Harborside Health & Rehabilitation

Inspectors wroteBased on observations, record reviews and staff interviews, for one (1) of four (4) sampled residents, facility staff failed to ensure the accurate reconciliation of narcotic/controlled medications; and failed to ensure that the established system to enable the accurate reconciliation of all narcotic/controlled medications was followed. Resident #1.

Inspectors wroteBased on record review and staff interviews, facility staff failed to implement an effective training program for existing staff as evidenced by Employee #6 (Licensed Practical Nurse/LPN) working a shift after suspension without receiving education on drug diversion/narcotics reconciliation after she was involved in a reported incident of missing narcotics.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 10 sampled residents, facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.24, Quality of Life, F678, Cardiopulmonary Resuscitation on February 25, 2026 at 3:40 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on February 25, 2026 at 8:19 PM. The Survey Team verified implementation of the abatement plan while onsite and the immediate jeopardy was lifted on [DATE] at 10:45 AM. After removal of the immediacy, the deficient practice was lowered to a scope and severity level of D.

Inspectors wroteBased on record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to administer 10 doses of Resident #71's ordered anticonvulsant medication from 06/06/25 through 06/12/25. Due to these failures, Resident #71 suffered harm as evidenced by having three (3) seizures during that time frame and required hospitalization.

Inspectors wroteBased on record review and staff interviews, facility staff failed to meet the State requirement of providing a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day on 02/22/26, when an Immediate Jeopardy was identified. The census on that day was 117.

Inspectors wroteBased on record review and staff interview, for one (1) of ten (10) sampled residents, facility staff failed to report, within two (2) hours, an incident that resulted in serious bodily injury, harm and or death. Resident #5.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to have an extra tracheostomy tube at Resident #6's bedside in the event of an accidental dislodgment or decannulation.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of ten (10) sampled residents, facility staff failed to demonstrate the competencies and skills sets to provide safe nursing and related services. Residents' #5 and #71.

Inspectors wroteBased on observations, record reviews and staff interviews, for three (3) of ten (10) sampled residents, facility staff failed to ensure controlled substances were reconciled as evidenced by not signing off the controlled medication forms when medications were administered. Residents' #9, #11, and #10.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of 10 sampled residents, facility staff failed to follow its policy and procedures for controlled substance disposal for Resident #8's Lacosamide (anticonvulsant medication) 100 MG (milligrams) tablets.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of ten (10) sampled residents, facility staff falsely documented that they administered medications to Resident #71.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of seven (7) sampled residents, the facility staff failed to ensure residents' records contained accurate information. As evidence by:(1). Staff documented Resident #1 had a Gastrostomy Tube (G-tube) instead of a Jejunostomy Tube (J-Tube). (2) Staff documented Resident #4 had a right check bruise instead of a right eyebrow bruise.

Inspectors wroteBased on record review and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to provide Resident #67 with the necessary respiratory care per the residents comprehensive care plan and the facility's policy after decannulation of her tracheostomy (trach) tube.

Inspectors wroteBased on record review and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to demonstrate competencies and skills to provide safe nursing care and services as evidenced by a nurse, who was not trained to do so, reinserting Resident #67's tracheostomy tube after decannulation.

Inspectors wroteBased on record review and staff interview for one (1) of 55 sampled residents, facility staff failed to ensure that Resident #67 (who is dependent on staff for activities of daily living, bed mobility and transferring from bed to chair) received adequate supervision when staff failed to use two staff person(s) while attempting to transfer a resident from bed to chair, subsequently the resident fell from the bed to the floor and sustained a neck fracture. Actual harm was identified on 7/15/2024 for resident #67.

Inspectors wroteBased on record review and staff interviews, for four (4) of fifty-five (55) sampled residents, the facility staff failed to ensure that a Resident's assessment accurately reflected the resident's nutrition status by documenting an inaccurate weight. Residents' #85, #71, #121 and #381.

