Heritage Care Center

Inspectors wroteBased on review of facility policy, Resident Council meeting minutes, and resident and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (February 2026, March 2026, and April 2026).

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 one of two residents sampled with facility-initiated transfers (Resident R1) and 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 one of two resident hospital transfers (Residents R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R6).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for bathing for six of seven residents sampled (Resident R1, R2, R3, R4, R5, and R6). Findings Include:Review of the facility policy Homelike Environment dated 10/7/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. During a facility tour and observation with Maintenance Director Employee E1 on 2/25/26, between 9:00 a.m. and 9:28 a.m. [...]

Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide residents with food products based on their preferences for 18 of 27 residents (Resident R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710). Based on observations, resident and staff interviews it was determined that the facility failed to provide residents with food products based on their preferences for eighteen of twenty-seven residents (Resident R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710). [...]

Inspectors wroteBased on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly label and date food products in the walk-in cooler and freezer in the designated main kitchen.

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for two of four residents (Resident R60 and R99) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing and gloving during medication administration for one of five residents observed (Resident R19), and failed to complete Infection Control surveillance from November 2024 through November 2025, failed to monitor Antibiotic Stewardship for May 2025 and failed to provide vaccines for flu, pneumonia and COVID-19 to 105 of 105 residents for the 2025 season, resulting in substandard quality of care.

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for one of 11 months (May 2025).

Inspectors wroteBased on a review of facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for 105 of 105 residents reviewed for influenza and pneumococcal immunizations resulting in substandard quality of care.

Inspectors wroteBased on review of clinical records and interview with staff, it was determined that facility failed to ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105 residents.

Inspectors wroteBased on review of facility policy, resident and staff interview it was determined that the facility failed to follow up on resident grievances for eleven residents. Finding s include: Review of the facility policy dated 2/1/25, Skilled Nursing Facility Grievance Policy indicated: Purpose - To ensure all residents resident representatives and responsible parties in the skilled nursing facility have the right to voice concerns, file grievances, and receive a prompt, though, an impartial response without fear of retaliation. Acknowledgement the grievance official will acknowledge receipt of the grievance in 3 business days. A written decision will be issued within one week unless extenuating circumstances. [...]

Inspectors wroteBased on observation, resident and staff interview identified that the facility failed to protect Resident R111 from potential burn accident/incident when providing a hot pack without a Physician order and monitoring the use /time placed and failed to provide adequate supervision for Resident R20 during med pass for one of two nursing units. During an observation on 11/18/25, at 8:25 a.m., Resident R111 asked the SA to go into her bedside stand drawer and get out the hot pack and place it on her left shoulder. The SA observed the disposable hot pack and told the resident that the nurse would be told. Resident R111 stated that the nurses always give me them. During a clinical record review Resident R111 was admitted to the facility on [DATE], with diagnoses which included a stoke causing left side hemiparesis. [...]

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of three residents (Resident R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment center for one of three residents (Resident R120).

Inspectors wroteBased on review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 105 of 105 residents.

Inspectors wroteBased on 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 three of three quarterly meetings (Quarter one, two, three of 2025).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen.

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R42). Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R42).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to assess and accommodate a resident's request for enabler rails (Resident R105).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post complete and current contact information for the Adult Protective Services, State Long Term Care Ombudsman, and correct information for the Grievance Officer on two of two nursing units (Second and Third Floor nursing units).

Inspectors wroteBased on observation, resident and staff interview, it was determined that the facility failed to ensure all residents had access to a resident only telephone (Second and Third floor nursing units).

Inspectors wroteBased on review of clinical records and resident family and staff interviews it was determined that the facility failed to notify the residents responsible party of a change in a residents nursing care status (skilled nursing care with therapy to nursing care without therapy) for one of three residents Resident R119.

Inspectors wroteBased on review of facility policy, observations, resident and staff interviews it was determined that the facility failed to maintain a homelike environment for three of nine residents (Resident R7, R24, and R46).

Inspectors wroteBased on review of clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of three residents (Residents R20).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for three of twelve residents (Resident R10, R69, and R84).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of six residents (Residents R105) to accurately reflect the current status of the resident.

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 (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of four residents (Residents R60, R99, and R117).

