Heritage Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were able to communicate freely with the State Survey Agency (SSA) when the facility's Social Service Director (SSD) and Administrator confronted one resident after the resident voiced concerns about calling the SSA hotline (Resident #15). The sample was 10. The census was 103. Review of the facility's Grievance policy, dated 12/27/24, showed the following:-Purpose: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal;-Resident Right to File a Grievance: Every resident has the right to voice their grievance with the facility or other agency. Grievances could include care and treatment that was not provided, behavior or staff or other residents, or any other concerns regarding their stay. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the rights of residents to choose their own physician. The facility discontinued services with Physician A, who provided care to 15 residents. Of those, 4 residents were sampled and 2 reported concerns with being unable to choose their physician (Residents #2 and #7). The sample was 8. The census was 104. Review of the facility's Resident Rights policy, dated 9/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. Facility must protect and promote rights of each resident, including each of the following rights:--Notice of Rights and Services: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #7), who had a history of elopement at prior facilities, was provided adequate supervision, when staff did not confirm the resident's whereabouts for at least 4.5 hours (from 2:30 P.M. to approximately 7:00 P.M.) on 01/12/26. Review of the resident's record showed the resident had a legal guardian and diagnoses which included schizoaffective disorder (a chronic mental health condition of schizophrenia symptoms (such as hallucinations, delusions, or disorganized thinking), bipolar type (involves alternating 'poles' of intense, elevated, or irritable mania/hypomania and profound, low energy depressive episodes that severely disrupt life), lack of coordination and muscle weakness. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policies when staff failed to conduct a thorough investigation of a resident-to-resident altercation between two residents, when one resident (Resident #1) pulled a screwdriver on another resident (Resident #2) and attempted to stab him/her. The sample was eight. The census was 109. Review of the facility's Incidents and Accidents policy, revised 05/18/24, showed:-Purpose: It is the policy of this facility for staff to utilize Point Click Care Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident;-Definition:Incident: An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization;-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. In addition, the facility failed to have a facility assessment that addressed staffing ratios required per shift to meet the needs of residents, the need for a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, designated an RN to serve as the Director of Nursing (DON), and followed their infection control prevention and control program by ensuring residents received required immunizations. There was no documentation of ratios of direct care staff, restorative therapy staff, Social Services staff, dietary staff, housekeeping and laundry staff necessary on each shift to ensure the needs of residents are met. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they failed to ensure they implemented appropriate interventions to correct on-going, systemic issues. This had the potential to affect all residents. The census was 105. Review of the facility's QAPI Plan, dated 5/14/21, showed:-This QAPI plan provides guidance for the facility overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when the facility failed to ensure an active Legionnaires' (Legionella, bacteria in water that causes pneumonia) program was in place. In addition, staff did not pick up or replace oxygen or nebulizer tubing left on the bedroom floor for 3 of 3 residents sampled who received oxygen and breathing treatments (Residents #54, #2 and #45). The sample was 43. The census was 105. Review of the infection prevention and control program, revised 5/7/24, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship program was in place and in use by failing to collect data regarding antibiotic treatment, reviewing and documenting the data to the antibiotic surveillance program. Five residents were identified as receiving antibiotics and issues were discovered with all five (Residents #9, #34, #2, #72 and #64). The sample was 43. The census was 105. Review of the Infection prevention and control program, revised 5/7/24, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training and certification in infection prevention and control as the Infection Control Preventionist (ICP) for the facility's infection prevention control program. The census was 105. Review of the Infection prevention and control program, revised 5/7/24, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment for resident areas throughout the building. The census was 105. 1. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The census was 105. Review of the facility's Registered Nurse (RN) policy, dated 4/30/24, showed:-Purpose: It is the intent of the facility to comply with Registered Nurse staffing requirements;-Full-time is defined as working 40 or more hours a week;-Charge Nurse is a licensed nurse with specific responsibilities designed by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care;-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for nine residents (Residents #2, #7, #11, #72, #64, #13, #67, #35 and #85). The sample was 43. The census was 105. Review of the facility's Medication Regimen Review (MRR) policy, dated 6/26/24, showed: -Purpose: the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the medical chart;-Policy: -MRR or drug regimen review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate, as desired, eligible residents with the pneumococcal (pneumonia) and influenza (flu) vaccine for 5 out of 5 residents sampled for immunizations (Residents #85, #72, #67, #54 and #45). The sample was 43. The census was 105. Review of the influenza and pneumococcal immunization policy, revised 5/14/24, showed:-Purpose: to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease;-Procedure: -At admission, the resident and/or the resident's legal representative will be provided education on the benefits and potential side effects of both the influenza and pneumococcal immunizations; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who experienced bilateral (both sides) finger amputations, had an accessible device to call for staff assistance (Resident #40). The sample was 43. The census was 105. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/11/25, showed:-Cognitively intact;-Able to make needs and wants known;-Required physical assistance for eating; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 98 residents. The census was 105. Review of the facility's Resident Trust policy, dated 6/12/25, showed Resident Trust clerk must reconcile the cash left in the box with the receipts in the box by completing the Resident Trust Petty Cash Reconciliation Form. Attach all receipts in the petty cash box to the Resident Trust Petty Cash Reconciliation form. The administrator signs reconciliation form for approval. Review of the facility-maintained bank statements for the months 4/25 through 7/25, showed no documentation of reconciliations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident was placed in a head lock by Floor Tech N (Resident #39). The sample was 43. The census was 105. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following:-Purpose: -It is the policy of this facility ensure all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Physical Abuse: -Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of one resident's patient trust funds, which was used without authorization of the resident. The funds were withdrawn from resident's patient trust account between the dates of 4/10 and 4/17/25, with total withdrawals of $7,877.01 (Resident #20). The census was 105. Review of the facility's policy titled, Abuse and Neglect, dated 6/12/24, showed:-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent;-Theft of money from bank accounts;-Unauthorized or coerced purchases from resident's funds;-The Administrator will conduct all investigations. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital and the facility's bed hold policy at the time of transfer for three residents who were discharged to the hospital (Residents #119, #69 and #114) out of three residents sampled for bed hold notification. The census was 105. Review of the facility's undated admission agreement, showed facility offers a bed hold policy which assures you of re-occupation to your bed during a temporary absence from facility due to therapeutic leave or hospital admission. If you choose not to hold the bed during an absence from the facility, that bed shall be considered vacant and facility may place another resident in it for occupancy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify the residents' hospice admission (Residents #10 and #36). The facility identified three residents receiving hospice services, two were sampled. The census was 105. 1. Review of Resident #10's face sheet, showed his/her diagnoses included malignant neoplasm (cancerous tumors) of cecum (pouch that forms the first part of the large intestine), secondary malignant neoplasm of liver and intrahepatic bile duct, and secondary malignant neoplasm of left lung. Review of the resident's Physician's Orders Sheet (POS), showed an order, dated 5/20/25, okay for hospice to evaluate and treat. Review of the resident's care plan, in use during survey, showed:-Problem: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who re-admitted to the facility on [DATE] with a recommended hospice evaluation received the ordered hospice evaluation. The resident's physician assessed the resident on 7/18/25 and documented the resident received hospice services. On 7/30/25, the resident experienced a change in condition. Staff discovered the resident had not been enrolled into hospice services and did not notify the physician of the discovery. The resident expired at the facility approximately three hours after the change in condition (Resident #118). The census was 105. Review of the notifying clinician's policy, revised 6/26/24, showed:-Purpose: to ensure clinicians are properly notified of a resident's change in condition and overall, health and mental status;-Policy: -Process for notification: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete smoking assessments for two residents, to evaluate their smoking behavior risks. Both residents were smoking in their rooms. In addition, the facility failed to develop and implement appropriate safety interventions (Residents #7 and #108). The census was 105. Review of the facility's policy entitled, Smoking Safety Regulations, dated 6/23, showed:-Policy: to ensure staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protections Association (NFPA).-Facility will provide direct supervision for smoking by patients classified as not responsible. Review of the facility's undated admission agreement, showed:-Section M, entitled Smoking: smoking is allowed only in designated smoking areas and times set forth by the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pain management regime for one sampled resident (Resident #90). Staff failed to ensure Resident #90, who experienced pain related to chronic osteomyelitis with drainage sinus, right tibia and fibula involvement (a long-standing bone infection affecting the shinbone) and chronic pain most severe on the right knee, received physician prescribed Percocet (narcotic which treats moderate to moderately severe pain). The sample was 21. The census was 105. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free from significant medication errors. Staff attempted incorrect administration technique for one resident, when he/she did not prime the insulin Flex pen in accordance with facility policy (Resident #2). The census was 105. Review of the facility's medication administration of insulin policy, revised May 2024, showed:-Prepare an insulin dose, before administering insulin, perform two nurse verifications of the correct resident, dose calculations, and correct route of administration.-Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir,-Dial 2 units (U) by turning the dose selector clockwise,-With the needle pointed up, push the plunger and watch to see that at least one drop (gtt) appears. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain controlled substances in a restricted area until appropriate medical staff could destroy them. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) medication cart assigned to the B and D halls held two discharged residents' narcotics for several weeks (Residents #114 and #117). The census was 105. Review of the facility's Narcotic Destruction Policy, revision date 6/24, showed:-All controlled substances shall be retained in a securely locked area with restricted access until authorized nursing personnel destroy them;-Any medication that is to be destroyed is to be locked in a separate cabinet and labeled to be destroyed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pain management regime for one of three sampled residents (Resident #1). Staff failed to administer a stronger physician ordered pain medication for Resident #1, who complained of severe back pain. The census was 112. Review of the facility's Pain Management Policy, updated 6/26/24, showed the following: -Purpose: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan and the resident's goals and preferences; -Policy: The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain; -Recognition of Pain: 1 a. [...]

