Hidden Valley Center

Inspectors wroteBased on staff interview and observation, the facility failed to ensure a safe, clean home-like environment for residents by not providing clean linen and an adequate amount of linen available for resident use. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 76.a) Mary's Garden On 05/12/26 at 1:00 PM, a tour of the unit was completed. The linen storage room was observed. The observation found minimal linen available for residents. There were seven (7) towels found in the closet. One (1) of the seven (7) towels was noted with a dark brown stain. There were 11 wash cloths found in the closet. Eight (8) of the 11 wash clothes were noted with dark brown stains, white bleach stains as well as faded colors and frayed areas. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure a safe environment from avoidable accidents/hazards over which the facility had control. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 76.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect all of the residents. Facility census: 74.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to provide a homelike dining environment for the resident's in the facility's main dining room. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 74.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the residents' environment remains as free, from accident hazards as possible, by leaving a medication cart unlocked. This was a random opportunity for discovery. Facility Census: 74.a) Medication Cart On 04/15/26 at 4:40 PM, staff observed an unlocked medication cart near the nurses' station. At this time, no staff members were near the medication cart. Assistant Administrator #83 was present during this observation. Assistant Administrator #83 entered the nurses' station and asked, Whose medication cart is this? Licensed Practical Nurse (LPN) #76 stated, It's mine . I usually always lock it. Assistant Administrator #83 confirmed the medication cart was unlocked while unattended. [...]

Inspectors wroteBased on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure hot foods were served hot. This failed practice was true for one (1) of one (1) meal trays tested throughout the survey process. Residents identified: #20 and #50. Facility census: 74.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to maintain an infection control program during medication administration and offering hand hygiene prior to the meal service. These were random opportunities for discovery. Resident identifiers: #45, #84, #41, #87 and #50. Facility Census: 74. Findings Include: a) Resident #45 On 04/21/26 at 8:15 AM, observations were made of Licensed Practical Nurse (LPN) #24 during medication administration. LPN #24 touched the pills while removing them from the bubble pack: [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to promote respect and dignity during care for a resident during mealtime. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #48. Facility Census: 74.

Inspectors wroteBased on interview and record review, the facility failed to ensure they implemented their policy on abuse to ensure allegations of abuse were properly identified, reported, and thoroughly investigated in accordance with the facility's abuse prevention policies. This deficient practice placed residents at risk for unrecognized and unaddressed abuse. Resident identifier: #25. Facility census: 74.

Inspectors wroteBased on record review and staff interview the facility failed to report an allegation of physical abuse between residents within two (2) hours of the incident. This was discovered during an investigation into a Facility Reported Incident (FRI) and was true for Resident #28. Resident Identifier: #28. Facility Census: 74. Findings Include: a) Resident #28 A review of a Facility Reported Incident (FRI) dated 11/09/24 found the following: A co-resident punched the resident in the shoulder. An X-ray was completed, and the resident was not injured. The incident occurred on 11/09/24 at 12:40 PM. A further review of the initial report showed it was filed on 11/09/24 but no time was identified. A further review of the information provided by the facility found no fax confirmation sheet to identify when the facility submitted the report. [...]

Inspectors wroteBased on a review of a facility reported incident (FRI) and staff interview it was determiend the facility failed to use the results of the investigation to determine the appropriate action to take regarding education of staff following a resident's fall with major injury. Resident identifier: #78. Facility census: 74. a) Resident #78 An investigation for a Facility Reported Incident (FRI) was initiated on 04/20/26. A random discovery was found pertaining to an additional FRI dated 06/13/25 that was reviewed during the investigation. It was determined the facility failed to implement corrective action for staff education following a fall with major injury for Resident #78 for FRI dated 06/13/25. The Initial Report of Allegations dated 06/13/25 stated the resident had a fall and was sent to the hospital. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment upon discharge for Resident #79. This was true for one (1) of four (4) residents reviewed under the care area of discharges. Resident Identifier: #79. Facility Census: 74. Findings Include: a) Resident #79 On 04/21/2026 at 1:20 PM, a record review was completed for Resident #79. The review found the resident was discharged from the facility on 08/27/24. The resident would not be returning to the facility. However, the MDS, dated [DATE], indicated the resident was discharged but return to the facility was anticipated. On 04/21/26 at 1:40 PM, Corporate Nurse #80 confirmed the resident was discharged from the facility and did not return.