Inspectors wroteBased on record review and staff interview for four (4) of 55 sampled residents, facility staff failed to develop a person-centered care plan with goals and interventions for residents with bowel and bladder incontinence, a resident with hearing loss, a resident with fall mats on both sides of the bed and for a resident's refusal of respiratory care/treatments. Residents' #377, #381, #71 and #121. The findingd inclued: 1. Resident #377 was admitted to the facility on [DATE] with multiple diagnoses that included: Disorientation, Hemiplegia, Chronic Respiratory Failure, Dependence on Respirator and End Stage Renal Disease. A review of Resident #377's medical record revealed: An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15' indicating the resident was cognitively intact; [...]

Inspectors wroteBased on record review and staff and resident interviews, for four (4) of 55 sampled residents, the facility staff failed to provide: (1) documented evidence that Resident #44 who was dependent on staff for toileting hygiene was provided incontinent care within 12 hours on 10/01/24 and with eight hours on 10/02/24, (2) activities of daily living (ADL) care assistance for Resident #10, #29, #68, (3) incontinent care and turn and repostion Resident #105 every two (2) hours as perscibed, and (4) incontinent care in a timely manner for Resident #377.

Inspectors wroteBased on observation, record review and interview, for two (2) of 55 sampled residents, the facility staff failed to: (1) follow Infection Prevention and Control measures. As evidenced by, a staff member placing a gallon of tea that was in Resident #8's room who was Enhanced Barrier Precautions in the community refrigerator. 2. maintain infection prevention and control to help prevent the transmission of communicable diseases and infections as evidenced by failing to don PPE prior to weighing Resident #277, who was on contact precautions and failing to disinfect equipment in between use.

Inspectors wroteBased on record review and staff interviews, for one (1) out of 55 sampled residents, facility staff failed to ensure that the resident's preference/choice was honored as evidence by failing to get the resident out of bed and into the Geri chair. Resident #72.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 55 sampled residents, facility staff failed to have documented evidence that the resident or their representative (RP) were provided with written information concerning the right to accept or refuse to formulate an Advance Directive (AD). Resident #121.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by a torn privacy curtain in one (1) of 18 resident's rooms, an entrance door in one (1) of 18 resident's rooms that would not stay open, and broken furniture such as two (2) of two (2) Geri chairs, and one (1) of one (1) broken desk that were stored in the dayroom located on resident care unit 3 West; and facility staff failed to exercise reasonable care for the protection of the resident's property from loss or theft when the resident was transferred to a local hospital. Resident #329.

Inspectors wroteBased on record review and staff interviews, for one (1) of 55 sampled residents, facility staff failed to have documented evidence that they made any prompt efforts to resolve one resident's complaint/grievance regarding Americans with Disabilities Act (ADA) accessibility at the facility when resident alleged that hand was smashed in a door. Resident #71.

Inspectors wroteBased on observations, record review and staff interviews, for one (1) of 55 sampled residents, facility staff failed to ensure that 1 resident was free from any physical restraints imposed for purposes of convenience that was not required to treat the resident's medical symptoms. Resident #10.

Inspectors wroteBased on record review and interview, the facility staff failed to implement it's Abuse Prevention Program policy, As evidenced by not having documented evidence of that an investigation was conducted for an allegation of missing items for one (1) of 55 sampled residents. (Resident #226)

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 55 sampled residents, facility staff failed to report the results their investigation of alleged neglect to the State Agency within five (5) days; and failed to report the results of their investigation for one resident's allegation of abuse to the State Agency. Residents #68 and #276.

Inspectors wroteBased on record review and interview, for two (2) of 55 sampled residents, the facility staff failed to ensure thorough investigations was conducted to adresss: (1) an allegation of missing items for Resident #226's; and (2) an allegation of abuse for Resident #276. (Residents #226 and #276)

Inspectors wroteBased on observations, record review, and interviews, for three (3) of fifty-five (55) sampled residents, the facility staff failed to provide written notification to a resident or the Resident's representative(s), which explained the reasons for a resident's transfer or discharge to the hospital. Residents #122, #328 and #67.

