Heritage Center

Inspectors wroteBased on record review, staff interviews, and family interviews, the facility failed to keep the resident environment as free of accident hazards as possible, by not ensuring Resident #157 had assistive devices in place to prevent avoidable accidents. The State Agency (SA) determined that the potential for harm occurred on 12/24/25 when Resident #157 changed rooms and his bed rails did not go with him. Actual harm occurred on 12/26/25 when Resident #157 had a fall from bed resulting in a confirmed brain bleed. The facility was back in compliance on 12/30/25 after the last current staff member had been re-educated. This failed practice was found true for (1) one of (3) residents reviewed for fall prevention safety during the Complaint Survey. Resident identifier: #157. Facility Census: 156.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 156. Findings Include:a) 3rd floor dining roomAn observation on 05/19/26 at 8:45 AM of the 3rd floor dining room found a set of cabinets. The bottom cabinet was full of trash such as wrappers, napkins, etc., and lots of food crumbs. The drawer on the right side was stuffed with a dirty brief. During an interview on 05/19/26 at 9:00 AM, The Administrator and Director of Nursing both confirmed that the cabinet was dirty. The DON stated, I am so embarrassed.b) 2nd floor lounge areaAn observation on 05/19/26 at 10:00 AM, of the 2nd floor found a resident lounge. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure dependent residents had assistance with activities of daily living regarding assistance with eating and showers. Resident identifier: #20, #102, and #112. Facility census: 156.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to Resident #158 and caregiver to ensure safe and orderly discharge from the facility. This was true for one (1) of three (3) residents sampled for discharges during the complaint investigation. Census: 156 Resident identifier: #158Findings include:a) Resident #158During a phone interview with Resident #158's daughter at 4:00PM on 05/19/26, she stated the facility contacted her two (2) hours after the appeal deadline to notify her of discharge plans, which occurred the day before her father's discharge. Complainant states at that time, the facility representative also said they did not yet have the admission paperwork signed and asked if they could email her the paperwork. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to provide activities of daily living, specifically showers, to dependent residents. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of activities of daily living. Resident Identifier: #34. Facility census: 157.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure a physician order was correctly entered into the medical record. Additionally, the facility failed to ensure insulin was administered in accordance with professional standards of care. There was no order to hold the resident's medication for fingerstick blood glucose less than 150. These were random opportunities for discovery throughout the Long-Term Care Survey Process. Resident identifiers: #122 and #99. Facility census: 157.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure assessment and treatment of pressure ulcers in accordance with professional standards of treatment. This deficient practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #164. Facility census: 157.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately document the administration and refusal of medications. The facility also failed to ensure residents had current orders for medication given. These were random opportunities for discovery. Resident Identifiers: #51 and #34. Facility census: 157.

Inspectors wroteBased upon record review and staff interview, the facility failed to complete a drug regimen review at least once a month by a licensed pharmacist, and the facility's medical director failed to act upon irregularities reported by the pharmacist. This was found to be true for three (3) of five (5) residents reviewed during the long-term care survey process. Resident identifiers: #1,#10, #100. Facility census: 157.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store medications within accepted standards of care. A multi-use vial of tubersol injection had been in use over 30 days. These was a random opportunity for discovery. Facility census: 157.

Inspectors wroteBased upon Observation and Staff interviews the facility failed to ensure that dishware and serving items are kept in clean and sanitary area once cleaned. They were stored in the hallway to finish drying, allowing for possible recontamination. The hallway was in a main intersection of the first floor and had lots of foot traffic and people moving through it. This was a random opportunity for discovery that has the potential to effect more then one resident. Facility census: 157. On 09/29/25 at 9:03 PM an observation revealed dishes, cups, tray tops and glasses left out in hallway (main hall outside dining area). The dishes were exposed to possible recontamination. This hallway is in the main intersection on the first floor and has lots of foot traffic and items passing through it daily. The area is also under a vent that can allow dust to fall upon the clean dishes. [...]