Inspectors wroteBased upon record review and staff interviews, the facility failed to refer one (1) of one (1) residents who had a newly evident serious mental health disorder diagnosis for a level II review. This was true for one (1) of one (1) records reviewed. Resident identifier: #20. Facility census: 74. a) Resident #20 On 04/14/26 During a record review for Resident #20, the surveyor could not find the level II PASARR. 04/15/26 9:22 AM Record review and interview revealed that on 03/27/26 a PASARR was completed on Resident #20. A level II was identified as needing to be completed and never was. At 8:58 AM, the surveyor asked the Administrator why the Level II was not completed as required. She stated, I will find out and get back to you. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) included a diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for one (1) of 28 residents reviewed during the survey process. Resident #13. Facility Census: 74. Findings Include: a) Resident #13 Resident #13 was admitted on [DATE]. A review of the resident's comprehensive minimum data set (MDS) with an assessment reference date (ARD) of 03/03/26 revealed a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the PASARR dated 02/20/26 found that the diagnosis of Post-Traumatic Stress Disorder (PTSD) was not included in the PASARR. On 04/13/26 at 4:00 PM, Corporate Registered Nurse (RN) #80 confirmed the PTSD diagnosis was not included on the PASARR.

Inspectors wroteBased on record review and staff interview, the facilty failed to develop a care plan regarding a urinary catheter for Resident #5 and failed to implement a care plan for blood glucose monitoring for Resident #8. Resident Identifiers: #5 and #8. Facility Census: 74.a) Resident #8 Review of clinical documentation revealed a blood glucose (BG) result of 67 mg/dL on 04/1/26 at 08:07 AM The resident's care plan specified that the physician must be notified for blood glucose readings less than 70 mg/dL or greater than 450 mg/dL. However, the medical record contained no evidence that the physician was notified of the low blood glucose result as required by the care plan. This failure to implement the care plan interventions placed the resident at risk for delayed recognition and treatment of hypoglycemia. This was confirmed with Corporate Nurse #80 on 04/15/26 at approximately 9:00 AM. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's plan of care was updated for a Change in Condition (CIC). This failed practice had the potential to affect a limited number of residents. Resident Identifier: #46. Facility Census: 74.

Inspectors wroteBased on record review, staff interview, resident interview and observation, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of the residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #68 and #69. Facility Census: 74.

Inspectors wroteThe facility failed to follow physician orders regarding required notification parameters for abnormal blood glucose results. Resident #8. The physician order directed staff to notify the physician when blood glucose levels were less than 70 mg/dL or greater than 450 mg/dL. On 4/1/2026 at 08:07, a blood glucose reading of 67 mg/dL was obtained and documented; however, the physician was not notified of this abnormal result. During confirmation on 4/15/2026 at 4:30 PM with Corporate Nurse, it was acknowledged that physician notification did not occur as required. This failure to follow physician orders placed the resident at risk for delayed medical intervention and potential adverse outcomes related to hypoglycemia.

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacy recommendations were acted upon by the resident attending physician. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: 72. Facility Census: 74. Findings Include: a) Resident #72 A review of Resident #72's medical record found a pharmacy recommendation dated 10?04/25 which read as follows: This resident is diagnosed with dementia and receiving the antipsychotic Zyprexa 5 mg twice daily. Please indicate the appropriate clinical situation the continued use of this medication: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Physician's Order for Scope of Treatment (POST) and eight (8) consents were signed and dated by Resident #13, who has capacity, and ensure a resident's code status was correctly documented in the medical record for Resident #48. This was true for two (2) of 28 residents reviewed during the survey process. Resident Identifiers: Resident #13 and #48. Findings Include: a) Resident #13 On 04/14/2026 at 1:12 PM, a record review was completed for Resident #13. The review found the resident had capacity to make medication decisions. The physician's determination of capacity was completed by the facility physician on 03/04/26. Upon further review, the following forms and consents were not signed by the resident: [...]