Inspectors wroteBased on observations, record review, policy review and staff interviews, facility staff failed to adhere to professional standards of Practice for administering medication via G-tube for four (4) of seven (7) Medpass observations.

Inspectors wroteBased on record review and interview, for one (1) of 55 sampled residents, the facility staff failed to: (1) have a physician order to irrigate and remove a urinary catheter for Resident #103 who was bleeding from thr catheter insertion site.(2). follow the physician's order to keep [fall] mats bilaterally on the floor for Resident #71, who has a history of falls with injury.

Inspectors wroteBased on observation, record reviews, and staff interviews, for two (2) of 55 sampled resident the facility failed to ensure the residents received proper treatment and care to maintain good foot health. As evidenced by the residents were observed with elongated and thickened toenails. (Resident #7 and Resident #38)

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of 55 sampled residents, the facility staff failed to provide appropriate treatment and services for a resident with an indwelling catheter. As evidenced, by not having documented evidence that the resident's urinary put was monitored every shift, as ordered.

Inspectors wroteBased on record review and staff interview for one (1) of 55 sampled residents, facility staff failed to ensure Dialysis treatments were provided according to physician orders, subsequently the resident became increasingly confused and had to be transferred to the hospital for urgent dialysis. Resident #383.

Inspectors wroteBased on record review and staff interviews, facility staff failed to have sufficient nursing staff to provide nursing and related services to assure resident safety based on the Payroll Based Journal (PBJ). The census on the first day of the survey was 112.

Inspectors wroteBased on record review and staff interviews, facility staff failed to ensure one resident controlled medications were accurately recorded by documented as given and accurately reconciled controlled medications showing amount remaining for one (1) of three (3) sampled resident controlled drug records reviewed. Residents #76.

Inspectors wroteBased on observation, record review and staff interview two (2) of three (3) medication storage rooms observation, facility staff failed to ensure proper and accurate temperature control for one refrigerator used for storing the resident's medication was maintained and the daily documentation of glucometer calibration record for use was completed on the date and in the space allotted to do so.

Inspectors wroteBased on observations and interview, facility staff failed to store and distribute food under sanitary condition as evidenced by a clogged floor drain line on the cook line, two (2) of approximately ten (10) dented cans of Sharp Aged Cheddar Cheese in dry food storage, one (1) of one (1) soiled food slicer, disposable items that were stored uncovered in dry food storage, ready-to-eat cold foods and drinks that tested above 41degrees Fahrenheit (F), and a frozen condensate pipeline in one (1) of one (1) walk-in-freezer.

Inspectors wroteBased on observation, record review, and resident and staff interviews, for one (1) of 55 sampled residents, the facility staff failed to be compliance with the District of Columbia's state regulation (3211.1). As evidenced by staff not promptly responding to an activated call bell. Consequently, a resident waited 41 minutes for staff to answer the call light. (Resident #103)

Inspectors wroteBased on observation and staff interviews for two (2) of 55 sampled residents, facility staff failed to ensure that the call bell device was within reach that would allow residents to call for staff assistance, as evidenced by the call bell device found hanging on the oxygen flow meter attached to the wall behind the resident's bed. Residents' #376 and #378.

Inspectors wroteBased on observations, record review, and interviews, for one of fifty-five (55) sampled residents, the facility staff failed to provide documented evidence that they provided education and training to a staff that was investigated for an incident of alleged staff-to-resident abuse. Resident # 122 Resident # 122 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Chronic Respiratory Failure, Atrial Fibrillation, Acute Kidney Failure, Respiratory Conditions Due To Smoke Inhalation Type 2 Diabetes Mellitus, and Anxiety Disorder. The State Agency received a facility-reported (FRI), (Incident DC ~13151), submitted on 09/21/24 at 10:39 PM that documented: [...]

Inspectors wroteBased on record review and staff interview for one (1) of three (3) sampled residents, facility staff failed to develop a care plan with goals and approaches to address Resident #1 being discharged from the facility.

