Harmar Village Health & Rehab Center

Inspectors wroteBased on meal observation, clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (eating supervision and assistance) for three of twelve residents reviewed (Residents R1, R2, and R3).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) machine for one of three residents (Residents R4).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of five residents (Resident R1, and R2).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident wheelchairs (Resident R56), two of five resident rooms (Resident R26, and Resident R59), and two of three resident elevators (beside dietary entrance). Findings Include: Review of the face sheet indicated Resident R56 was admitted to the facility on [DATE]. Observation on 3/30/26, at 11:22 a.m. Resident R56 was in the main dining room sitting in a wheelchair. The seat and cushion of the wheelchair were completely covered in dried foods, sticky substance, and dark grime. Interview on 3/30/26, at 11:23 a.m. Respiratory Therapist Employee E3 confirmed Resident R56 was in the main dining room sitting in a wheelchair. [...]

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to provide a dignified dining experience for one of three residents (Resident R81).

Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications without adequate indications for use for one of five residents (Resident R122)

Inspectors wroteBased on review of facility policy, clinical record review, and staff and resident interviews, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders to treat constipation for two of six residents (Resident R31 and R65). Findings Include: Review of the facility's Bowel Tracking Protocol Policy last reviewed 1/31/26, revealed the facility will record and monitor bowel activity of residents each shift and address issues identified. Diarrhea, constipation, bloody stools, or any other concerns will be reported to the licensed nurse. The Director of Nursing will be responsible for ensuring a daily auditing process is in place to identify residents who have no had a bowel movement in 2 full days (48 hours). [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice for two of six residents (Resident R6 and Closed Record CR42), and failed to prevent the development of pressure ulcers (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) one of six residents (Closed Resident Record CR42).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility had a physician order for a sling for one of two residents (Residents R124).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to obtain appropriate physician orders for a urinary catheter (insertion of a tube into the bladder to remove urine) for one out of two sampled residents (Resident R72).

Inspectors wroteBased on review of facility policies and clinical records, facility provided documents, as well as staff interviews, it was determined that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences and failed to address discontinued resident specific interventions for one of three residents (Resident R13) reviewed.

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of two resident reviewed (Resident 118).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of three residents (Residents R56, R65, and R101).

Inspectors wroteBased on facility policy review, staff interview, and observations, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on three medication errors out of 36 opportunities.

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R61).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to store medications properly, for three of three treatment carts (Treatment cart outside room [ROOM NUMBER], Treatment cart outside room [ROOM NUMBER], and 2nd floor treatment cart) and one of three medication carts (East Medication Cart), and two of five residents with treatment medications at bedside (Resident R3, and R40).

Inspectors wroteBased on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of three residents (Resident R14).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for two of four quarterly meetings (Quarter Two 2025, Quarter Three 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 8/15/25, indicated QAPI efforts are a component of the facility QAA (Quality Assessment and Assurance) Committee's responsibilities. The QAA Committee is responsible for both Quality Assessment and Assurance activities (QA) and ongoing, proactive, Performance Improvement (PI) activities. QAPI represents the merger of these two processes. The Committee will meet on a regular basis (at least quarterly, and as needed) to coordinate and evaluate activities of the QAPI program/plan. [...]

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that Enhanced Barrier Precautions (EBP) were managed properly for one of three resident (Resident R12) and failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R44).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations were tracked in the electronic health record (Residents R12, and R44).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of three residents (Resident R1).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for two of five residents reviewed (Residents R2 and R3).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to accurately document the need to crush medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36) and failed to ensure that residents are free of significant medication errors which resulted in an immediate jeopardy situation for one of five residents (Resident R1).

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to ensure equipment was in safe operating condition for two of two crash carts (carts maintained with equipment used in emergencies) which caused the actual harm of a delay in emergency care for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify a medical provider of a change in condition for two of seven residents (Resident R6 and R7).

Inspectors wroteBased on facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to procure physician's orders for the need to have crushed medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36).

Inspectors wroteBased on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for of 14 of 104 residents (R2, R8, R14, R16, R17, R21, R32, R33, R37, R39, R40, R41, R43, and R44). During an interview on [DATE], at approximately 12:30 p.m. when asked how they ascertain if a resident required their medications to be crushed, Licensed Practical Nurse (LPN) Employee E8 stated she reviews the physician's orders. LPN Employee E8 displayed the physician's order screen in the electronic charting system, and indicated an order that stated, May crush medications unless contraindicated. Additionally, LPN Employee E8 stated that there were report sheets at the nurse's station that indicate if residents required their medications crushed. [...]

Inspectors wroteBased on a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop a person-centered care plan related to the need for crushed medications for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident records and staff interviews it was determined that the facility failed to make certain that a controlled substance (drugs with the potential to be abused) was disposed of as per acceptable standards of practice for one of three closed resident records (Closed Resident Record CR1).