Inspectors wrotePlease see deficiency cited at F689 in Event ID 533H12. This citation is uncorrected. See the narrative at Event ID 533H11. This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 3/14/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), with a known history of suicidal ideation, high risk of suicide and frequent self-harming behavior received adequate supervision. The facility determined the resident required close supervision, defined as supervision from three to five feet, to ensure the resident's safety and well-being. Per the resident's care plan, the resident was to receive 1:1 monitoring. On 3/3/25, staff assigned to provide 1:1 supervision for the resident were reassigned to other duties and left the resident unsupervised in his/her room with the door closed. The resident broke the window in his/her room and used the glass to cut himself/herself resulting in multiple deep cuts requiring medical intervention. The sample size was eleven. The census was 106. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to allow one resident (Resident #4) to participate in his/her own plan of care, when the resident was placed in a secured/locked unit based solely on his/her history of justice involvement. This failure did not support the resident's goals, choices, and preferences. This practice affected one resident who was admitted into the facility and immediately placed on the secured unit due to his/her status as a sex offender (Resident #4). The resident was described as being visibly upset when he/she got to the facility. The resident stated he/she did not want to come to this facility, and no one asked or provided him/her any paperwork. The resident stated he/she didn't do anything and didn't know why he/she was locked up in this place. The sample was 5. The census was 111. [...]