Inspectors wroteBased on record review and staff interview for one (1) of three (3) sampled residents, facility staff failed to maintain accurate medical records for Resident #1.

Inspectors wroteBased on observation, record review, and staff interviews, for one (1) of 11 sampled residents, the facility staff failed to ensure that Resident #1, who was at risk for falls, received adequate supervision during an episode of confusion with aggressive behavior as evidenced by the resident having a witnessed fall with injury. Actual harm was determined for Resident #1 on 03/14/2024.

Inspectors wroteBased on record review and staff interview, for one (1) of 11 sampled residents, facility staff failed to code a resident's quarterly Minimum Data Set (MDS) Assessment accurately after a fall. Resident #2.

Inspectors wroteBased on record review and staff interview, for one (1) of 11 sampled residents, facility staff failed to update/revise a resident's care plan interventions after a fall. Resident #2.

Inspectors wroteBased on record review and staff interview, for one (1) of 11 sampled residents, facility staff failed to include accurate documentation for Resident #1's frequent monitoring from 03/09/24 to 03/20/24 in the resident's medical record.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by loose, torn, privacy curtains in 30 of 75 resident's rooms.

Inspectors wroteBased on record reviews and staff interviews for 1 (one) of 45 sampled residents, the facility staff failed to report the results of its investigation regarding a Resident's injury of unknown origin to the State Survey Agency within 5 (five) working days of the incident. Resident #83.

Inspectors wroteBased on record reviews and staff interviews for 1 (one) of 45 sampled residents, the facility staff failed to notify the Resident, the Resident's representative(s), and the Office of the State Long-Term Care Ombudsman of the reason for a resident's transfer to the hospital (in detail), before the Resident's transfer. Resident #84.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 45 sampled residents, the facility staff failed to provide bed hold notices that included the number of bed hold days and/or the facility's bed hold policy to residents or their representatives at or before the residents' transfers to the hospital. Residents #84 and #97.

Inspectors wroteBased on record review and staff interview, the facility's staff failed to ensure a resident's Significant Change MDS (Minimum Data Set) contained accurate information related to skin condition for one (1) of 45 sampled residents. (Resident #107)

Inspectors wroteBased on observation, record review, and staff interview, the facility's staff failed to develop a resident's comprehensive person-centered care plan with goals and interventions to address a resident's unplanned weight loss of 11 percent in 30-Days, a resident use of a Ventilator/Trach, and a resident use of hand mittens, use of anticoagulant (Warfarin) and use of nine (9) or more medications for three (3) of 45 sampled residents. (Resident #105, #109 and #111).

Inspectors wroteBased on observation, record review and interviews for one (1) of 45 sampled residents, facility staff failed to update the person center comprehensive care plan with goals and approaches to address Resident #111's use of vent/trach.

Inspectors wroteBased on observations, record reviews, residents' interviews, and staff interviews, the facility staff failed to ensure residents who were dependent on staff for activities of daily living received incontinent care, regularly scheduled showers, and foot care to maintain good personal hygiene for five (5) of 45 sampled residents. (Residents #29,#8, #33, #68, and #76)

Inspectors wroteBased on observations, record reviews, staff, and resident interviews for four (4) of 45 sampled residents, facility staff failed to ensure that residents received the treatment and care per standards of practice as evidenced by: 1) failure to provide a Gastro-Intestinal Consultation in a timely manner for one (1) resident #105 who had a 11 percent unplanned weight loss in 29 days 2) failure to follow physicians' orders for three residents. Residents #18, #53, and #97.