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed parenteral fluids (the delivery of medication or nutrition into the body via routes that bypass the gastrointestinal tract) consistent with professional standards of practice for one of two residents (Resident R93).

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 five of eight sampled residents (Residents R35, R74, R99, R105, and R120).

Inspectors wroteBased on observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident R19).

Inspectors wroteBased on observation, review of facility policy, manufacturer recommendations, resident interviews, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents observed (Resident R19).

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

Inspectors wroteBased on observation, and staff interview it was determined that the facility failed to properly approve the current menu cycle with the registered dietician as required for two of two nursing units (second and third floor nursing units).

Inspectors wroteBased on facility policy, observation and resident and staff interview it was determined that the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for one of two residents (Resident R111). During an interview on 11/18/25, at 8:25 a.m., Resident R111 was attempting to eat her breakfast out of a foam container. Resident R111 stated that she is supposed to have a scoop plate so she can feed herself, but the dish machine has been broken, and the facility has been using foam. Review of Resident R111's current care plan indicated the use of a scoop dish for all meals. [...]

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

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop and implement discharge planning processes that focused on residents discharge goals for one out of three discharged residents sampled (Resident R1). Findings Include: Review of facility policy Transfer or Discharge, Preparing a Resident for, dated 9/5/25, previously reviewed 9/25/24, indicated residents will be prepared in advance for discharge. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly store food products and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on review of resident clinical records and staff interview it was determined the facility failed to have active physician orders for dialysis for two of two residents (Resident R2 and R3).

Inspectors wroteBased on review of resident clinical records and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of seven residents (Resident R1 and R4).

Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly store chemicals, properly label and date food products, properly store food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, maintain the cleanliness and sanitation of the Main Kitchen. (Main Kitchen).

Inspectors wroteBased on a review of facility policies,documents, observations and staff interviews it was determined that the facility failed to provide a dignified dining experience on 2/19/25, during the lunch meal service to four of seven residents. (Resident R1, R2, R3, and R4).

Inspectors wroteBased on a review of facility job descriptions and staff interviews it was determined that the facility failed to provide a qualified Food Service Director (FSD) to manage the daily operations of the Food Service Department for 99 days (11/22/24, through 2/18/25)

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for three of ten residents (Residents R4, R33, and R60) to accurately reflect the current status of the resident.

Inspectors wroteBased on review of facility policies, observations, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R19, R42, and R53).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R63, and R86), and failed to have a care plan for monitoring of access site for one of two residents (Resident R86).

Inspectors wroteBased on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for three of three sampled records (Nurse aide (NA) Employees E14, E15, and E16).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications on four of four medications carts (2 West, 2 East, 3 East and 3 South Medication Cart) and for one of three residents (Resident R87).

Inspectors wroteBased on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for three of three residents (Resident R6, R33, and R35).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to provide a bed, a mattress and functional furniture in resident rooms on the first floor for 13 out of 13 rooms (First Floor).

Inspectors wroteBased on review of observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for two of five residents (Resident R19 and R24).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to uphold privacy and dignity of resident information for one of three sampled resident (Resident R77). Findings Include: The facility Resident rights policy dated 9/25/24, indicated that Federal and state law guarantees certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. Review of Resident R77's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R77's MDS assessment (MDS-Minimum Data Set assessment: [...]

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for one out of five personnel records (Registered Nurse Employee E2).

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 two out of four residents sampled with facility-initiated transfers (Residents R48 and R53).

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 (CR1).

Inspectors wroteBased on review of clinical records, resident and staff interview it was determined that the facility failed to assess a CGM (continuous glucose monitoring device), obtain physician orders for care and management of and failed to have a care plan for care and management of the device for one of three residents (Resident R309).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of three residents (Resident R4, R35).

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for one of four residents (Resident R11) with an indwelling urinary catheter.

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 one of four residents (Residents R22).

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 three residents (Resident R89).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two out of six months (July 2024 and September 2024).

Inspectors wroteBased on observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident R96, and R80).

Inspectors wroteBased on review of facility meal delivery times, observations and staff interview, it was determined that the facility failed to deliver meals in a timely manner for one of two meal observations (Third floor).

Inspectors wroteBased on review of facility policies and 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 one of three residents (Resident R53).

Inspectors wroteBased on review of facility documents, resident clinical record and staff interviews 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 sampled residents (Resident R96).