Inspectors wroteBased on observation, interview, and record review, the facility placed one resident (Resident #4) on a secured/locked unit within the facility, without clinical justification and an assessment of whether the individual met the criteria for admission on to a secured unit. The facility placed the resident, who was cognitively intact and their own responsible person, on the secured unit- based solely on his/her status as a registered sex offender. The resident stated he/she did not want to come to this facility, and no one asked or provided him any paperwork. The resident stated he/she didn't do anything and didn't know why he/she was locked up in this place. The sample was 5. The census was 111. Review of the facility's Sex Offender (Resident) Policy, revised 12/1/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to facilitate residents' rights to have reasonable reliable access to and privacy in their use of electronic communications such as email and video communications, for internet research and to watch television when the facility failed to provide WiFi services. This had the potential to affect all residents at the facility. The sample was 7. The census was 106. Review of facility's Internet Provider documentation, showed: -Notice of Material Breach: -The facility was sent notification on/or around 9/16/24 by the Internet Provider that detailed the facility's violation of their Acceptable User Policy and the agreement. The facility shared its business/office only internet with the residents living at the facility. The residents then hooked up their personal devices to the business/office only internet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain effective pest control by ensuring resident rooms were free from mice and/or mice excrement in Residents #9, #10, and #11's rooms. In addition the facility failed to ensure the common/activity area on C-Hall was free from roaches. The sample was eleven. The census was 106. Review of the facility's Pest Control policy, last reviewed 5/14/24, showed: -Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats); -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure before the facility transferred or discharged a resident, they notified the resident, who was his/her own responsible party, of the transfer or discharge and the reasons for the move in writing. The facility failed to ensure the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged , and that the discharge or transfer notice included the reason for transfer or discharge, effective date, location in which the resident would be discharged , and the resident's right to appeal for one resident (Resident #5). The sample was 5. The census was 111. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, revised 5/14/24, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when staff did not clarify the instructions on one resident's discharge paperwork with the eye clinic after his/her eye appointment, which resulted in his/her eye surgery not being scheduled (Resident #6). The sample was 5. The census was 111. Review of the facility's Transcription of Orders/Following Physician's Order policy, revised 5/18/24, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Procedure: Clarification of physician's orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the physician's orders. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete a comprehensive discharge summary for one discharged resident record reviewed (Resident #5). The sample was 5. The census was 111. Review of the facility's Nursing Discharge Summary policy, revised 5/14/24, showed: -Purpose: It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies; -Definitions: -Anticipated discharge means that the discharge is planned and not due to the resident's death or an emergency; -Continuing care provider means the entity or person who will assume responsibility for the resident's care after discharge. This includes licensed facilities, agencies, physicians, practitioners, and/or other licensed caregivers; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there were sufficient and competent staff to care for one resident who required 1:1 staff supervision for safety and behaviors (Resident #1). Staff failed to follow the resident's care plan intervention of avoiding power struggles when the resident wanted to go to bed but was told there was not enough staff to take him/her. This contributed to the resident's escalated aggressive behavior which resulted in the resident being sent out to the hospital via ambulance. The sample was 8. The census was 106. Review of the facility's Sufficient Staff policy, revised 5/18/24, showed: -Purpose: [...]