Inspectors wroteBased upon Observation and Staff interviews the facility failed to ensure use of proper infection control practices to prevent the potential spread of disease through improper/non use of PPE while in a Enhanced Barrier Protection room. This was observed on more than one occasion. Resident identifiers: #80, #9 and #14. Census: 157. a) Resident #80 During med pass LPN #38 did not use PPE while giving resident #80 her medications. Resident is currently on enhanced barrier precautions (EBP) and the sign is present on door with marking for who it applies to. The LPN did sanitize hands, but did not apply PPE per policy. She had direct contact with resident, LPN adjusted resident in bed as well as hugged resident before leaving room. [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to inform the resident or resident's representative in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This was found to be true for two (2) of five (5) residents reviewed for psychotropic medication use during the long-term care survey process. Resident identifiers: # 1, #10. Facility census: 157.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a Notice of Transfer/Discharge, and a written Bed Hold notice to a resident and/or the resident's legal representative when the resident was transferred to the hospital. This was true for one (1) of nine (9) residents reviewed for hospitalizations. Resident identifier: #177. Facility census. 157.

Inspectors wroteBased upon record review and staff interview, the facility failed to develop a person-centered comprehensive care plan, and implement the plan to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was found to be true for three (2) of thirty-four (34) residents reviewed during the long-term care survey process. Resident identifiers: #8, #100. Facility census: 157.

Inspectors wroteBased on record review and staff interview, the facility failed to obtain lab services in a timely fashion for a resident. This was true for one (1) of five (5) residents reviewed for unnecessary medications throughout the Long-Term Care Survey Process. Resident identifier: #6. Facility census:157.

Inspectors wroteBased on record review and staff interview the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were accurately documented. This was a random opportunity for discovery. Resident #6. Facility census: 157.

Inspectors wroteBased on record review and staff interview, the facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice. This deficient practice had to potential to affect one (1) of five (5) residents reviewed for the care area of vaccinations. Resident Identifier: #34. Facility Census: 157. a) Resident #34 The facility's policy titled Pneumococcal Vaccination with effective date 05/04/15 and revision date 09/15/25 stated pneumococcal vaccinations in adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention. [...]

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to ensure the procedures they had in place for verifying a resident's choices Cardiopulmonary Resuscitation (CPR) were able to communicated as soon as possible so that staff know immediately what action to take or not when an emergency arises. The facility used the POST form to document and verify the resident's choices regarding cardiopulmonary resuscitation. The facility failed to ensure the POST form was kept on the medical record in the event of an emergency. This process had the potential to affect all residents in the facility. Facility census: 149. The process of not ensuring POST forms were kept on the medical record in the event of an emergency created an immediate jeopardy situation. The facility was informed of this immediate jeopardy situation on [DATE] at 6:06 PM. [...]

Inspectors wroteThe facility failed to ensure the quality assessment and assurance committee failed to identify quality deficiencies. In [DATE] Resident #150 was given cardiopulmonary resuscitation when his advanced directive indicated he wished to not be resuscitated. The facility quality assessment and assurance (QAA) committee addressed the issue of staff not identifying a resident's correct code status from [DATE] until [DATE]. After stopping the QAA code checks the facility developed another code status issue. Staff members were taking POST forms off the medical records for audits. The nursing staff stated the POST forms are where they would check for a resident's code status in an emergency. This practice had the potential to affect more than a limited number of residents. Facility census: 149.