Inspectors wroteBased on resident interview, staff interview, record review and observation, the facility failed to ensure a call light was placed within a resident's reach while in bed. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #40. Facility Census: 74.

Inspectors wroteBased on record review and staff, hospital, and ombudsman interviews, the facility failed to ensure Resident #80 was permitted to return to the facility following a hospitalization for behavioral evaluation. The facility's refusal to readmit the resident was based solely on behaviors that occurred prior to the hospitalization. This deficient practice resulted in an involuntary discharge without adherence to federal discharge requirements. Resident Identifier: #80 Facility Census: 77Findings include:Record review revealed Resident #80 was transferred to hospital on [DATE] due to aggressive behavior and bipolar disorder. Progress notes from [DATE] documented that the resident exhibited increased agitation, verbal aggression, and non-redirectable behaviors, and was sent to the hospital for further evaluation per physician order. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide required written notice to the resident, resident representative, and the long-term care ombudsman prior to discharging Resident #80 and refusing readmission following hospitalization. The facility's failure to issue appropriate notice deprived the resident and representative of their right to appeal and participate in discharge planning. Resident Identifier: #80 Facility Census: 77Findingd Include:Record review showed Resident #80 was transferred tohospital on 8/31/25 and remained hospitalized beyond the bed-hold period. Despite hospital documentation showing the resident was ready for return, the facility declined readmission. Interviews with the Hospital Care Manager and Ombudsman confirmed the resident and representative were not notified in writing of the facility's decision to refuse return. [...]

Inspectors wroteBased on the observation and staff interview the facility failed to maintain a comfortable and sanitary environment for residents. These findings had the potential to affect more than an isolated number of residents. Facility census: 74. A tour of the facility on 09/08/25 at 11:00 AM revealed the following observations: a) room [ROOM NUMBER] A brown substance was around the base of the toilet. The room had lots of white dry wall mud patches. b) room [ROOM NUMBER] Dry wall mud patches were on the walls of the room. A toilet paper roll holder was missing, and the toilet paper was sitting on top of the back of the commode. c) room [ROOM NUMBER] The ring around the base of the toilet was brown. The room had several dry wall mud patches throughout. The painted finish was observed coming off the handrails on the Alzheimer's/Dementia Unit. [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure Resident #21 received liquid at the appropriate thickness as ordered by the physician. Resident #21 would have been given regular consistency tea had the surveyor not intervened. Resident #21 physician's orders indicated she should only receive pudding/spoon thickened liquids. The State Agency (SA) found this failure rose to the level of an Immediate Jeopardy (IJ). The Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the IJ on 09/25/24 at 3:45 PM. The SA accepted the plan of Correction (POC) at 6:40 PM on 09/25/24. After verification of the steps of the POC being Implemented the IJ was abated at 3:15 PM on 09/26/24. This failed practice was true for Resident #21 but had the potential to affect any resident receiving thickened liquids. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to proved sufficient nurse staffing numbers. This had the potential to affect all residents. Facility census: 77.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse was available 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 77.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to prevent potential further abuse of all residents while investigating an allegation of resident-to-resident abuse and failed to complete a thorough investigation. Resident identifiers: #72 and Resident #31. Facility Census: 77.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #12 had a bottle of vitamins at her bedside, which had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Additionally, Resident #34 did not have non-slip socks on at the time of a fall. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of falls. Resident identifiers: #12, #34. Facility census: 77.

Inspectors wroteBased on observation, resident interview, record review, and staff interview, the facility failed to provide hydration care and services to each resident, consistent with the resident's comprehensive assessment and their needs and preferences. This deficient practice had the potential to affect three (3) of 13 residents reviewed for the care area of hydration. Resident identifiers: #68, #59, and #180. Facility census: 77.

