Highland Hills Post Acute

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to obtain a physician order for wound care and failed to provide appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents (discharged Resident R1 and Resident R3).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined and failed to obtain failed to obtain a physician order for a hospital transfer for one of four residents (Resident R3) and failed to obtain physician orders for management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for one of two residents (discharged Resident R2).

Inspectors wroteBased on review of facility policy, observations and resident and staff interviews it was determined that the facility failed to make certain that nail care was provided for four of ten residents (Resident R3, R4, R5, and R6).

Inspectors wroteBased on review of facility policy, clinical record review, observations, resident interview, and staff interview, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for three of three residents (Residents R1, R2, and R3).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain resident's confidential personal and medical records for one of three residents (Resident R1).

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

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for the facility's Automated External Defibrillators (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias) (Second floor and first floor) and crash cart (a supply cart used in an emergency - second floor).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to follow established procedures of water storage to ensure that water is available to essential areas when there is a loss of normal water supply.

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for four of seven residents (Resident R31, R40, R70 and R102).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews it was determined that the facility failed to include hypoglycemia protocols for one of three sampled residents (Resident R19) and failed to obtain a physician order for three of four residents (Resident R10, R102 and R149).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for four of six residents (Residents R10, R127, R158 and R172).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R7) and failed to ensure that Enhanced Barrier Precautions were managed properly for three of three residents (Resident R16, Resident R89, and Resident R159).

Inspectors wroteBased on resident group meeting, clinical record review, observation and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R149).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one of three sampled resident records (Resident R134).

Inspectors wroteBased on review of facility policy, resident council group interview, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three common areas (Vending machine area).

Inspectors wroteBased on review of facility policies, facility documents, resident clinical records, and staff interviews it was determined that the facility failed to maintain an environment free of abuse for one of five sampled residents (Resident R167).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of five residents (Resident R11).

Inspectors wroteBased on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of four residents (Resident R127 and R161).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of six sampled residents (Resident R109).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in two of five medications carts (first floor medication cart four and second floor medication cart two) and two of two medication rooms (first floor, and second floor medication rooms).

Inspectors wroteBased on review of clinical records, observations, staff, and resident interviews, it was determined that the facility failed to provide residents food products based on their preferences for two of eight residents (Resident R149, R174).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of twelve residents (Resident R1) identified as having a high risk for wandering.

Inspectors wroteBased on review of facility files and an interview with the Human Resources Director Employee E9, it was determined that the facility failed to employ a full-time qualified social worker from 7/27/25, through 9/2/25.

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for three of five employees (Nurse Aide (NA) Employee E15, and NA Employee E5, and Licensed Practical Nurse (LPN) Employee E16).

Inspectors wroteBased on review of facility policies, clinical records, and facility provided documents, as well as staff interviews, it was determined that the facility failed to ensure that one of four residents (Resident R3) was free from abuse perpetrated by a resident with aggressive behaviors (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of two allegations of abuse for two of three residents (Resident R1 and R3).

Inspectors wroteBased on review of facility policy, resident clinical records, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for two of three residents (Resident R1, and R3).

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

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents (Resident R4).

Inspectors wroteBased on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in transferring to the Veterans Affairs (VA) for a behavioral bed for one of twelve residents (Resident R1).

Inspectors wroteBased on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.

Inspectors wroteBased on a review of regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Nursing Home Administrator (NHA) at the time of the change.

Inspectors wroteBased on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employee E15, and NA Employee E5).

Inspectors wroteBased on review of facility policy, clinical record review, incident reports, facility documents, employee statements, and staff interview it was determined that the facility failed to ensure that a resident received adequate supervision who was an elopement risk which resulted in an elopement for one of seven residents (Resident R1). This was identified for past non-compliance for Resident R1.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of three residents reviewed (Resident R1 and R2).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2).

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

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician, failed to notify family, and failed to complete an assessment of a resident after an abuse allegation was made for three abuse allegations for two of three residents (Resident R1 and R2).

Inspectors wroteBased on manufacturer's instructions, clinical record reviews, and staff interviews it was determined that the facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed two of two residents in immediate jeopardy in which health and safety were impacted (Resident R1, and R2).

Inspectors wroteBased on review of clinical record, and staff interview, it was determined that the facility failed to develop a baseline care plan that included Life Vest (wearable defibrillator designed to protect residents from sudden cardiac death), and interventions needed to provide effective and person-centered care for two of two residents (Resident R1, and R2).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of two residents (Resident R1).