Inspectors wroteBased on resident interview, family interview, record review, and staff interview, the facility failed to protect residents from sexual abuse. Resident #208 had a previous history of sexual behaviors toward other residents. The facility failed to protect Resident #15 from unwanted sexual touching by Resident #208. Although Resident #208 had been transferred to another facility by the time of the survey, the State Agency determined the facility's processes that failed to protect Resident #15 placed all residents in the facility in an immediate jeopardy situation. The State Agency notified the Nursing Home Administrator of the immediate jeopardy situation on 03/25/24 at 4:27 PM. The facility submitted a plan of correction (POC) on 03/25/24 at 7:19 PM. The State Agency requested revisions and an additional POC was submitted on 03/25/24 at 8:08 PM. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide appropriate infection surveillance. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 150. Findings Included: a) Infection Surveillance Record review of the facility's Infection control practices found the facility was unable to provide the required infection surveillance documentation of communicable illnesses. During an interview on 03/26/24 at 1:25 PM, Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they were unable to locate the documentation of the infection control surveillance. [...]

Inspectors wroteBased on record review and interview the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use reviewed for antibiotic stewardship. This has the potential to affect all residents in the facility. Facility Census: 150.

Inspectors wroteBased on facility documentation and staff interview the facility failed to have a designated certified Infection Preventionist (IP). This failed practice had the potential to affect all residents residing at the facility. Facility Census: 150. Findings Included: Record review of the facility's documentation of Infection control practices found the facility was unable to provide the required Infection surveillance and antibiotic stewardship documentation. During a facility record review found a certificate for Nursing Home Infection Preventionist with the Assistant Director of Nursing (ADON). During an interview on 03/26/24 at 11:43 the Corporate Administrator stated that the facility has not dedicated an IP, since the previous IP quit. She stated that the ADON and Director of Nursing (DON) has been working on Infection control. [...]

Inspectors wroteBased on observation, family interview, policy review and staff interview, the facility failed to honor the right of the resident to file grievances anonymously as the residents did not have access to the grievance forms. This has the potential to affect more than a limited number of residents. Resident Identifier: #71. Census: 150.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorder were referred for Level II resident review. This failed practice had the potential to affect seven (7) of eight (8) residents reviewed for the care area of Preadmission Screening and Resident Review. Resident identifiers: #23, #15, #74, #29, #66, #17, #33. Facility census: 150.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the Centers for Disease Control and Prevention (CDC) in a timely manner and failed to follow physician's orders, notify residents physician, collaborate with Hospices services, or do pacemaker checks. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident Identifier: #73, #79, #23, and #19. Facility Census: 150.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure nurse aides (NAs) completed the competencies and skill sets for the residents needs, safety and in a manner that promotes each residents rights, physical, mental and psychosocial well-being. This was true for three (3) of five (5) staff competency records reviewed during the survey process. This has the potential to affect a limited number of residents residing in the facility. Staff identifiers: #92, #129 and #164. Facility census: 150. a) NA #92 During a review of the Nursing Assistant competencies on 03/26/24 at approximately 4:10 PM the following NA competencies were identified as not completed: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all residents. Facility Census 150 a) Accurate and Current Data On 03/25/24 at 11:00 AM, during a review of the facility daily time detail by department for Nursing- Direct Care and the Daily Nurse Staffing Posting Form, it was identified that on the following follow days the nursing administrative staff hours were calculated in with the Nursing Direct Care hours. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure food was prepared and stored in a safe sanitary manor. Sliced ham was not dated in the walk-in refrigerator and the flat top grill was dirty. This failed practice had the potential to affect more than a limited number of residents. Facility census 150. a) Storage of ham Initial tour of the kitchen on 03/18/24 at 11:32 AM, revealed there was ham stored in the walk in refrigerator in a clear container with no date. During an interview on 03/18/24 at 11:34 AM, the Dietary Manager (DM), confirmed that everything in the walk-in should be dated. A review on the facilities policy on 03/18/24 at 2:00 PM, titled {Refrigerated/Frozen Storage} reads under Process, Number (1) one Refrigeration, Number 1.4 as follows: All foods are labeled with name of product and the date received and 'use by' date once opened. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician's Orders for Scope and Treatment (POST) forms were not complete for four (4) of 16 residents reviewed for the care area of advance directives. Meal intakes were not completely recorded for one (1) of (1) residents reviewed for the care area of tube feeding. Resident identifiers: #14, #23, #15, #141. Facility census: 150.

