroteThe facility did not ensure the facility assessment was updated to include the details regarding the water management committee, the infection preventionist and infectious disease management. This has the potential to affect all 76 residents residing in the facility. *The Facility Assessment lacked infection prevention and water management information.

Inspectors wroteBased on observation, interview and record review, the Facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 76 residents. Additionally, 1 (R450) of 1 residents reviewed for medication administration had their medication handled bare handed by a nurse during preparation. *The Facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Reflect changes in program members, last updated June 2023. -Include the Facility's Infection Preventionist (IP). [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 5 of 5, CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours.

Inspectors wroteBased on interview and record review, the Facility did not ensure the medical record contained signed advanced directive election forms for 1 (R71) of 18 residents reviewed. R71's Cardiopulmonary Resuscitation (CPR) advance directive election form Consent to CPR was not completed until [DATE], the day the Surveyor requested the information from the Facility. R71 had no care plan for advance directives completed.

Inspectors wroteBased on interview and record review the Facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 (R426) of 1 residents reviewed for dialysis. R426 was admitted to the Facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. Assessments were not completed before or after dialysis sessions. No care plan was in place for monitoring and care of R426 related to dialysis and complications. There wasn't communication between the Facility and the dialysis center with each visit.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure 2 residents (R7, R66) of 2 residents were properly assessed or risks explained for the use of bed rails. A routine maintenance and inspection schedule was not enforced by the Facility. *R7's Bed Rail Assessment was not updated since 1/25/2024 and Bed Rails Informed Consent for Use was not updated since 2/1/2024. R7's bed was observed to have grab bars on both sides of bed. *R66 has a right grab bar attached to bed frame but there is no evidence that risks were explained to R66 or their representative. *Routine maintenance and inspection of the grab bars was not documented or completed.

Inspectors wroteBased upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 75 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or invoiced amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body.

Inspectors wroteBased on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse, for 1 CNA (Certified Nursing Assistant)-GG of 1 CNA reviewed who was involved in an allegation of sexual assault against 1 (R10) of 1 residents who alleged sexual assault. The deficient practice has the potential to affect a pattern of the 69 residents residing in the facility as the staff on night shift float to assist on other units. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 (R6) of 3 residents. R6 did not have a CBC (complete blood count) & BMP (basic metabolic panel) during the week of 5/19/24 to 5/25/24 according to physician orders. CNAs (Certified Nursing Assistants) documented 14 episodes of loose, watery, diarrhea stools starting 5/25/24. On 5/28/24, Imodium 2 mg (milligram) was ordered every six hours as needed. Also on 5/28/24, NP (Nurse Practitioner) recommended Metamucil for R6. [...]

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing for 2 of 4 (R4 and R5) residents reviewed for pressure injuries. R4 was dependent for bed mobility and identified to be at high risk for pressure injuries. Care plan interventions to include offloading, turning, and repositioning were not implemented. R4 developed a stage 3 pressure injury to her buttock and the care plan was not revised to include increased offloading, turning, and repositioning. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff received annual QAPI (Quality Assurance and Performance Improvement) training for 4 of 5 Certified Nursing Assistants (CNA) reviewed. This practice had the potential to affect all 69 residents in the facility. The facility did not provide staff with the required annual QAPI training.

Inspectors wroteBased on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R 7) of 1 residents reviewed for self-administration of medication. R7 was admitted to the facility on [DATE]. From 4/18/2024 through 5/3/2024, the facility documented that R7 was self-administering Entresto (a medication given to treat heart failure). R7 did not have a self-administration of medication assessment completed prior to administering Entresto. R7 did not have a physician's order to self-administer medication. R7 did not have a care plan regarding self-administration of medication.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident's right to privacy was maintained when receiving mail for 1 (R7) of 1 residents reviewed. R7's package was opened by facility staff without R7's permission.

Inspectors wroteBased on interview and record review the Facility did not promptly investigate and resolve grievances for 3 (R16, R17, & R18) of 9 resident grievances reviewed.

Inspectors wroteBased on interview and record review the facility did not report 2 (R10 & R3) of 6 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. * An allegation of sexual assault involving R10 was not reported to the Administrator and the State agency immediately but not later than 2 hours after the allegation was made. * An allegation of physical abuse involving R3 was not reported to the State Survey agency within 2 hours of the allegation being made.