Inspectors wroteSee the narrative at event ID WGJ612 Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated 9/13/24, for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on 1/13/25, staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on 1/17/25. The sample was 10. The census was 110.

Inspectors wroteThis citation is uncorrected. See the narrative at Event ID WGJ612 This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated [DATE]. Based on interview and record review, the facility failed to follow their abuse and neglect policy by failing to conduct a thorough investigation for one resident (Resident #7) who had an order for a mechanical soft diet and was served a regular diet. The resident choked and later expired in the hospital. The sample was 10. The census was 110.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated 9/13/24, for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on 1/13/25, staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on 1/17/25. The sample was 10. The census was 110. The Administrator was notified on 1/30/25 at 12:23 P.M. of an Immediate Jeopardy (IJ) which began on 1/13/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they followed their abuse and neglect policy by failing to conduct a thorough investigation into one resident (Resident #8) who was found to have unknown pills in his/her possession and allegedly drank a solution of magnesium citrate (a salt that contains magnesium and citrate ions which is commonly used as a laxative to treat occasional constipation). The sample was eight. The census was 110. Review of the facility's policy, When to Notify Management, dated 8/2/24, showed the following: -Purpose: The purpose of this policy is to ensure that the facility management and Regional Director are notified for concerns related to the protective oversight of residents and facility operations. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident (Resident #2) and another resident (Resident #3) were involved in three resident to resident altercations before Resident #2 was moved to another hall. In addition, the facility did not update the residents' care plans with interventions after each resident to resident altercation. The sample was five. The census was 112. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection, Covid 19 (respiratory virus spread by breathing, coughing and sneezing). The facility had active Covid 19 infections on all halls per signage upon entering. The signs instructed all visitors and staff to wear an N95 mask. Visitors and staff failed to wear N95 masks and or failed to wear them appropriately. This had the potential to affect all residents. The census was 112. Review of the facility's policy on Personal Protective Equipment, updated 6/26/24, showed the following: -Purpose: Thee facility promotes appropriate use of personal protective equipment (PPE) to prevent the transmission of pathogens to residents, visitors and other staff; -Policy: A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities for errors, six errors occurred, resulting in an 22.22% medication error rate (Resident #6). The census was 112. Review of the facility's Medication Administration Policy, dated 6/26/24, showed the following: -Purpose: Medications are administered by licensed nurses and other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice. It is the policy of this facility to ensure the safe and effective administration of of all medications by utilizing best practice guidelines; -Policy: General Medication Administration Practice: C. Identify resident by photo in the medication administration record (MAR). J. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a significant medication error. Staff failed to transcribe antipsychotic medication as ordered for one of six sampled residents, resulting in the resident receiving the incorrect dosage of an antipsychotic medication (Resident #6). The census was 112. Review of Resident #6's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/24, showed the following: -Diagnoses of high blood pressure, anxiety and depression; -No cognitive impairment; -No mood problems; -No behavior problems; -Receives antipsychotic medicine: yes. Review of the facility's Medication Administration Policy, dated 6/26/24, showed the following: -Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to one of five sampled residents with a history of elopement, hallucinations/delusions, behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management, and limited insight and judgement. Facility staff failed to make visual observations of the resident hourly, staff failed to follow up after not seeing the resident to administer ordered medications, and failed to ensure exit doors were working properly. Resident #1 left the building without staff's knowledge on 6/10/24 at 6:37 AM. Facility staff responsible for conducting visual checks- failed to do so, although they were documented as completed. The resident remained gone from the facility for over 24 hours before staff realized the resident was missing on 6/11/24 at 8:00 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of seven sampled residents was free from physical abuse. The resident's right to be free from physical abuse (Resident #5) was violated when another resident (Resident #4) hit the resident in the face and knocked him/her to the floor. The census was 113. On [DATE] at 3:30 P.M., the Administrator was notified of the past noncompliance, which occurred on [DATE]. On [DATE], the Administrator was notified by staff of the incident and an investigation was started. The facility immediately took steps to protect the residents and set interventions in place to prevent further abuse. The alleged violation was reported within the required timeframe. Facility staff received education on the facility's Behavioral Emergency Policy and Abuse and Neglect Policy. Both residents' care plans were updated. [...]

Inspectors wroteSee the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. [...]

Inspectors wroteSee the deficiency cited at Event 6lBE12. Based on observation, interview and record review, the facility failed to provide a safe, comfortable and homelike environment by staff using an employee break room as a smoking area for both residents and staff. The employee break room was not an approved, designated smoking area for the facility. The sample was 11. The census was 111. Review of the facility's resident smoking policy, last reviewed December 2023, showed: -Guidelines: The residents will be safe and have protective oversight during smoke breaks; -The staff will ensure the residents are appropriately dressed for the weather during smoke break times; -There was nothing found in the policy regarding only using designated smoking areas. [...]

Inspectors wroteSee the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to immediately report an allegation of staff to resident abuse involving Resident #1 and Hall Monitor A to the Department of Health of Senior Services within the required two-hour time frame. The sample was 14. The census was 111. Review of the facility's abuse and neglect policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. [...]