Inspectors wroteBased on observation, and staff interview the facility failed to maintain all of the call system functioning. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 150.

Inspectors wroteBased on observation, record review, staff interview, and resident interview, the facility failed to provide reasonable accommodations of needs, by not providing Resident #17 a readily accessible wheelchair. This failed practice was found true for (1) one of (3) three residents reviewed for environment during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 150. Findings Included: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 was non-verbal and uses an alphabet board to communicate, by pointing out the letters to spell words. During an interview on 03/18/24 at 3:52 PM with Resident #17 he communicated, They will not get me up. They say they don't have a wheelchair for me. During an interview on 03/19/24 at 12:10 PM with the Assistant Nursing Director, (AND) she stated , He is in a Geri chair. He does not have one up here. [...]

Inspectors wroteBased on observation, record review, staff interview, and resident interview, the facility failed to give Resident #17 a choice regarding daily routine by not providing him with a readily accessible wheelchair to be gotten up in when he chooses. This failed practice was found true for (1) one of (7) seven residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 150. Findings Included: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 is non-verbal and uses an alphabet board to communicate, by pointing out the letters to spell words. During an interview on 03/18/24 at 3:52 PM with Resident #17 he communicated, They will not get me up. They say they don't have a wheelchair for me. During an interview on 03/19/24 at 12:10 PM with Assistant Nursing Director (AND) she stated , He is in a Geri chair. [...]

Inspectors wroteBased on Resident Council meeting responses, and staff interviews, the facility failed to ensure Resident Council minutes had been reviewed and resident concerns/grievances were addressed. This failed practice had the potential to affect a limited number of residents. Facility census: 150.

Inspectors wroteBased on medical record review and staff interview the facility failed to electronically transmit accurate Minimum Data Set (MDS) data. This was true for two (2) of two (2) residents that the Minimum Data Sets (MDS's) were reviewed for discharges. Resident identifiers: #148 and #149. Facility census: 150.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate pre-admission screening had been performed for residents with serious mental disorders prior to their admission. This failed practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of Preadmission Screening and Resident Review. Resident identifier: #23. Facility census: 150.

Inspectors wroteBased on record review and staff interview the facility failed to revise care plans in a timely manner related to behaviors, and smoking. This failed practice was found true for (2) two of 30 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: #14 and #24. Facility census: 150.

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to provide an activity program to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Resident #17 was not provided with a wheelchair to attend activities of his choice and Resident #29 was not provided with scheduled one to one visits. This failed practice was found true for (2) two of (4) four residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers: #17, and #29. Facility census: 150. Findings Include: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 was non-verbal and used an alphabet board to communicate, by pointing out the letters to spell words. [...]

Inspectors wroteBased on observation, resident interviews and staff interviews, the facility failed to ensure the residents environment remained free of accident hazards and that each resident received adequate supervision. Resident #29's landline telephone was sitting directly above the residents head on the edge of the over the bed light fixture. Resident #15 was observed taking medication out of a medicine cup without a nurse present. This was random opportunities for discovery and had the potential to affect a limited number of residents. Resident identifiers: #29 and #15. Facility Census: 150.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to care for residents' catheters in accordance with professional standards of care. The urine collection bag was observed lying on the floor for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #49. Facility census: 150.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to store oxygen tanks in a safe manner consistent with professional standards of practice. This failed practice was a random opportunity for discovery. Facility Census 150. a) Facility An observation on 03/19/24 at 1:59 PM, of the facilities courtyard, there was found to be an empty oxygen tank stored in the seat of a wheelchair. During an interview on 03/19/24 at 2:00 PM, with the Corporate Administrator #182, she stated, No, that is not the proper way to store tanks full or empty. A review on 03/20/24 at 9:00 AM, of the facilities policy titled, SH500 Compressed Gases'', under process number (3) three, 3.3 reads: {Cylinders must be stored in and approved cabinet, holder, or secured by cylinder brackets or chains. The restraining mechanism must be above the midpoint of the cylinder.}

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to assist a resident in obtaining dental care. This was true for one (1) of one (1) residents reviewed for dental care. Resident identifier: #120. Facility Census: 150.