Inspectors wroteBased on interview and record review the Facility did not have evidence allegations of abuse, misappropriation of property & mistreatment were thoroughly investigated for 3 (R10, R15, & R11) of 6 Residents reviewed for abuse. * The facility did not thoroughly investigate R10's allegation of sexual assault. * The facility did not thoroughly investigate R15's allegation of missing $416 and CNA-GG not assisting R15 with toileting. * The facility did not thoroughly investigate R11's allegation of neglect.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R7) of 7 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene. R7 had no documented showers provided by facility staff from 4/18/2024 through 5/19/2024.

Inspectors wroteBased on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 1 (R10) of 5 Residents. R10's fall interventions of body pillow to the side closest to the door and call light within reach were not observed when R10 was in bed during multiple observations.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R7) of 1 residents reviewed for respiratory care received such services consistent with professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. R7 did not have MD (Medical Doctor) orders documenting the settings or cleaning of a CPAP (Continuous Positive Airway Pressure) machine per the facility policy. R7 did not have a Care Plan addressing the CPAP machine.

Inspectors wroteBased on interview and record review the Facility did not ensure 2 (R8 and R9) of 4 residents were free from significant medication errors. *R8 had a MD (medical doctor) order to receive Tacrolimus (a medication to prevent rejection of a transplanted organ) 2 times a day. R8 did not receive 6 administrations during the first 5 days of R8's admission to the facility. *R9 had a MD order to receive Ivabradine (a medication to treat heart failure) 2 times a day. R9 did not receive 9 administrations of Ivabradine from 1/4/2024 through 1/9/2024.

Inspectors wroteBased on interview and record review, the facility did not maintain records that were accurately documented for 1 (R10) of 15 residents reviewed. R10's diagnoses includes diabetes mellitus and right & left above knee amputation. There is a doctors order dated 4/4/24 for diabetic foot checks and starting on 4/4/24 licensed nursing staff were checking and initialing on the April, May, & June 2024 MAR (medication administration record) diabetic foot checks were being done when R10 does not have feet.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure 1 (R1) of 4 residents reviewed for quality of care received with treatments and care provided to facility residents. R1 was having pain across his chest and his rib area. R1 was given Tylenol by Med Tech (MT)-D. Med Tech-D did not alert a Registered Nurse to assess the resident's cardiac status, did not obtain vital signs and did not ask the resident what level of pain (on a 0 to 10 scale) he was at. MT-D charted that the medication was effective but he did not return to the resident to ask the resident if the medication was effective. No MD was updated on the resident's chest pain and possible change of condition.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R1) of 3 residents reviewed for medications were adequately monitored for Warfarin side effects. R1 was admitted to the facility with an order for Warfarin daily. The facility did not implement a care plan or orders to monitor for any adverse side effects that could result from taking an anticoagulant.

Inspectors wroteBased on interviews, and record reviews, the facility failed to formulate a comprehensive care plan for 2 of 11 sampled residents (R6 and R8).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure quality of care for 2 of 11 sampled residents (R6 and R7). Specifically, the facility failed to ensure R6 received wound care services and laboratory services, and the facility failed to follow physician orders for R7's pain medication.

Inspectors wroteBased on interviews, record reviews, and review of the policy, the facility failed to ensure 1 of 11 sampled residents (R7) received toileting care as needed to maintain continence level as assessed on admission. Findings Include: R7 was admitted to the facility on [DATE] with diagnosis of but not limited to age-related osteoporosis without current pathological fracture, neuromuscular scoliosis, lumbosacral region, displaced transverse fracture of right patella, and radiculopathy. R7's Minimum Data Set, dated [DATE] a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R7 was cognitively intact. R7 was documented as dependent on toileting hygiene and transfer and was occasionally incontinent of urine. During an interview on 01/25/24 at 2:15 PM, R7 revealed she was continent of urine but had struggled with toileting since admission. [...]

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure that 1 of 9 sampled residents (R1) was provided appropriate assistance with transfers resulting in fall.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 2 of 9 sampled residents (R4 and R5) reviewed for treatment administration had complete and accurately documented medical records. Specifically, the facility failed to ensure treatment administrations for R4 and R5 contained accurate documentation of physician treatment orders.

