Highland Manor of Fallon Rehabilitation LLC

Inspectors wroteBased on observation, interviews, clinical record review, and document review, the facility failed to 1) ensure that 1 of 4 residents (Resident #97) investigated for abuse and/or neglect received the necessary care and services to prevent a wound from deteriorating and becoming infected, resulting in the resident requiring emergent care for sepsis at an acute care hospital, where the resident subsequently expired due to sepsis and 2) protect residents' right to be free from neglect when signs and symptoms of infection and a change in skin condition in 1 of 18 sampled residents (Resident #24) were not reported timely to the physician by a Licensed Practical Nurse (LPN), resulting in the resident experiencing testicular pain and swelling and developing an infection that required intravenous antibiotic treatment at an acute care hospital. [...]

Inspectors wroteBased on clinical record review, personnel record review, document review, and interviews, the facility failed to 1) ensure that Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) accurately reflected each resident's status and were completed with appropriate participation from qualified health professionals, 2) ensure the MDS assessment was completed accurately for 1 of 18 sampled residents (Resident #34). These deficient practices had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 9 administration errors including administration of an incorrect medication, failure to administer medications in accordance with professional standards and principles, omission, and incorrect timing. The error rate was 34.62%.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure expired medications were removed from 1 of 1 medication storage rooms and 2 of 3 medication storage carts inspected. This deficient practice had the potential to result in expired medications being administered to residents.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure residents or resident representatives were informed of the benefits, risks and alternatives of an antidepressant medication for 1 of 18 sampled residents (Resident #5), and of an antianxiety medication for 1 of 18 sampled residents (Resident #10). This deficient practice had the potential to result in residents receiving an antidepressant or antianxiety medication not having been informed of the risks and benefits of the medication or the option to decline the medication prior to administration.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure upper side rails attached to a resident's bed were not used as a restraint with the intent to prevent a resident from ambulating on their own for 1 of 18 sampled residents (Resident #21). This deficient practice had the potential for a resident to experience psychosocial or physical harm from the resident's freedom of movement and activity being unnecessarily prohibited.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a bed hold notification was provided to a resident/resident representative, and the resident, the resident representative, and the Ombudsman were notified of the reason for transfer in writing when a resident was transferred to an acute care hospital for inpatient care for 1 of 12 sampled residents (Resident #40) and 1 of 3 residents reviewed for closed records (Resident #2) and/or the residents representative were provided notification of the facility's bed hold policy upon transfer to an acute care hospital. [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a level II Pre-admission Screening and Resident Review (PASARR) resident was referred for level II resident review upon diagnosis of new mental disorders for 1 of 18 sampled residents (Resident #10). This deficient practice had the potential to result in service not provided to assist in maintaining the resident's highest practicable level of functioning, placement in an inappropriate level of care, and avoidable psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's baseline care plan included the necessary care to provide for a resident with a skin condition requiring medicated cream to treat symptoms of swelling and itching for 1 of 18 sampled residents (Resident #99). This deficient practice had the potential to result in facility staff not being aware of a resident's need for a prescribed treatment resulting in the resident experiencing increased discomfort and skin irritation.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) implement the care planned intervention for a resident with side rails installed on the resident's bed leading to the side rails not being reevaluated at least quarterly for 1 of 18 sampled residents (Resident #21). This deficient practice had the potential to result in a resident experiencing physical harm from entrapment due to the risks not being reevaluated as care planned. 2) identify and document a resident's trauma-specific interventions for a resident with a trauma diagnosis for 1 of 18 sampled residents (Resident #5). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of trauma-specific interventions not having been documented in the care plan. [...]

Inspectors wrote[NAME] based on Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident's prescription topical cream was applied as ordered for 1 of 18 sampled residents (Resident #99), 2) a Licensed Practical Nurse (LPN) administered medications in accordance with physician orders and 3) an LPN was knowledgeable regarding indications for medications and potential side effects to monitor for and provided accurate information to residents prior to administering medications to 2 of 5 residents observed for medication administration (Resident #100 and #40). [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) ensure neurological assessments were documented for a resident with a fall and loss of consciousness for 1 of 18 sampled residents (Resident #98), and 2) ensure a resident with a skin condition requiring medicated cream for treatment had an accurate skin integrity assessment completed upon admission to the facility for 1 of 18 sampled resident (Resident #99). These deficient practices had the potential to result in 1) unmonitored and avoidable physical harm to the resident, and 2) the resident's skin condition not being treated timely and potentially worsening without a baseline assessment for comparison or accurate assessment information to communicate to all staff responsible for the resident's care.