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial comprehensive visit for three of six residents (Residents R3, R4, and R5).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff had the specific competencies and skill set necessary to provide care for residents with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death).

Inspectors wroteBased on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Inspectors wroteBased on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for four of seven residents (Resident R1, R2, R3, and R4).

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

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for seven of 15 resident wheelchairs (Residents R4, R5, R9, R49, R69, R89, and R93), failed to maintain structure of wall surface in two area (Resident R144's room and Arcadia Unit Dining Room), failed to maintain an adequate supply of washcloths readily available for staff use on two of four units (LTC and TCC units), and failed to ensure the privacy curtains were clean and sanitary for two of ten resident rooms (Residents R81 and R124).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of ten residents reviewed (Residents R2, R91, R107, R132, R256, and R259).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set assessments were completed within the required time frame for 21 of 38 residents reviewed (Resident R17, R29, R30, R32, R33, R34, R38, R51, R55, R61, R79, R97, R101, R102, R105, R117, R122, R123, R124, R127, and R136).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R139 and R143).

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers/wounds from developing or worsening for three of three residents (Residents R140, R150, and R152).

Inspectors wroteBased on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided for two of four with an indwelling urinary catheter (Residents R12 and R97) and one of two residents with an external urinary catheter (R65).

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for three or three residents reviewed (Residents R139, R143, and R259). Findings Include: Review of facility policy Enteral Nutrition dated 11/1/24, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc); d. administration method (continuous, bolus, intermittent); e. volume and rate administration; f. the volume/rate goals and recommendations for advancement towards these; and g. [...]

Inspectors wroteBased on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained and failed to maintain an accurate care plan for dialysis access site for three of three dialysis resident (Resident R14, R33, and R48).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in three of six medications carts (LTC cart 1, LTC cart 2, and Grand Heritage cart) and medications found unsecured at resident's bedside for three of 10 residents (Residents R2, R105, and R110).

Inspectors wroteBased on review of facility policy, facility documentation, and resident and staff interviews, it was determined that the facility failed to address repetitive grievances/concerns voiced during resident council meetings and individual grievances for four of six months (August 2024, September 2024, October 2024, and November 2024).

Inspectors wroteBased on the Code of Federal Regulations (CFR), clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide timely notice of the Notice of Medicare Non-Coverage (NOMNC) for one of three sampled resident records (Closed Resident Record CR1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of six residents reviewed (Residents R67 and R106).

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to ensure that residents received consistent post fall monitoring for two of seven residents (Residents R15 and R79).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen/nebulizer management for two of three residents (Residents R39 and R121).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R110).

Inspectors wroteBased on review of facility policy, meal observations, resident interviews, and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of five breakfast meal observations on the Arcadia Unit (12/8/24, 12/9/24, 12/10/24, 12/11/24, and 12/12/24).

Inspectors wroteBased on observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R87).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of four quarters (April 2024, through June 2024).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions and failed to implement a care plan containing interventions for enhanced precautions which created the potential for cross-contamination and the spread of diseases and infections for one of four residents (Resident R139).

Inspectors wroteBased on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for 24 or 24 months (8/22, 9/22. 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 4/24, 5/24, 6/24, and 7/24) as required.

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident R11). Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], at 2:45 p.m. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/11/24 included diagnoses of fracture of sacrum (bone at bottom of spine), hypertension (high blood pressure), and depression. Review of Section J: Health Conditions revealed resident R11 is on a scheduled pain medication regimen. Review of Resident R 11's clinical admission dated 4/4/24, 2:45 p.m. [...]

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for one of two residents and failed to provide food products based off the resident's food preference for one of two residents (Resident R9). Review of facility policy Resident Rights, dated 2/1/23, last reviewed 3/5/24, indicates to incorporate each residents ' goals, preferences, and choices into care. Review 4/30/24, of Resident R9's breakfast tray card indicated that the resident was to receive two bananas with breakfast daily. Interview 4/30/24, at 11:55 a.m. Dietary manager Employee E14 confirmed Resident R9 has not been receiving bananas as ordered as they are only ordered every 3 weeks on Tuesdays. Interview with Registered Dietician Employee E13 also confirmed that Resident R9 has not received his bananas as ordered. Interview 4/30/24, at 11:57 a.m. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of seven residents (Resident R1 and R2).