Inspectors wrote3) R97 was admitted to the facility on [DATE]. Diagnoses includes end stage renal disease, diabetes mellitus with foot ulcer, heart failure, hypertension, and dependence on renal dialysis. The hospital Discharge summary dated [DATE] under principle diagnosis includes Bilateral diabetic foot ulcers without infection. The Clinical admission assessment dated [DATE] is checked for diabetic foot ulcer(s). The physician orders dated 6/3/23 documents, Left dorsal foot: Wash with soap/water, pat dry. Apply Iodosorb f/b (followed by) secondary dry dressing. Change daily and prn (as needed.) Every evening shift for wound care. Review of R97's June TAR (treatment administration record) reveals the treatment is not initialed as being completed on 6/6/23, 6/8/23, 6/9/23, 6/11/23, 6/12/23, & 6/13/23. The physician order dated 6/3/23 documents Right hallux (big toe): Wash with soap and water, pat dry. [...]

Inspectors wroteBased on observations, interviews and record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 6 of 7 (R197, R21, R199, R22, R245, R15) residents reviewed for pressure injuries. R197 admitted to the facility without pressure injuries and was identified to be at risk. No preventative care plan (CP) interventions to offload heels were implemented. [...]

Inspectors wrote4) R6 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left-Dominant Side, Sleep Apnea, Insomnia, Other Idiopathic Scoliosis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Other Obsessive-Compulsive Disorder, Unspecified Attention-Deficit Hyperactivity Disorder, and Other Psychoactive Substance Abuse. R6 is currently their own responsible party. R6's 5 day Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R6 is cognitively intact for daily decision making. R6's MDS also documents R6 requires extensive assistance of 2 staff for bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not: identify and seek ways to support resident's individual needs through the assessment and care planning process, make referrals and obtain needed services from outside entities, and provide and arrange for needed mental and psychosocial services related to difficulty coping with change in condition and loss of meaningful life, and need for emotional support for 1 of 1 Residents (R6) reviewed for medically related social services. R6 was not provided medical related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. *R6's electronic medical record (EMR) documents that R6 had suicidal ideation on [DATE], and was given a 30 day discharge notice on [DATE], 1 day after having suicidal ideation. [...]

Inspectors wrote2.) R95 was admitted to the facility on [DATE]. R95's physician order with a start date of 2/19/23 & end date of 2/20/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. R95's physician order with a start date of 2/21/23 & end date of 2/22/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. R95's physician order with a start date of 2/23/23 & end date of 2/24/23 documents Rapid Covid test day of admission, 48 hours after admission and 48 hours after one time a day for 1 Administration. The nurses note dated 2/20/23 at 10:19 a.m. documents Patient tested this morning for COVID. Patient tested positive. Patient and family member notified that patient has COVID. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R6) of 17 sampled residents was given the right to formulate their preference regarding their code status and have the facility correctly reflect that preference. *R6 elected to be a full code upon admission to the facility on [DATE], a new document was initiated for Do Not Resuscitate (DNR) on [DATE] with DNR physician's orders. The electronic medical record contained conflicting details regarding R6's code status. R6 verbally expressed during survey they are to be a full code. Interviews with facility staff indicated the facility did not have an effective system to ensure residents are able to accurately formulate their code status and have it honored. Findings Include: Surveyor reviewed the facility Communication of Code Status policy and procedure implemented [DATE]. .Policy: [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R22) of 17 sampled Residents reviewed had facility staff consult with the Resident's physician according to their physician orders. R22's physician orders for Januvia 50 mg (milligrams) includes to call MD (medical doctor) if blood sugar is less than 70 or greater than 400. On 6/9/23 R22's blood sugar was 67. There is no evidence R22's physician was consulted with when staff identified the low blood sugar.

Inspectors wroteBased on record review and interview the Facility did not ensure 1 (R6) of 1 Residents who received a facility initiated 30 day notice of discharge received a notice that contained the required contents. R6's 30 day notice of discharge included the incorrect address and phone number of the Division of Quality Assurance (DQA), Southeastern Regional Office, the incorrect information for the Division of Hearings and Appeals notification, and the 30 day notice incorrectly advises R6 to contact the Department of Human Services (DHS) for assistance with filing an appeal. Findings Include: Surveyor reviewed the facility's Transfer and Discharge policy and procedure dated 10/1/22 and notes the following applicable to 30 day discharge notices: .Policy Explanation and Compliance Guidelines: . 3. [...]

Inspectors wroteBased on interviews, and record review, the facility did not ensure the PASARR (Pre-admission Screen and Resident Review) for 1(R6) of 1 Residents reviewed for PASARR screening was completed accurately and referred for a Level II screen when a change in status occurred. *R6's Pre-admission Screen and Resident Review (PASARR) dated 9/10/20 does not accurately document R6's mental disorders and current medications used for treatment upon admission to the facility. R6's PASARR was not updated when the facility identified R6's placement was going to exceed the 30 day exemption nor when R6's was evaluated by psychiatric services for hallucinations, and delusions and new mental disorder diagnoses were given thus resulting in an inaccurate screening. With an inaccurate Level I screen the facility did not refer R6 for a Level II screen. [...]