Inspectors wroteBased on resident interview, staff interview, and test tray temperature measurements, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice has the potential to affect more than a limited number of residents. Facility Census: 77. Findings Included: a) Resident Interviews During an interview with Resident #68 on 09/23/24 at 11:41 AM he stated the food is always cold and is not good. He stated, he does not like rice, and he gets it at least three (3) times a week. During an interview with Resident #15 on 09/23/24 at 12:00 PM he reported he often orders cheeseburgers from the kitchen because the food does not have a good taste. During an interview with Resident #180 on 09/23/24 at 2:57 PM the resident stated the food is tasteless and it is always cold when it gets to his room. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was served in a safe and sanitary manner. This was a random opportunity for discovery and had the potential to affect more than an limited number of residents. Facility Census: 77. Findings Included: a) Tray Line Observation An observation of the meal service for the noon time meal on 09/25/24 beginning at 11:30 am found the following, Resident #52 was served Salisbury steak covered in gravy from the kitchen. The meal went directly from the kitchen to the dining room and was served to the resident. After it was served [NAME] #69 obtained a thermometer to obtain the temperature of the gravy which had been sitting on the stove cooling. The temperature was 122 degree Fahrenheit (F). The cook stated, I need to reheat this and turned on the stove to reheat the gravy. [...]

Inspectors wroteBased on observation, medical website review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility stored items under a sink area, which had the potential to affect more than a limited number of residents. Additionally, Resident #13's urinal was on the overbed table while he was eating. These were random opportunities for discovery. Resident identifier: #13. Facility census: 77.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure Resident #44 was afforded the right for a dignified experience while using the restroom. This was a random opportunity for discovery and was true for Resident #44. Facility Census: 77.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were given the opportunity to make decisions regarding end-of-life care. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advance directives. Resident identifier: #59. Facility census: 77.

Inspectors wroteBased on record review and staff interview, the facility failed to provide proof the required Notification of Medicare Non-Coverage (NOMNC) liability and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) notices were issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. NOMNC was improperly dated. This failure had the potential to place the resident at risk of not being informed of their appeal rights prior to the end of Medicare covered services as well as being informed of their rights prior to the end of Medicare Part A covered services . Resident identifier: #281. Facility census: 77.

Inspectors wroteBased on observation, staff interview and resident interview, the facility failed to provide a safe, clean and comfortable home like environment. Resident #50 did not have a screen in his window. This failed practice was found true for (1) one of 12 residents reviewed for the environment during the Long-Term Care Survey Process. Resident identifier #50. Facility Census 77. Findings Included: a) Resident #50 During the initial interview on 09/23/24 at 1:38 PM, Resident #50 stated, I cannot open this window because there is not a screen in it. I have asked several times to get a screen but still do not have one. An observation on 09/23/24 at 1:38 PM, revealed that Resident #50 had four (4) windows in his room and the second window did not have a screen. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #20's Minimum Data Set (MDS) was correct in the area of falls with injury. This was true for one (1) of 12 residents reviewed for the care area of accidents during the long-term care survey process. Resident identifier: #20. Facility census: 77.

Inspectors wroteBased on record review and staff interview, the facility failed to correctly identify diagnosis on a new Pre-admissions Screening and Resident Review (PASSAR). This failed practice was found true for (1) one of (2) two residents reviewed for PASSAR accuracy during the Long-Term Care Survey Process. Resident Identifier: #1. Facility Census 77. Findings Included: a) Resident #1 A record review on 09/23/24 at 3:30 PM, revealed that Resident #1 has a diagnosis that included Schizophrenia and Epilepsy. Further record review revealed that a new PASSAR was completed on 02/17/22 and did not include the diagnosis of Schizophrenia and Epilepsy. During an interview on 09/25/24 at 12:28 PM, the Social Worker (SW) stated, I must have missed that one. When I first started I had to do an audit of them all so I guess I missed that one. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to develop and/or implement care plans related to fall interventions and depression. This failed practice was found true for (1) one of (5) five residents reviewed for mood and behavior and (1) one of 12 residents reviewed for accidents. Resident identifiers #34 and #42. Facility Census: 77. Findings Included: a) Resident #34 A record review on 10/01/24 at 9:30 AM revealed that Resident #34 had a fall on 08/21/24. On 08/22/24 Resident #34 was complaining of pain where it was revealed that she had a right hip fracture. Further record review revealed a fall care plan that reads as follows: Focus: Resident has experienced falls and is at risk for further falls r/t cognitive loss, lack of safety awareness, history of fall with fracture. Goal: Resident will have no further falls with injury through next review. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. 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: #6. Facility census: 77.