Inspectors wroteSee the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to complete a thorough investigation and to prevent further potential abuse while the investigation was in progress, after being notified by Resident #1 of an allegation of physical abuse. The sample was 14. The census was 111. Review of the facility's Abuse and Neglect policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide protective oversight for one resident (Resident #1) who had a history of elopement and a diagnosis of schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) when staff failed to provide supervision during a smoke break, failed to conduct a head count after the smoke break, failed to conduct hourly face checks, and did not discover the resident was missing until nine hours after the resident left the building. The resident sample was 4. The census was 114. The Administrator was notified on 12/10/23 at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on 12/8/23. The IJ was removed on 12/11/23, as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring/Visual Checks policy, revised on 6/30/23, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of treatment and services for one resident (Resident #1), diagnosed with a mental health disorder and post-traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) to attain the highest practicable mental and psychosocial well-being. The facility failed to provide or arrange for mental health services, and failed to notify psychiatric services of suicide attempts and of the contents of the suicide note authored by the resident. Facility staff also did not follow the facility's program for a proper therapeutic hold while the resident had a behavior emergency. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M., of an Immediate Jeopardy (IJ) which began on 12/27/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable and homelike environment by staff using an employee break room as a smoking area for both residents and staff. The employee break room was not an approved, designated smoking area for the facility. The sample was 11. The census was 111. Review of the facility's resident smoking policy, last reviewed December 2023, showed: -Guidelines: The residents will be safe and have protective oversight during smoke breaks; -The staff will ensure the residents are appropriately dressed for the weather during smoke break times; -There was nothing found in the policy regarding only using designated smoking areas. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/23, showed: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of staff to resident abuse involving Resident #1 and Hall Monitor A to the Department of Health of Senior Services within the required two-hour time frame. The sample was 14. The census was 111. Review of the facility's abuse and neglect policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation and to prevent further potential abuse while the investigation was in progress, after being notified by Resident #1 of an allegation of physical abuse. The sample was 14. The census was 111. Review of the facility's Abuse and Neglect policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health services according to the resident's plan of care for one resident (Resident #2). During an episode of resident agitation, a staff member completed a one-person hold and brought the resident to the floor by him/herself, which was against facility policy. The facility also failed to follow the resident's care plan which instructed staff not to use the Crisis, Alleviation, Lessons and Methods (per facility policy, CALM) physical intervention with this resident. The sample was four. The census was 114. The Administrator was notified on 12/12/23 of the past non-compliance. [...]

Inspectors wroteBased on observations, interviews, record reviews, facility policy reviews, and review of a manufacturer's user's guide, the facility failed to ensure a multi-use blood glucose meter was cleaned and disinfected after each use for three (Residents #4, #28, and #35) of six sampled residents reviewed for medication administration. The facility also failed to ensure staff did not touch medication with their bare hands for one (Resident #24) of six sampled residents reviewed for medication administration. Further, the facility failed to ensure staff washed their hands before and after gloves were removed during wound care for one (Resident #211) of twenty seven sampled residents. [...]

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure one (Resident #363) of ten residents were properly supervised to prevent an accident. The facility failed to ensure Resident #363, who had a diagnoses of suicidal ideation and schizophrenia, was supervised with a razor, which resulted in Resident #363 cutting him/her self with the razor, causing injuries to the neck and wrists. The facility census was 108.

Inspectors wroteBased on observations, interviews, and facility record and policy reviews, the facility failed to store foods off the floor and away from chemicals, ensure employees wore hair restraints, and failed to maintain the ice machine to prevent dirt/grime build up for all residents who received nourishment from the kitchen. The facility census was 108.