Inspectors wroteBased on an observations, record reviews, and staff interviews, the facility's staff failed to ensure a resident's wound care was provided in consistency with professional standards, as evidence by not providing wound treatment as ordered for one (1) of 45 sampled residents. (Resident #105)

Inspectors wroteBased on observation record reviews, staff, and resident interviews for one (1) of 45 sampled residents, the facility staff failed to follow professional standards of practice when administering medication to a resident. Resident #18 Resident #18 was admitted to the facility on [DATE] with diagnoses including Other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified Affecting Left Nondominant Side, Schizophreniform Disorder, Tremor, Unspecified, Vitamin Deficiency, Unspecified, and Hypomagnesemia. A review of Resident #18's medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documenting the Resident had a Brief Interview for Mental Status Summary (BIMS) score of 14, indicating the Resident had intact cognition; [...]

Inspectors wroteBased on observations and staff interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on seven (7) of seven (7) observations, four (4) of four (4) convection ovens that were soiled throughout, and cooking equipment such as two (2) of two (2) grease fryers, one (1) of one (1) tilt skillet, and one (1) of one (1) grill that were exposed to potential food contamination.

Inspectors wroteBased on observations, record reviews, staff, and resident interviews for three (3) of 45 sampled residents, the facility staff failed to provide restorative nursing services for three residents. Residents #18, #22, and #53. 1. Facility staff failed to offer Resident #18 restorative nursing for donning and doffing an orthotic to the Resident's left elbow which was contracted. Resident #18 was admitted to the facility on [DATE] with diagnoses including Other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified Affecting Left Nondominant Side, Schizophreniform Disorder, Contracture, Right Hand. A review of Resident #18's medical record revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documenting that the Resident had a Brief Interview for Mental Status Summary (BIMS) score of 14, indicating the Resident had intact cognition; [...]

Inspectors wroteBased on record review and staff interview staff failed to ensure medical record (Treatment Administration Record) for two (2) of 45 sampled resident were complete. (Resident #5, and #104)

Inspectors wroteBased on record review and staff interview, the facility's staff failed to maintain Infection Control and Prevention Practices during wound care for one (1) of 45 sampled residents. (Resident #107).

Inspectors wroteBased on a review of clinical records, facility documentation, facility policies, and resident and staff interviews, for one (1) of 44 sampled residents, the facility's staff failed to prevent and protect Resident #105 from psychological and physical abuse by Employee #5 and because of the Employee's employment history, there is a likelihood of the employee abusing other residents. Due to these failures, an immediate jeopardy situation was identified on September 8, 2021 at 1:55 PM. The facility submitted a plan of action to the survey team that was on onsite at 7:32 PM on September 8, 2021, and the plan was accepted. The survey team returned on September 16, 2021 to validate the facility's plan, and the immediate jeopardy was lifted on September 16, 2021, at 7:52 PM. [...]

Inspectors wroteBased on observation, record reviews and staff interviews, facility staff failed to ensure that staff were reporting and documenting changes in resident skin condition as so identified. Subsequently, five (5) of five (5) residents identified by the facility as high risk for developing pressure ulcers had pressure ulcers/injuries first observed by staff at an advance stage (Stage 3, Stage 4 and Unstageable). (Residents' #87, #83, #73, #62, and #42) Due to these failures an immediate jeopardy situation was identified on September 8, 2021 at 2:01 PM. The facility submitted a plan of action to the survey team on site at 7:31 PM on September 8, 2021 and the plan was accepted. The survey team returned on September 16, 2021 to validate the facility's plan, and the immediate jeopardy was lifted on September 16, 2021 at 7:52 PM. [...]

Inspectors wroteBased on record review and staff interview, for five (5) of 11 complaints and facility reported incidences, facility staff failed to thoroughly conduct an investigation: for three (3) residents who alleged physical abuse from an employee; for an allegation of misappropriation of one (1) resident's property; and for improper use of a restraint for one (1) resident. (Residents' #23, #37, #95, #102 and #105).

Inspectors wroteBased on observation, record review and staff interview, facility staff failed to maintain sufficient nursing staff to provide a shower to resident; to turn and reposition two (2) of 44 sampled residents as prescribed for wound prevention; and failed to ensure that staff were reporting and documenting changes in resident skin condition as so identified. Subsequently, five (5) of five (5) residents identified by the facility as high risk for developing pressure ulcers had pressure ulcers/injuries first observed by staff at an advance stage (Stage 3, Stage 4 and Unstageable).