Inspectors wroteBased on facility documentation and staff interviews, the facility failed to identify the Certified Nursing Assistant (CNA) staff competencies that were necessary to provide the level and types of care needed for the resident population in the Facility Assessment. This had the potential to affect more than a limited number of residents in the facility. Facility census: 150. a) Facility Assessment. On 03/26/24 at approximately 3:15 PM during a review of the Facility Assessment, the NA competencies that were required to be completed based on the level and types of care needed for the resident population in the Facility Assessment could not be identified. In reviewing each category under Section II. Staffing, Training, Services & Personnel sub section A). [...]

Inspectors wroteBased on ombudsman interview, resident interview, record review and staff interview, the facility failed to ensure activities of daily living were performed for dependent residents. This failed practice had the potential to affect four (4) of five (5) residents reviewed for the care area of activities of daily living. Resident identifiers: #118, #122, #84, #143. Facility census: 152.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the use of bed rails was in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of five (5) residents reviewed for the care area of bed rails. Resident identifiers: #155, #112, #118, #99. Facility census: 152.

Inspectors wroteBased on observation, resident, family, and staff interviews, the facility failed to ensure palatable food. Hot and cold food were outside the palatable temperatures at the time of service. This had the potential to affect all residents receiving nutrition from the kitchen. Resident identifiers: #84, and #21 Facility Census: 152.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Resident #21's medical record was complete and accurate. The meal percentages documented by nurse aides in the task report and by nurses on the medication administration record (MAR) did not match. This was true for one (1) of twelve (12) residents reviewed in the complaint sample. Resident identifier: #21 Facility census: 152.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure Resident #97 was treated with dignity and respect. This was a random opportunity for discovery. Resident identifier: #97 Facility Census: 152.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment. This was a random opportunity for discovery. Room identifiers: #313 and #314 Facility census: 152.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure alleged violations of neglect were reported to all state agencies in a timely manner. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of neglect. Resident identifier: #155. Facility census: 152.

Inspectors wroteBased on record review and staff interview the facility failed to follow Resident #21's physician orders when the resident refused meals. This was a random opportunity for discovery and was true for Resident #21. Resident Identifier: #21. Facility Census: 152.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Pain medication was administered outside the prescribed time period for one (1) of three (3) residents receiving scheduled pain medications who were reviewed during the complaint investigation. Resident identifier: #44. Facility census: 150.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days or, if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, the rationale was documented in the resident's medical record and the duration for the PRN order was indicated. This was a random opportunity for discovery during the complaint investigation process. Resident identifier: #150. Facility census: 150.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #75. Facility Census:

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for two (2) of four (4) residents reviewed for a complaint survey. The physician's orders were not followed for Resident #146 and Resident #4 had a delay in treatment. Resident identifiers: #146 and #4. Facility census: 150.