Inspectors wroteBased on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for enhanced barrier precautions (EBP- a type of isolation requiring gloves, gowns, and possible face shield to be worn with care) for two of three residents (Resident R16 and R48), and failed to adhere to proper handwashing prior to insulin administratioin for one of two residents (Resident R16).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three out of nine residents (Residents R1, R2, R3).

Inspectors wroteBased on a review of facility policies, documents, menus, observations, and resident family and staff interviews it was determined that the facility failed to follow resident food preferences for six of 12 residents (Resident R1, R4, R5, R10, R11, and Resident R12.)

Inspectors wroteBased on a review of facility policy, observations, and staff interviews it was determined that the facility failed to make certain that residents are served food products that meet their dietary needs for one of eight residents (Resident R7).

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 dislocated shoulder for Resident R1.

Inspectors wroteBased on review of facility documents, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate assistance with an appropriate device to prevent falls for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1.

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 conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care.

Inspectors wroteBased on a review of 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 two residents (Resident R1).

Inspectors wroteBased on review of clinical records, resident interview, and staff interviews, it was determined that the facility failed to document and/or institute interventions for a fall for one of two residents (Residents R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for one of two residents (Residents R2).

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 units (Second floor).

Inspectors wroteBased on a review of facility policies, observations and resident and staff interviews it was determined that that the facility failed to provide the residents a dignified dining experience for the breakfast and lunch meals on 7/26/24. (Breakfast and lunch meals)

Inspectors wroteBased on a review of facility standardized recipes, observations and staff interviews it was determined that the facility failed to provide alternate menu selections of equal or greater nutrient value for the chef salad alternate selection.

Inspectors wroteBased on a review of facility policies, documents, menus, observations, and resident family and staff interviews it was determined that the facility failed to follow resident food preferences for seven of eight residents (Resident R1, R2, R3, R4, R5. R6. and R8), to make certain all alternative menu selections offered on the Always Available menu are available (food supply Main Kitchen) , and provide an easy process for alternative menu selections be made by the resident or resident representative for the breakfast and lunch meals on 7/26/24. (Breakfast and lunch meals 7/26/24).

Inspectors wroteBased on a review of facility policy, documents, observations and staff interviews it was determined that the facility failed to provide two of two meals on 7/26/24, [NAME] timely manner. (Breakfast and Lunch meal service 7/26/24)

Inspectors wroteBased on a review of facility policies, documents and staff interviews it was determined that the facility failed to resolve five of 12 grievances from the time period of 4/1/24 through 7/18/24 (4/1/24, 4/28/24, 5/19/24, 6/12/24, and 7/1/24).

Inspectors wroteBased on a review of facility documents it was determined that the facility failed to assess, analyze and sustain improvements (Plan of Correction (POC) in deficient practices cited for abbreviated surveys completed on 5/22/24 and 6/16/24. ( POC for survey completed on 5/22/24 and 6/16/24)

Inspectors wroteBased on review of facility policy, documents and staff interviews it was determined that the facility failed to permit Resident R9 to return to the facility as required. (Resident R9)

Inspectors wroteBased on a review of facility documents and staff interviews it was determined that the facility failed to provide proper supervision to a resident (Resident R9) which resulted in the residents's elopement. (Resident R9)

Inspectors wroteBased on a review of facility policy, observations and staff interviews it was determined that the facility failed to make certain that residents are served food products that meet their dietary needs for one of eight residents (Resident R7).

Inspectors wroteBased on a review of facility policies, Resident Council Minutes, and resident and staff interviews it was determined that the facility failed to provide a nourishing evening snacks to all residents. (all residents)

Inspectors wroteBased on a review of facility policy, documents, and resident and staff interviews, it was determined that the facility failed to provide Facility Sponsored Group activities during the evening hours during the week and on weekends for six of six months. (1/24, 2/24, 3/24, 4/24, 5/24, and 6/24)

Inspectors wroteBased on a review of facility policies, three week Spring/Summer 2018 cycle menu, and staff interviews it was determined that the facility failed to provide the residents an alternative menu selection for the lunch and dinner meals that was of equal or greater nutrient value and appeal for the three week menu cycle. (Week One, Week Two, and Week Three)

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, functional environment for residents, staff and visitors on two of two nursing units (Second Floor Nursing Unit and Third Floor Nursing Unit)

Inspectors wroteBased on review of facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen.