Inspectors wroteBased on staff interview, Administration failed to ensure that action plans were developed and implemented to ensure freedom from abuse, neglect and exploitation, to ensure a resident was restraint free, to thorough investigate all allegations of abuse, failed to implement measures to protect a resident involved in the abuse investigation, and to ensure that staff were reporting and documenting changes in resident skin condition as so identified. The resident census was 122.

Inspectors wroteBased on staff interview, the Governing Body failed to ensure that action plans were developed and implemented to ensure freedom from abuse, neglect and exploitation, to ensure a resident was restraint free, to thorough investigate all allegations of abuse, failed to implement measures to protect a resident involved in the abuse investigation, and to ensure that staff were reporting and documenting changes in resident skin condition as so identified. The resident census was 122.

Inspectors wroteBased on observations, record review, resident and staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 122.

Inspectors wroteBased on observation, record review, and interview, for three (3) of 44 sampled residents, the facility's staff failed to maintain Infection Control Practices when: preparing, serving, and distributing foods under sanitary conditions, as evidenced by using a cooling fan in the kitchen; while providing wound care for one (1) resident, administering medications to one (1) resident; and not sanitizing their hands before entering a resident's room to provide care. (Residents' #87 #47 and #100).

Inspectors wroteBased on record review and staff interview for seven (7) of 44 sampled residents, the facility's staff failed to inform residents or their representatives of their rights to formulate Advance Directives for six (6) residents and failed to confirm one (1) resident's code status. (Residents' #3, #5, #21, #37, #76, #95 and #105)

Inspectors wroteSurveyor: [NAME], [NAME] Based on record reviews and staff interviews, for seven (7) of 44 sampled residents, facility staff failed to develop and implement comprehensive person -centered care plans. (Residents' #56, #68, #87, #95, #100, #102 and #105)

Inspectors wroteBased on observation, record review and staff interview, for five (5) of 44 sampled residents, the facility's staff failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with residents' choices as evidenced by: facility staff failed to turn and reposition two (2) residents as prescribed for wound prevention; failed to elevate head of bed at a 45-degree angle while one (1) resident's tube (enteral) feeding was infusing; failed to ensure one (1) received restorative nursing for contracture management; failed to follow the physician's orders to obtain one (1) resident's trough levels (lab value). (Residents' #68, #76, #87, #100 and #372)

Inspectors wroteBased on observation, record review staff and resident interview, for one (1) of 44 sampled, residents, facility staff failed to provide respiratory care consistent with the professional standards of practice as evidenced by failure to ensure one (1) resident receiving oxygen therapy had physician's orders to direct the amount of oxygen to be delivered to the resident. Resident #21.

Inspectors wroteBased on record review and staff interview for two (2) of 44 sampled residents, facility staff failed to accurately reassess and evaluate the resident pain after administering her pain medication. Residents' #56 and #87.

Inspectors wroteBased on observations, record reviews and staff interviews, for one (1) of 44 sampled residents, the facility staff failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety as evidence by: failure to maintain Infection Control Practices when administering medications to Resident #47.

Inspectors wroteBased on observation and staff interview, facility staff failed to safely store medications.

Inspectors wroteBased on observations and staff interview, the facility failed to prepare, serve, and distribute foods under sanitary conditions, as evidenced by a cooling fan that was in use in the kitchenh and food temperatures that were below 135 degrees Fahrenheit (F) on three (3) of nine (9) observations.

Inspectors wroteBased on record review and staff interview, for three (3) of 44 sampled residents, facility staff failed to: (1) document in the resident's medical record the information/education provided regarding the benefits and risks of immunization. (2) ensure eligible residents received their immunizations. Residents' #21, #95 and #105.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain mechanical/electrical equipment in safe operating condition as evidenced by: failure to ensure the air handler was working as intended, and failed to ensure a residents's low-air pressure bed was operating as intended. Resident # 68.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure all staff participated in an abuse, neglect, and exploitation prevention training program and failed to have a process in place to track attendance. The census on the first day of survey was 122.