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for each resident. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility areas: Second (2nd) Floor and Main dining room Facility Census: 144 Findings Included: a) Second Floor rooms 201-218 On 8/08/22 at 9:44 AM during the initial interview process of the survey it was observed that the walls in several of the Residents rooms on the second (2nd) floor were in need of repairs. Many of them have holes, anchor wall plugs left in the wall where nothing is hanging, entire lengths of corner trim missing and scrapes and discoloration of the walls. Of the rooms observed from 201-218 the following rooms are in need of repairs to ensure a homelike environment. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to send a copy of the notice of transfer to the representative of the Office of the State Long-Term Ombudsman. This was true for six (6) of seven (7) residents reviewed during the survey process. Resident Identifiers: #42, #48, #96, #202, #152 and #153. Facility Census: 144. Findings Included: a) Resident #42 A review of Resident #42's medical record on 08/09/22 found on 05/22/22, the resident was sent to an acute care facility due to lethargy. The resident returned to the facility on [DATE] with the following diagnoses: --Lethargy --Asymptomatic bacteruria On 08/09/22 9:31 AM, the Director of Nursing (DON) stated, we do not have the notification to the Ombudsman. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure laboratory testing for Resident #76 was performed as ordered by the physician. The facility also failed to initiate treatment for Resident #108's Urinary Tract Infection (UTI) timely after the culture and sensitivity was received to determine what antibiotic the infection was sensitive to. Finally, the facility also failed to ensure bleeding experienced by Resident #85 was thoroughly investigated and reported to the physician. This deficient practice had the potential to affect three (3) of 38 residents reviewed in the long-term care survey sample. Resident identifiers: #76, #108 and #85. Facility census: 144.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure meal percentages were documented for residents with fluctuating weight. This was true for three (3) of seven (7) residents reviewed for the care area of nutrition during the Long Term Care Survey Process (LTCSP). Resident identifiers: #43, #77 and #87. Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to maintain a sanitary condition at the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect more than a limited number of residents that reside in the facility. Facility Census: 144. Findings Included: a) Outside garbage receptacle Observation made during the outside tour at 12:30 PM on 08/08/22 revealed the garbage receptacle and the area around the facility had trash scattered about on the ground which included: used gloves, used masks, plastic silverware, multiple used cigarettes butts, toothbrushes, straws, straw paper, empty pop bottle, food/cup lids and other trash items. During an interview on 08/08/22 at 12:40 PM the Administrator stated we will get it cleaned up right away, cigarette butts have always been a problem, but not all this. .

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This was true for three (3) of 38 residents reviewed during the long-term survey process. Resident Identifiers: #96, #48 and #76. Facility Census: 144. Findings Included: a) Resident #96 A review of the medical record was completed on 08/09/22. A Facility To Hospital Transfer Form was reviewed. Resident #96 was transferred to an acute care facility on 05/21/22. However, the date of transfer on the form was listed as 04/20/21. On 08/09/22 at 10:38 AM, the Director of Nursing (DON) confirmed the transfer form had the incorrect date of transfer listed. b) Resident #48 A review of Resident #48's medical record completed on 08/09/22 found Resident #48 was transferred to an acute care facility on 07/18/22. [...]

Inspectors wroteBased on record review, staff interview, and policy review the Quality Assessment and Assurance (QAA) committee failed to identify and/or correct quality deficiencies of which it was aware of or should have been aware. The facility failed to develop a policy to ensure lab services were btained and processed as physician's orders. The facility failed to ensure meal percentage were recorded for three (3) meals a day for all residents. The facility failed to ensure when residents were transferred and/or discharged from the facility that the transfer form was communicated to the Ombudsman as directed. Finally, the facility failed to have a pressure ulcer system to identify, assess and treat pressure ulcers in an effective manner. These failed practices had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 144.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Physician orders for scope of treatment (POST) forms were fully completed and accurately represented the resident and/or responsible party's wishes. This was true for Two (2) of Two Residents reviewed for the care area of advance directives. Resident Identifiers: #72 and #48 Facility Census:

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) was accurate in skin condition status for Resident #19. This was true for one (1) of 38 sampled residents. Resident Identifier: #19. Facility Census: 144. Findings Included: a) Resident #19 Review of Resident #19s medical record review found skin and wound evaluations dated 05/10/2022 which indicated the resident had the following skin conditions: --One (1) unstageable pressure ulcer on the left lateral malleolus. --Two (2) DTI ( Deep Tissue Injury) areas located on the right and left heel. --One (1) venous and arterial ulcer on the left dorsal foot. Further review of the medical record found a MDS with an assessment reference date (ARD) of 05/23/22. Review of this MDS found section M skin conditions indicated Resident #19 only listed one (1) DTI wound present. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop an accurate care plan for pressure ulcer treatment for one (1) of six (6) residents reviewed for pressure ulcers. Resident identifier: #152. Facility census: 144.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan for Resident #42 in the care area of diagnosis for a foley catheter and skin conditions for Resident #77. This was true for two (2) of 38 residents reviewed during the long-term survey process. Resident Identifiers: #42 and #77. Facility Census: 144. Findings Included: a) Resident #42 On 08/08/22 at 1:27 PM, a review of Resident #42's care plan was completed. The review did not find a diagnosis for the use of the foley catheter. A progress note dated 05/31/22 at 1:45 PM states, Resident has had a decrease in urine output. Foley catheter placed per verbal order from (Name of facility Nurse Practitioner). 600 ml (milliliters) emptied from drainage bag. No complaints of pain. (Typed as written.) A review of the current physician's orders were completed on 08/09/22. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure activities of daily living (ADL) care was provided to residents who were unable to carry out these activities on their own. This deficient practice was true for one (1) of five (5) residents reviewed for activities of daily living. Resident identifier: #77. Facility census: 144.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of six (6) residents reviewed for the care area of pressure ulcers received care, consistent with professional standards of practice for assessing and treating pressure ulcers. Resident identifiers: #152 and #45. Census: 144.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide respiratory services in accordance to professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services. Resident identifier: #106 Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to ensure they established and implemented a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility failed to ensure that two (2) licensed professionals were present when controlled substances were destroyed as required by law and the facility policy. These were random opportunities for discovery and was true for Resident #552 and Resident #153. Resident Identifier: #552 and #153. Facility Census: 144. Findings Included: a) Resident #552 A review of Resident #552 medical record on [DATE] found she had expired at the facility on [DATE]. At the time of her death she had the following controlled substances remaining: -- Hydrocodone 5- 325 milligram (MG) - 5 pills remaining. -- Hydrocodone 5- 325 mg - 30 pills remaining. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to date a Novolog Flex-pen when opened for insulin administration. This was true for one (1) of three (3) residents reviewed during medication administration. Resident Identifier: #44. Facility Census: 144. Findings Included: a) Resident #44 On 08/10/22 at approximately 9:25 AM, the medication cart was reviewed. A Novolog Flex-Pen was labeled with Resident #44's name. However, there was no open date noted on the Novolog Flex-Pen or the plastic bag in which it was stored. On 08/10/22 at 9:30 AM, the Unit Manager (UM) #114 was notified of the undated insulin pen. UM #114 confirmed the insulin pen was not dated when opened. The UM #114 stated, we will get rid of it and get a new one .we don't know when it was opened. The facility policy entitled Medication Administration: [...]

Inspectors wroteBased on observation, resident council meeting minutes, policy review, resident interview, and staff interview the facility failed to serve food that was palatable and at a preferable temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility census 144. Finding Included: a) Cold Food A review of a facility policy titled 4.7 Food Handling with an effective date of 07/01/98 and revision date of 06/15/18 stated: .16. All Time/Temperature Control for Safety Food must maintain an internal temperature of 41 degree F of lower, or 135 degree F or higher while being held for service. During an interview on 08/08/22 at 10:04 AM Resident #78 stated The food is always served cold. On 08/09/22 at 1:00 PM temperatures were obtained on the lunch tray for Resident #32 at the time of service. [...]

Inspectors wroteBased on observation, and staff interview, the facility failed to correctly document the cook dish sink temperatures. This deficient practice has the potential to affect a limited number of residents. Facility Census: 144. Findings Included: a) [NAME] Dish Sink Temperature Log The initial tour of the kitchen with Dietary Manager in Training(DMIT) #173 at 9:15 AM on 08/08/22 revealed the cook dish sink temperature log was completed for the lunch section with the following temperatures. Lunch: Wash: 170 Rinse: 180 Initials: RO During an interview on 08/08/22 the DMIT #173 and Dietary District Manager #193 acknowledged the cook dish sink temperature log was completed for the lunch section at 9:18 AM and should not have been completed until lunch time. .