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to follow physician orders for medication and treatment administration for four of four residents reviewed (Resident R1, R2, R4, and R5).

Inspectors wroteBased on resident interviews, staff interviews, clinical record review, 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 ten of 17 residents reviewed (Resident R1, R2, R3, R4, R6, R7, R8, R9, R11, and R12).

Inspectors wroteBased on resident interviews, and staff interviews, it was determined that the facility failed to serve food products at palatable temperatures for three weeks.

Inspectors wroteBased on facility documents, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of four residents ordered nectar thickened liquids (liquids that are thickened to ease with swallowing difficulties), and one in 20 residents ordered easy to chew diet textures.

Inspectors wroteBased on review of facility documents, resident interviews, and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for three weeks.

Inspectors wroteBased on review of facility documents, meal delivery observations, resident interviews, and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for three weeks.

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident was free of a significant medication error for one of four residents (Resident R4).

Inspectors wroteBased on a review of facility admission information packet, resident records, and staff interviews, it was determined that the facility failed to provide advanced (48 hours) written notification of changes in the covered services provided to the residents for all payment sources for three of four residents (Resident R1, R2 and R3)

Inspectors wroteBased on a review of facility policies, review of medical records, and insurance provider reviewer and staff interviews it was determined that the facility failed to properly implement a facility initiated discharge for one of 10 residents (Resident R1)

Inspectors wroteBased on a review of facility policies, documents, resident records and staff interviews it was determined that the facility failed to properly provide written motivation of discharge from the facility for one of 10 residents (Resident R1)

Inspectors wroteBased on a review of facility policies, documents, resident medical records and staff interviews it was determined that the facility failed to implement a safe and orderly discharge from the facility for one of 10 residents (Resident R1)

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, maintain equipment in a sanitary manner and maintain the appropriate chemical strength for the sanitizing solution in the Main Kitchen. (Main Kitchen)

Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly dispose of refuse, properly store soiled linen, and maintain the outdoor refuse area in a clean and sanitary manner to prevent the potential for rodent and insect infestation in the outdoor refuse area. (Outdoor Refuse Area)

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to use PPE (Personal Protective Equipment) appropriately which created the potential for the cross-contamination and the spread of diseases and infections on one of three nursing units (Second floor nursing).

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 three residents reviewed (Resident R6).

Inspectors wroteBased on review of facility policy, resident record, investigation documents and staff interview, it was determined that the facility failed to report an incident of neglect for one of three sampled residents (Resident R113).

Inspectors wroteBased on a review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for four of four residents (Resident R22, R30, R121 and R7).

Inspectors wroteBased on a review of facility policy, documents, and staff interviews, it was determined that the facility failed to follow a physician order, and failed to coordinate a diagnostic imaging procedure for one of seven residents (Resident R17), and the facility failed to transcribe and follow a physician order for one of seven residents with skin impairment (Resident R121). Review of Resident R17's admission record indicated he was admitted on [DATE], with diagnoses that included osteomyelitis (bone infection), muscle wasting, morbid obesity and chronic heart failure (heart muscle doesn't pump blood as well as it should). Review of Resident R17's MDS assessment (Minimum Data Set assessment- a periodic assessment of resident care needs) dated 11/7/23 indicated that these diagnoses current upon review. [...]

Inspectors wroteBased on review of facility policies, observations, clinical record, communication documents and staff interview it was determined that the the facility failed to coordinate care and acquire a physician's order to modify the route of medication administration for one of six residents receiving medications via a G-tube (Resident R113), and failed to adminster enteral feedings as per pharmacy standards for one of six sampled residents (Resident R30).

Inspectors wroteBased on review of manufacturer's recommendations, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R82).

Inspectors wroteBased on a review of the facility's three week cycle menu and staff interviews it was determined that the Registered Dietitian (RD) failed to approve the menu prior to implementation for three of three cycle menu weeks (Week one, Week two and Week three).

Inspectors wroteBased on observations, review of facility documents, and interviews with staff and residents, it was determined that the facility failed to serve food that was following resident preference and selections on meal tickets for three of eight residents (Residents R45, R51, and R83).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment and floors in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for two of five residents. (Resident R1 and R2).