Inspectors wroteBased on review of facility policy, facility documents, meal delivery observations, resident group interview, resident and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for two out of five days (1/8/24 and 1/9/24).

Inspectors wroteBased on review of facility policy, clinical records, resident group interview, resident interviews and staff interview it was determined that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for five out of seven residents (Residents R3, R39, R57, R123, and R125).

Inspectors wroteBased on review of resident clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide consistent and complete communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents (Residents R45 and R56), and failed to have physician orders for monitoring of access sites for one of three residents (Resident R25).

Inspectors wroteBased on review of facility policy, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for three out of six nursing personnel (Nurse Aide (NA) Employee E21, Licensed Practical Nurse (LPN) Employee E22, and Registered Nurse (RN) Employee E23).

Inspectors wroteBased on facility policy, facility documents, clinical record review and staff interview, it was determined that the facility failed to accurately assess residents for social services needs for three of nine residents (Resident R86, R138, and R153). Review of the facility Social Service Director job description indicated that responsibilities include to complete or ensure that patients, family, and staff interviews are conducted for completion of relevant Minimum Data Set (MDS -periodic assessment of care needs) sections (i.e. cognitive, mood, behavior, patient goal setting) and Care Area Assessments are completed in accordance with regulation. [...]

Inspectors wroteBased on review of facility policy, resident records, observations and staff interview it was determined that the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R117), failed to utilize infection control precautions and prevent the potential for cross-contamination in a room with a COVID-19 positive resident (Resident R181), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 12 months (February 2023, March 2023, May 2023, and December 2023)

Inspectors wroteBased on a review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide an environment that maintained and enhanced each resident's quality of life for one of eight residents (Resident R153).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that a resident representative was informed, in advance, of changes to the plan of care and failed to ensure a resident representative was notified in advance of care conference meetings for two of three sampled residents (Resident R43 and Closed Resident Record CR166).

Inspectors wroteBased on review of facility policy, notice of non-coverage documents, clinical record review and staff interview, it was determined that the facility failed to issue a Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), for one of three residents (Resident R293).

Inspectors wroteBased on review of facility policies, clinical records, facility submitted documents, incident reports, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect for one of four sampled residents (Resident R95).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employee by completing a State background check prior to hire for one out of five personnel records (Agency Dietary Aide Employee E20).

Inspectors wroteBased on review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of four sampled residents (Resident R123).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed develop and implement a base line care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of six residents (Resident R292) reviewed.

Inspectors wroteBased on review of facility policy, resident records, and staff interview it was determined that the facility failed to identify a pressure ulcer during the admission evaluation for one of nine sampled residents with a pressure ulcer (Resident R175).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to prevent injury during a shower, resulting in a fall that required transfer to the hospital for one of three residents sampled (Resident R123) and that the facility failed to ensure that a resident received neurological assessment after an incident involving a fall for two of three sampled residents (Closed Resident Record CR166).

Inspectors wroteBased on clinical records and staff interviews, it was determined that the facility failed to monitor a resident's weight for one of five residents (Resident R45)

Inspectors wroteBased on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Resident R13, R39, and R56).

Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely pharmacy medication recommendations for two out of five sampled residents (Resident R39 and R92).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of five sampled residents (Resident R39).

Inspectors wroteBased on review of facility policies, observations, and staff interviews it was determined that the facility failed to accurately label and date open medications for two sampled medication carts (Arcadia medication cart and Second floor medication cart number one), and failed to secure medications in two out of six medication carts (First floor Skilled Medication Carts One and Two), and failed to ensure that outdated biologicals were discarded in one of two medication rooms (LTC Unit)

Inspectors wroteBased on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (second quarter, April - June 2023).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of twelve months (February 2023, March 2023, and December 2023).

Inspectors wroteBased on review of facility policy, staff personnel records and staff interviews it was determined that the facility failed to provide newly hired staff with an orientation involving training for resident abuse and exploitation for one out of five personnel records (Agency Dietary Aide Employee E20).

Inspectors wroteBased on a review of clinical record review and staff interview, it was determined that the facility failed to timely provide the skilled nursing facility Notice of Medicare Non-coverage (NOMNC) form as required for one of five residents (Resident R1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for one of five residents (Resident R2).

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

Inspectors wroteBased on review of facility documents, observation, and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information for two of 11 residents (Resident R6, and R7).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to make certain that a resident environment remained free of potential accidents or hazards by padlocking a means of egress for one of eight units (Arcadia).