Inspectors wroteBased on interview and record review, the facility failed to keep residents accounts from going into a negative balance which allowed the residents to spend another resident's money without written authorization. The facility managed funds for 82 residents. A sample of six were chosen and the practice affected three residents (Residents #6, #9, and #10). Additionally, the facility failed to ensure resident funds were placed in an account, separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 14 residents (Residents #1, #2, #3, #4, #5, #11, #12, #14, #18, #20, #45, #102, #108, and #411). The census was 108. Review of the facility's Resident Trust Policy, dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not reconciling all outstanding checks each month dating back to 2012. The facility managed funds for 82 residents. The census was 108. Review of the facility's Resident Trust Policy, dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; -Resident Trust Bank Reconciliation: -A reconciliation of the bank statement will be completed by the Corporate Management Company staff accountant. Exceptions may be considered on a case by case basis. The reconciliation must be done by someone other than the Resident Trust Clerk; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 108. Review of the facility's Resident Trust Policy, revised dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; -The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half (1 & 1/2) times the average total of reconciled monthly balances. A copy of the current bond shall be kept in a file in the facility by the Resident Trust Clerk. [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Specifically, the facility's medication error rate was 19.23%, with 5 errors out of 26 opportunities. This affected three (Resident #24, #35, and #59) of six sampled residents reviewed for medication administration. The facility census was 108.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to immediately notify the Responsible Party of a change in condition, hospitalization, and room changes for one (Resident #29) of three residents reviewed for notification. Specifically, the facility failed to notify Resident #29's Responsible Party (RP) of the resident's change in condition and transfer to the hospital in a timely manner and failed to notify Resident #29's RP when the resident was moved to a different room. The census was 108.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report three injuries of an unknown origin to the state survey agency for one (Resident #68) of two residents reviewed for abuse. The census was 108.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of injuries of an unknown origin for one (Resident #68) of two sampled residents reviewed for abuse. The census was 108.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one (Resident #68) of four sampled residents reviewed for discharge, was allowed to remain in the facility without appropriate justification and documentation for a facility-initiated immediate discharge. The facility failed to provide evidence of physician documentation to indicate the basis for Resident #68's facility-initiated discharge from the facility or any resident's needs the facility was not able to provide. The census was 108.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one (Resident #68) of four sampled residents reviewed for discharge, received a 30-day notice of discharge when the facility initiated a discharge to another long-term care facility. The census was 108.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (Resident #54) of three residents reviewed for activities of daily living (ADLs) had a comprehensive care plan to address the resident's ADL status and assistance required. The census was 108.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure pressure ulcer wound care was provided as ordered by the physician for one (Resident #311) of two residents reviewed with pressure ulcers. The census was 108.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure the medical record for two (Resident #161 and Resident #311) of two sampled residents reviewed for urinary incontinence included the providers clinical indication for use of an indwelling urinary catheter and a physicians' orders for care of the residents' catheter. In addition, there was no documented evidence indwelling urinary catheter care was provided for Resident #311 from admission on [DATE] through April 2022. The facility census was 108.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to obtain orders for the use and care of a colostomy (a surgical procedure that diverted stool to an opening in the abdominal wall) for one (Resident #311) of two residents reviewed for colostomy care. Facility documentation failed to show evidence of colostomy care being provided from admission on [DATE] through April 2022. The facility census was 108.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (Resident #7) of two sampled residents reviewed for respiratory care had orders for the use and care of a continuous positive airway pressure (CPAP) device. The facility further failed to ensure the CPAP contained water for use and that staff cleaned and stored the CPAP equipment appropriately. The facility census was 108.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to have ongoing communication and collaboration with the dialysis facility and provide care in accordance with facility policy for one (Resident #102) of one resident reviewed for dialysis services. The facility census was 108.

Inspectors wroteBased on observation, interviews, and facility document reviews, the facility failed to ensure Licensed Practical Nurse (LPN) #1 had the skills and competencies to perform duties as required. Specifically, the facility failed to ensure LPN #1 was competent to check one (Resident #28) of six sampled residents reviewed for medication administration blood glucose levels and maintain infection control standards. The facility census was 108.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #3) was free from unneccesary drugs when facility staff administered an intramuscular injection of an antipsychotic medication without adequate indications for use, when the resident became upset after requesting to speak to the administrator and being denied. Facility staff administered an antipsychotic drug medication, Haldol (used to manage positive symptoms of schizophrenia, such as hallucinations and delusions), prior to an order being obtained. The sample was three. The census was 108. Review of the facility's Indication for Use of Antipsychotic Drugs, dated July 2023, showed the following: -Policy: It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including antipsychotic drugs without adequate indications for use; -Procedure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmissions of communicable disease and infections by failing to provide perineal care according to professional standards for two (Resident #40 and #86) out of three residents observed to receive perineal care and failing to provide clean, sanitary laundry service room(s). The census was 111. Review of the facility's perineal care (cleansing the portion of the body in the pelvis occupied by urogenital passages and the rectum) policy, dated 4/6/17, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent gnats in the kitchen, including in the food preparation area and in the dish machine room. This had the potential to affect all residents who ate from the facility kitchen. The census was 111. Observation on 7/21/19 at 6:48 A.M., showed gnats observed to fly around in the dry storage area. The dietary manager left the dry storage and returned with a can of pesticide spray. She began spraying the pesticide spray in the dry storage area, directing the can over the drain in the center of the floor. Within two feet of the drain, sacks of flour and other paper packaged items sat on the shelves. As she sprayed the can of pesticide spray, the surveyor could smell and taste the chemical in the air. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address hospice services and palliative care and failed to address residents future discharge plans and goals. For 21 of 23 sampled residents (Residents #82, #109, #112, #43, #98, #19, #73, #66, #70, #28, #81, #69, #92, #53, #34, #60, #80, #87, #32, #105, and #6). The census was 111. 1. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and is able to make self-understood; -Independent for bed mobility, transfers, walking in room, toilet use, and dressing; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance and failed to ensure food and drink that is palatable, attractive, and at a safe and appetizing temperature by failing to ensure food was cooked thoroughly, tasted appetizing, temperatures on the steam table were maintained at least at 140 degrees Fahrenheit (F), and tray service temperatures were maintained at least at 120 degrees F. The census was 111. Observation of residents during the lunch meal service in the main dining room, on 7/24/19 at 1:02 P.M., showed several residents observed to pick up their entrée of stuffed green peppers and eat the pepper like a sandwich. Upon closer observation, the contents of the suffered pepper appeared white and filled with rice. [...]