Inspectors wroteBased on resident interview, observation, record review, and staff interview, the facility failed to provide pressure ulcer treatment in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of pressure ulcers. Resident Identifier: #34. Facility census: 77.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure Resident #20's medical record was complete and accurate. This was true for one (1) of 31 sampled residents reviewed during the long-term care survey process. Resident Identifier: #20. Facility Census: 77. Finding Include: a) Resident #20 On 10/01/24 at approximately 10:15 AM Resident #20 was observed sitting in the tv lounge with her 10:00 AM supplement sitting in front of her. The supplement was still three quarters of the way full. A review of Resident #20's medical record at 10:25 am on 10/01/24 found the nurse had documented Resident #20 had consumed 100 percent of her house supplement. The surveyor returned to the TV lounge and Resident #20 still had her house supplement sitting in front of her on the table. It was still three fourths of the way full. [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow physician orders for Resident #3 to have accu checks three (3) times a day. This was true for one (1) of 20 sampled residents. Resident Identifier: #3. Facility Census: 76. Findings Include: a) Resident #3 A review of Resident #3's medical record on 04/22/24 found a physician order for Accu Check TID (three times a day). Notify Physician if blood sugar is less than 70 or greater than 450. This order was dated 03/18/24 and was the current order at the time of this review. A review of the medication administration record (MAR) and the blood sugar vital signs tab in the electronic medical record found the facility had not obtained a blood sugar since 04/09/24 at 10:20 am. The facility had missed obtaining the blood sugar for 13 days at the time of this review. [...]

Inspectors wroteBased on record review, observation, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #1 was assessed to be transferred with a total lift with the assistance of two (2) people. There were several occasions the staff indicated in their documentation he was transferred inappropriately. For Resident #4 the facility failed to implement a fall intervention. This was true for two (2) of four (4) sampled residents. Resident Identifiers: Resident #1 and Resident #4. Facility Census: 76.

Inspectors wroteBased on observation and staff interview the facility failed to distribute and serve food in accordance with professional standards for food service safety by activity staff serving ice cream on the unit. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility Census; 76 Findings Include: a) Ice Cream On 04/23/24 at 02:20 PM during a tour of the facility, Activities Assistant (AA) #18 was observed to be pushing a cart down Unit A with 5 open containers of vanilla ice cream. AA #18 stated she was serving the residents ice cream in their rooms if they wanted it. AA #18 stated she was told to prepare the open containers and place them on the cart without lids or covering the containers and to take it out on the floor to distribute. [...]

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity of discovery. This had the potential to affect more than an isolated number of residents. Facility Census:

Inspectors wroteBased on observation and staff interview the facility failed to ensure Resident #19 had a dignified dining experience during the noon time meal on 04/23/24. The facility failed to serve Resident #19 at the time her peers in the same dining area were served. Resident #19 was not served for 30 minutes after the last resident in the same dining room was served their meal. For Resident #18 the facility failed to ensure dignity while she was using the bedside commode. These were random opportunities for discovery and were true for Resident #19 and Resident #18. Resident Identifiers: #19 and #18. Facility Census: 76. Findings Include: a) Resident #19 An observation of the noon time meal began at 11:40 AM on 04/23/24. Upon entering the dining room it was noted Resident #19 was sitting at a table by herself in the back dining room. [...]

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure Resident #4's accident care plan was implemented. This was a random opportunity for discovery and was true for Resident #4. Resident Identifier: #4. Facility Census: 76.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to revise the comprehensive care plan for the use of a bedside commode. This was a random opportunity for discovery and was true for Resident #18. Resident identifier #18. Census: 76.