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1). This failure created an immediate jeopardy situation.

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of four residents (Resident R1)

Inspectors wroteBased on review of facility policy and facility documents it was determined that the facility failed to make certain controlled substances were accounted for accurately and destroyed approiately for one of four residents.

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined the facility failed to maintain clean equipment in a manner to prevent foodborne illness in the Main Kitchen.

Inspectors wroteBased on observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of two outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one).

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity on three of three units (Second Floor Resident R81, Third Floor Resident R31, and Memory Impaired Unit (MIU) Resident R65).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or was given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R31, and R42).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R26, R31, R44, and R95). Review of facility policy Transfers dated 1/10/25, indicated forms that need to be sent out with facility-initiated transfers to hospital: Discharge/Transfer Form, copy of care plan goals, and Bed Hold Notice. Review of the clinical record revealed that Resident R26 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of four resident hospital transfers (Residents R31, R44, R74, and R95). Review of facility policy Transfers dated 1/10/25, indicated forms that need to be sent out with facility-initiated transfers to hospital: Discharge/Transfer Form, copy of care plan goals, and Bed Hold Notice. Review of Resident R31's clinical record indicated the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for eight of 24 residents (Residents R1, R19, R47, R62, R81, R90, R203, and R253).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for two of four residents (Residents R65 and R81).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R31, and R95).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for six of six residents (Residents R31, R42, R74, R81, R203, and R253).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain a physician order and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs, and the risks associated with bedrail usage for three of five residents (Residents R47, R65, and R253).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Residents R1, R8, R22, R60, R81, and R90).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aide (NA) personnel records (NA Employee E11, E12, E13, E14, and E15).

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of three nursing units (Second Floor) and one of two medication rooms (Third Floor Medication Room).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for three of three residents (Residents R44, R62, and R65).

Inspectors wroteBased on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four of 21 residents (Residents R14, R42, R74, and R80).

Inspectors wroteBased on clinical record and interview, it was determined that the facility failed to notify the resident's responsible party of changes in condition for one of six sampled residents (Resident R71).

Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for one of two residents (Resident R100).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for two of five residents (Resident R90, and R203).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R50) to accurately reflect the current status of the resident and care needs.

Inspectors wroteBased on review of facility policy, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice by failing to complete an admission assessment for two of four residents (Residents R90 and R203).

Inspectors wroteBased on review of clinical record review and interview with staff, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of three residents (R46).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment and monitoring for pressure ulcers and failed to develop a plan of care timely for two of three residents (Residents R47 and R60).

Inspectors wroteBased on reviews of facility policy, observations, and staff interviews, it was determined that the facility failed to implement effective safety measures by not supervising residents during mealtime for one of three floors (Third Floor), and failed to make certain that each resident received adequate monitoring of elopement (leaving an area without permission) devices for one of two residents (Resident R82).

Inspectors wroteBased on review of resident clinical records and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R66) for two of four days.

Inspectors wroteBased on facility policies, clinical record review, and staff interview, it was determined that the facility failed to identify a diagnosed specific condition for treatment for one of three residents receiving psychotropic medications (Resident R62). Review of facility policy Psychoactive Medication Policy dated 1/10/25, indicated diagnoses supporting the use of psychoactive medication will be documented in the medical record. Review of the clinical record revealed Resident R62 was admitted to the facility on [DATE]. Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/25/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). [...]

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications on one of three nursing units (Second Floor), one of two medication rooms (Third Floor Medication Room), and two of three medication carts (Three South Medication Cart and Three East Medication Cart).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for three of four residents (Resident R39, R62, and R81).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R81).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for one of six residents (Resident R63).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for two of six residents (Resident R6, and R63).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication for four of five staff members (Employee E11, E12, E13, and E14).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview it was determined that the facility failed to make certain residents are free from significant medication errors for one of three ( Resident R1).

Inspectors wroteBased on review of facility policy, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on five of five medication carts reviewed (2 North, 2 South, 3 East, Memory Impaired Unit (MIU), and 3 South).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (3 East Medication Cart).

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to complete admission activites evaluation for three of three residents as required. (Residents R1, R2 and R3)

Inspectors wroteBased on clinical records and staff interview, it was determined that the facility failed to revise a care plan for one of three residents (Resident R3) to accurately reflect the current status of the resident.

Inspectors wroteBased on review of facility policy, resident grievances for 60 days, resident counsel meetings for 60 days, and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to a resident in a timely manner in relation to a concern documented via resident council minutes and complete the reports in their entirety for one of three concerns reviewed.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required time frame for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R1), which resulted in actual harm of a left arm humerus fracture for Resident R1. This deficiency is cited as past non-compliance.