Inspectors wroteBased on observation, interview, record review the facility failed to provide resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual for one resident (Resident #82) out of 23 sampled residents. The census was 111. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and able to make self-understood. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain and implement written policies and procedures regarding the residents' right to formulate an advance directive and refuse medical treatment by failing to ensure residents' code status matched the code status listed on the physician's order sheet, for one of 23 sampled residents (Residents #92). The census was 111. Review of the facility's advance directive policy, date 3/21/17, showed: -There shall be documented in the resident's medical record whether the resident has executed any advance directives, and copies shall be made a permanent part of the resident's medical record; -Advance directive includes any of the following which relate to providing of health care to a resident while he/she is incapacitated: -Living will; -Durable power of attorney for health care; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for three of three sampled residents (Resident #53, #163, and #93) who remained in the facility upon discharge from Medicare A services for rehabilitation services. The facility census was 111. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline, for four residents out of 23 sampled residents (Resident #67, #88, #101, and #109). The census was 111. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Care Assessment and Individualized Care Plans policy, dated 10/1/10, showed: -Section I in the MDS is to be completed by nursing staff. The most important part of this sections deals with active diagnoses. It gives an accurate picture of the resident's health status; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not providing grief counseling for one resident who experienced the death of a sibling and was unable to attend the funeral (Resident #82) out of 23 sampled residents. The census was 111. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and is able to make self-understood; -No behaviors listed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to document a reason for placing one resident (Resident #6) on Ambien as well as failure to provide a rationale for reordering the Ambien. In addition, the facility failed to obtain qualifying diagnoses for the use of antipsychotic medications for five residents (#6, #88, #101, #32, and #67) of eight residents investigated for unnecessary psychotropic medications. The sample size was 23. The census was 111. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/19, showed the following: -Cognitively intact; -Independent with toileting and transfers; -Required set up assistance only from staff for hygiene and dressing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in two out of seven medication/treatment carts. The census was 111. Review of the facility's Medication Rooms and Medication Carts Monthly Inspections Policy, dated 4/6/19, showed: -Purpose: to ensure that the facility is monitoring the labeling and storage of all medications within the facility on a routine monthly basis; -The facility will utilize a pharmacy consultant to review all resident's medication regimen and the facility's storage of medications. This will include inspections of the medication carts, treatment carts and medication rooms; -The medication carts, treatment carts, and medication rooms will be reviewed for the following areas: -Cleanliness; -Correct labeling; -Expiration dates; [...]

Inspectors wroteBased on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete and accurately documented by not documenting diagnoses for medications on the physician order sheets for three (Resident #88, #101 and #109) residents out of 23 sampled residents. The census was 111. 1. Review of Resident #88's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/16/19, showed: -Active diagnoses included heart failure, diabetes mellitus, and depression. Review of the resident's physician order sheet (POS), dated July 2019, showed: -Order dated 3/8/19, for Eliquis (anticoagulant) 2.5 milligram (mg), give one tablet twice a day; [...]