Inspectors wroteBased on record review and staff interview, facility staff failed to provide sufficient training to nurse's aides after it found that residents were observed/being treated in a manner that indicated additional training was needed. The resident census on the first day of survey was 122.

Inspectors wroteBased on observations, record review and staff interviews for one (1) of 44, sampled residents the facility ' s staff failed to ensure a resident was provided dignity and privacy due to not covering the urine collection bag. (Resident #102).

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by five (5) ceiling tiles in the supply room that were stained throughout and two (2) ceiling tiles in the staff breakroom that were also soiled.

Inspectors wroteBased on record review and staff interview, for one (1) of 44 sampled residents, facility staff failed to ensure that one resident was free from a physical restraint. (Resident #95)

Inspectors wroteSurveyor: [NAME], Gemina Based on record review and staff interview, facility's staff failed to ensure all the required documents were conveyed to the receiving health care provider for two (2) of 44 sampled residents that were transferred from the facility. (Residents' #97, and #103)

Inspectors wroteBased on observation, record review and interview, the facility's staff failed to ensure a Minimum Data Set Assessment accurately reflected a resident's mental status for one (1) of 44 sampled residents. (Resident #87)

Inspectors wroteBased on record review and staff interview, for three (3) of 44, sampled residents, facility staff failed to develop and implement a baseline care plan within 48 hours of admission. (Residents' #95, #105 and #372).

Inspectors wroteBased on record review and staff interview for three (3) of 44 sampled residents, the facility's staff failed to revise the person-centered care plan to address resident needs and diagnoses. (Residents' #56 #78, #87)

Inspectors wroteBased on observation, record review, staff and resident interview, for two (2) of 44 sampled residents, facility staff failed to ensure residents who are unable to carry out Activities of Daily Living (ADL) received the necessary personal hygiene. (Residents ' #25 and #37)

Inspectors wroteBased on observation, record review and staff interview for one (1) of 44, sampled residents, facility staff failed to implement the use of orthotics to prevent decrease in range of motion and mobility.

Inspectors wroteBased on observation and record review for one (1) of 44 sampled residents, facility staff failed to provide adequate supervision to monitor the residents whereabout in and out of the facility for Resident #93 who left the facility without the staff knowledge; and facility staff failed to provide an environment free from accident hazards as evidenced by a portable space heater that was seen in one (1) of 76 resident's rooms.

Inspectors wroteBased on observation and record review, for two (2) of 44 sampled residents, facility staff failed to weigh a resident every 30 days as ordered and verify accurate weights were being obtained. Residents' #37 and #95.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that the required daily nurse staffing information was posted.

Inspectors wroteBased on record review and staff interview, for two (2) of 44 sampled residents facility, staff failed to: monitor for side effects and effectiveness of the resident's prescribed psychotropic medications for depression and anxiety; and ensure a resident was evaluated by a psychiatrist, as ordered by the physician. Residents' #100 and #102.

Inspectors wroteBased on observation, record review and staff interview, facility staff failed to accurately reconcile narcotics.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure two (2) of 44 sampled residents were free from unnecessary pain medications. Resident #56 and #87.

Inspectors wroteBased on record review and staff interview, for three (3 ) of 44 sampled residents, facility's staff failed to: accurately document the resident's weight for one (1) resident; accurately document the side effects as ordered by the physician and as directed in the care plan for a resident receiving psychotropic medications for one (1) resident; and record the administration of the resident receiving Symbicort Aerosol and Peri trach care on the Treatment Administration Record and Respiratory Medication Administration for one (1) resident. Residents' #3, #5 and #119.

Inspectors wroteBased on record review and staff interview, facility staff failed to update the Facility Assessment to reflect the facility's current operations and emergencies. The resident census on the first day of survey was 122.