Inspectors wroteBased on review of facility documents, facility policy, and staff interviews, it was determined that the facility failed to implement written policies and procedures to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents were assessed and received the necessary services to prevent pressure ulcers/wounds from developing for one of three residents (Residents R1).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Residents R3, R4, R5, and R6). Findings Include: Review of the facility's undated Nurse Aide job description indicated the purpose of your job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Performs direct care to the residents as assigned, in accordance with the resident's care plan, and as directed by your supervisor. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection control measures during a COVID-19 outbreak for one of two nursing floors (2nd floor).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents it was determined that the facility failed to provide adequate supervision to prevent elopement for one of twenty Residents (Resident R1).

Inspectors wroteBased on review of facility documentation, and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for an elopement for one of 15 Residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview it was determined that the facility failed to implement a care plan for a behavior for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to identify a resident's risk for elopement and failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R1). [...]

Inspectors wroteBased on an observation and staff interviews, it was determined that the facility failed to prominently display Nurse Staffing Information on 7/30/24, as required

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to provide an environment that was free of accident hazards, failed to ensure that residents received neurological assessments after a fall, consistently document incident report and post-fall investigation in the (Electronic Health Record -E.H.R.), failed to complete a new nursing fall risk evaluation (E.H.R.) after a fall, and failed to consistently document regarding post-incident response/symptoms for seventy two hours after a fall, for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of two residents reviewed (Resident R3).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of five residents sampled with facility initiated transfers (Residents R35, R52, R54, R77 and Closed Record(CR) CR86).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R35, R52, R54, R77 and Closed Record (CR) R86). Findings Include: Review of the facility policy Bed Hold Letter Policy, dated 1/15/24, indicated it is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. Business office or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties' certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. [...]

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products, monitor food expiration dates, properly restrain facial hair, and properly maintain kitchen equipment in a sanitary condition in the Main Kitchen creating the potential for food-borne illness.

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for seven out of ten resident rooms (Resident R47, Resident R10, Resident R9, Resident R61, Resident R70, Residents R3, and Resident R63).

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that the facility develop and implement a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of nine residents (Residents R11, R32, R51), and failed to ensure the comprehensive care plan for a seat belt release was implemented for one of three residents (Resident R54).

Inspectors wroteBased on review of the pharmacy recommendations, clinical record, and staff interview, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for three of four residents (Resident R3, R41, and R60).

Inspectors wroteBased on review of facility policy, resident records, and staff interviews it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration for one of four residents and the facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications for three out of four residents (Residents R41, R60, and R61).

Inspectors wroteBased on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing floors (second floor).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure a resident representative was notified in advance of care conference meetings for one of two residents (Resident R3).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify a family representative of a change in condition for two of ten residents (Resident R41 and CR85).

Inspectors wroteBased on review of facility policy, resident records, resident group, and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for two of three residents (Resident R7 and R89).

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of five residents (Resident R11).

Inspectors wroteBased on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for two of six residents (Resident R32 and R77).

Inspectors wroteBased on clinical record review, job description review, observation, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of six residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical record review, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for one of two residents (Resident R14).

Inspectors wroteBased on review of wound tracking documentation, resident clinical records and staff interview it was determined that the facility failed to provide a weekly wound assessment for one of two resident records with a non-pressure skin concern (Resident R67).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to accurately monitor and assess for changes in skin condition for one of six residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to provide an environment that was free of accident hazards and the facility failed to ensure that residents received neurological assessments after an incident involving a fall for four of six residents (Residents R3, Resident R61, Resident R60, and Resident R88).

Inspectors wroteBased a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored, and a resident was timely assess for nutritional status for one of three residents (Resident R11).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for one of four residents (Resident R32).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R11).

Inspectors wroteBased on observations, clinical record review, resident council group interview, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two of ten residents (Resident R62 and R14). Findings Include: Review of the Facility assessment dated [DATE], indicated staff assignments are determined by acuity, interpersonal needs, and census to adequately provide person centered care. Within each assignment, the individual needs of the resident are acknowledged by the care nurse. It stated it is the facility's goal to ensure the health, safety, comfort, and well-being of the resident. [...]

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R62).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R3)

Inspectors wroteBased on a review of facility policies, facility documents, a resident group interview, resident representative interviews, and staff interviews, it was determined that the facility failed to serve food products that appeared palatable for the supper meal on 4/10/24. (supper meal 4/10/24)

Inspectors wroteBased on review of facility documents, resident clinical record, and staff interview it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of a resident lacking capacity to understand the agreement terms for one of three residents (Resident R50).

Inspectors wroteBased on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to dispose of PPE (Personal Protective Equipment) appropriately and perform hand hygiene practices consistent with accepted stands of practice, which created the potential for the cross-contamination and the spread of diseases and infections on one of two nursing floors (Third floor).

Inspectors wroteBased on facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of six residents (Resident R1).

Inspectors wroteBased on review of facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide access to medical records to a resident or representative within a 24 hour period and/or to provide copies of medical records to the resident or representative within 48 hours for one of seven residents (Resident R1).