Inspectors wroteBased on observation and staff interview the facility failed to deploy available staff in a manner which ensured Resident #19 was fed her noontime meal in a timely manner. Resident #19 was not assisted with her noon time meal for 30 minutes after the last resident in the same dining room was served their meal. This was a random opportunity for discovery and was true for Resident #19. Resident Identifiers: #19. Facility Census: 76. Findings Include: a) Resident #19 An observation of the lunch meal began at 11:40 AM on 04/23/24. Upon entering the dining room it was noted Resident #19 was sitting at a table by herself in the back dining room. Also seated in the dining room were seven (7) additional residents. At 12:00 PM the last tray was served to the seven (7) additional residents. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #2's medical record was complete and accurate. There was a nutritional assessment which indicated the resident had a significant weight gain when in fact she had not. This was true for one (1) of 20 sampled residents. Resident identifier: #2. Facility Census: 76.

Inspectors wroteBased on observation and staff interview the facility failed to post accurate data on the nursing staffing data forms to include the total number of staff and or the actual hours worked by the certified nursing assistants. This was true for two (2) of nine (9) daily nursing staffing forms reviewed. This had the potential to affect a limited number of residents. Inaccurate dates identifier: 03/09/24 and 03/10/24. Census; 76.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Multiple sharp items were found in the kitchen in the dementia care unit which currently houses 24 residents all of which have a diagnosis of dementia. This failed practice had the potential to affect more than an isolated number residents. Resident Identifiers: #1, #2, #5, #13, #14, #16, #17, #21, #25, #29, #32, #37, #38, #41, #42, #43, #44, #47, #54, #55, #65, #68, #72 and #78. Facility Census: 78 Findings Included: a) A tour of the dementia care unit on 09/25/23 at 11:00 am, found the following safety concerns in the resident kitchen area: -- In the drawer beside the refrigerator was two (2) vegetable peelers both of which were sharp. -- In the cabinet to left of the stove was two serrated steak knifes. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure bathroom call devices were assessable to residents in rooms #27 and #28 if residents were lying in the floor. This failed practice had the potential to only affect a limited number of Residents. Resident identifiers: #28, #21, #44, #37. Facility census: 79.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide residents with a safe, clean, comfortable and homelike environment. The facility failed to provide a homelike environment in the dining area. The facility also failed to provide a safe, clean shower area for the residents. The facility also failed to provide residents with furniture in good repair. This had the potential to affect more than a limited number of residents. Resident Identifier: #57 . Facility Census: 79 Findings Included: a) Dining Room A Dining Room observation on 01/09/23 at 11:15 AM revealed the dining room tables were lacking the varnish/vinyl on the top of several tables. The tables did not have tablecloths to cover the tables to provide a homelike environment to cover the poor condition of the tables. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This failed practice was true for three (3) out of (24) reviewed for advance directives Resident Identifiers: Resident #13, Resident #63 and Resident #176. Facility Census: 79. Findings Included: a) Resident #13 A review on 01/10/23 at 8:50 AM , found Resident #13 had a POST form signed and dated by Resident # 13 on 06/02/22. In addition to completing page 2 of the form, the POST requires the signature of the person preparing the form, the printed name of that person and the date. The staff member completing the form wrote Nursing Staff instead of their name. [...]

Inspectors wroteBased on observation, resident interview and staff interview 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 transmission of communicable diseases and infection related to clean linen carts and the resident shower/bathroom. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 79. Findings Included: a) Clean Linen Carts On 01/09/23 at 11:17 AM a random opportunity for discovery revealed a clean linen cart on the small hallway had two (2) opened boxes of gloves, body wash, shampoos, sprays and wash basins all sitting on the cart with the clean linen. [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. Resident Identifiers: Resident #13. Facility Census: 79 Findings Included: a) Resident #13 A review of facility policy titled Activities of Daily Living with a revision 06/01/21 read as following. Based on the comprehensive assessment of a resident/patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrate that a change was avoidable. .Activities of daily living include: Hygiene-bathing, dressing, grooming and oral care. [...]