Inspectors wroteBased on staff interview and record review, the Facility did not ensure a baseline care plan was developed and implemented within 48 hours of a Resident's admission for 3 (R22, R95, R97) of 17 Residents. * R22 was admitted to the facility on [DATE]. The Facility did not develop a baseline care plan for pain, pressure injuries, or falls. * R95 was admitted to the facility on [DATE]. The Facility did not develop a baseline urinary catheter care plan. * R97 was admitted to the facility on [DATE]. The Facility did not develop any baseline care plans.

Inspectors wroteBased on record review and interview, the facility did not ensure resident's had a comprehensive plan of care related to clinical concerns. This was observed with 2 (R146 and R38) of 18 resident reviews. -R146 did not have a comprehensive plan of care for continuously removing their oxygen to include interventions, goals and timeframes. -R38 did not have a comprehensive plan of care for fall interventions with goals and timeframes.

Inspectors wroteBased on interview, and record review, the facility did not develop and implement an effective discharge planning process including involving the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final discharge plan for 1 (R297) of 6 Residents reviewed for discharge planning. *R297 was discharged to another skilled nursing (SNF) facility on 6/4/22 without R297's activated Health Care Power of Attorney (HCPOA)'s authorization. On 6/3/22 the facility notified a family member of R297, not R297's Activated HCPOA, of the planned transfer of R297 to another SNF. R297's Activated HCPOA and/or interested family members were not involved in the discharge planning process including selection of the new SNF or ability to tour SNFs prior to agreement to transfer. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R6) of 5 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain good grooming and personal hygiene. *R6 had no documented showers provided by facility staff per their plan of care.

Inspectors wroteBased on interview and record review, the Facility did not ensure 1 (R95) of 2 Residents reviewed received appropriate treatment and services related to catheter care. *R95's medical record did not have any physician orders for R95's urinary catheter, there is not a diagnoses, size of the catheter, or any catheter care to be provided.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for for 2 of 2 (21 and R22) residents reviewed for respiratory care. R21 and R22 have a CPAP (Continuous Positive Airway Pressure) machine in their room. Neither resident had Physician's orders or a care plan for the CPAP.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure pain management was provided to Residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 Resident (R) (R6) of 3 sampled Residents who was experiencing pain. *R6's pain is not effectively managed through assessment, intervention, non-pharmacological interventions, and Resident advocacy to control R6's identified pain. Findings Include: [...]

Inspectors wroteBased on interview and record review the Facility did not ensure consistent communication for 1 (R97) of 1 Residents who receive dialysis services. R97's dialysis/observation communication forms were either missing or incomplete.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R6 and R38) of 2 residents reviewed for side rails had assessments for the need to use side rails, that consent was obtained for their use and that alternatives were attempted prior to installation. R6 and R38 were observed to have assist/side rails on their bed without assessments, and/or without care plans, consent, and without alternatives attempted. Findings Include: Surveyor requested a facility policy and procedure for re-positioning mobility bars. Surveyor notes the facility refers to re-positioning mobility bars as 'bed canes'. Surveyor reviewed the provided facility 'Proper Use of Bed Rails' policy and procedure dated 10/1/22 and notes the following applicable: .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure R299 received pharmaceutical services (accurate acquiring, dispensing and administering of all drugs and biologicals) to meet the needs of each resident. Surveyor observed Pepto Bismal and fiber powder, on R299's bedside table and a non prescription sleep aide was located in R299's drawer. R299 did not have a physician's order for the Pepto Bismal, fiber power, and non-prescription sleep aide. R299 was assessed to not be able to safely self-administer medication. The Facility was not aware R299 was self-administering Pepto Bismal, fiber powder and non-prescription sleep aide until the Surveyor alerted the Facility of the concern. Findings Include: Surveyor reviewed the facility's Storage of Medications policy and procedure dated 3/17 and notes the following: . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R15) of 5 residents reviewed for unnecessary medications had adequate behavior monitoring on a consistent basis while receiving psychotropic medications. *R15 was receiving Seroquel for Dementia with Delirium; there is no indication facility staff were monitoring individual behaviors for R15 including symptoms of delirium.