Inspectors wroteBased on observation, clinical record review, interview and document review, the facility failed to ensure nursing staff reported a wound to a physician/provider for 1 of 18 sampled residents (Resident #101), obtained an order for the care and monitoring of the wound, and continued to reassess the wound during daily skin assessments. This deficient practice had the potential to result in worsening of the wound including infection and increased pain for the resident.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with limited range of motion received appropriate services to maintain or improve mobility for 1 of 18 sampled residents (Resident #34). This deficient practice resulted in increased resident pain and had the potential to result in avoidable mobility decline.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the resident environment was free from accident hazards when a resident was observed smoking a cigarette inside the facility for 1 of 18 sampled residents (Resident #42). This deficient practice had the potential to result in harm to all residents of the facility.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure a resident with a trauma diagnosis was assessed for the facility to recognize and respond to the effects of the trauma for 1 of 18 sampled residents (Resident #5). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of assessments to recognize trauma-specific interventions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a refrigerator was maintained at a safe storage temperature in 1 of 4 satellite kitchens of the facility. This deficient practice had the potential to harm residents by increasing the risk of infection and foodborne illnesses.

Inspectors wroteBased on clinical record review, personnel record review, document review, and interview, the Administrator failed to ensure employees identified to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments (Employee #8 and #9) had the experience and knowledge to complete accurate resident evaluations, and failed to ensure the accuracy of the MDS assessments after having learned of a title discrepancy in the resident electronic health record (EHR) system. This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.

Inspectors wroteBased on clinical record review, personnel record review, document review, and interview, the facility failed to ensure employees trained to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) were qualified for 2 of 2 employees trained to complete sections of the MDS Resident Assessments (Employee #8 and #9). This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified a widespread concern with completion of Minimum Data Set (MDS) 3.0 assessments by non-qualified individuals. This deficient practice had the potential to result in residents not receiving the required care or services due to the potential for inaccurate care plans generated from the MDS assessment.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure infection control precautions were observed for 1 of 4 complaint residents when the resident's wound dressings were allowed to drip onto the floor in the hallways and common areas of the facility. This deficient practice had the potential to spread infection to other residents and staff throughout the facility.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a regular inspection of a resident's bed frame and bed rails was completed for a resident with upper bed rails attached to the resident's bed frame for 1 of 19 sampled residents (Resident #21). This deficient practice had the potential to result in a resident injury from entrapment resulting from incompatible or malfunctioning bed rails.

Inspectors wroteBased on interview and document review, the Administrator failed to ensure the facility did not employ a Certified Nursing Assistant (CNA) with a disciplinary action against the CNA's license as a result of a finding of abuse of a resident. This deficient practice placed residents in the facility at risk for abuse.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a significant medication error did not occur when a resident was administered a penicillin antibiotic when the resident had a known penicillin allergy for 1 of 7 sampled residents (Resident #1). This deficient practice resulted in the resident being hospitalized after developing symptoms of an allergic reaction.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident with a known history of significant weight loss was monitored for further weight loss upon readmission to the facility for 1 of 7 sampled residents (Resident #4). This deficient practice had the potential to result in a resident experiencing impaired nutrition without interventions to address nutritional need.

Inspectors wroteBased on interview, and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee held meetings quarterly at a minimum. This failure had the potential to result in the facility not identifying and addressing concerns related to the quality of care in all areas of the facility.

Inspectors wroteResident #52 Resident #52 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, type II diabetes mellitus with diabetic nephropathy, and personal history of methicillin resistant staphylococcus aureus (MRSA) infection. A physician's order dated 04/24/2024, documented to place Resident #52 in EBP due to a history of MRSA in a wound. On 08/20/2024 at 1:43 PM, a Licensed Practical Nurse (LPN)/Wound Care explained Resident #52 had wounds including an area of Moisture Associated Skin Damage (MASD) and a stage II pressure injury (PI) on the sacrum. The wound had progressed and appeared to be a [NAME] Ulcer. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure there were eight hours of consecutive Registered Nurse (RN) coverage for 6 of 90 days reviewed for staffing. This deficient practice could have allowed all 87 residents residing in the facility on the affected dates to go without proper assessments or certain cares RNs can perform.

Inspectors wroteResident #79 Resident #79 was admitted to the facility on [DATE], with diagnoses including effusion, right knee and pain, unspecified. On 08/19/2024 at 3:00 PM, Resident #79 verbalized the resident has 10 out of 10 knee pain and takes pain medications and Lidocaine patches to manage the pain. The resident explained the facility ran out of Lidocaine patches and the resident went without for a couple of weeks. A physician order dated 06/10/2024, documented Lidocaine external patch 4 percent (%), apply to right knee topically one time a day related to pain, unspecified. On 08/21/2024 at 2:42 PM, a Licensed Practical Nurse (LPN1) verbalized Resident #79 received pain medication, Voltaren gel, and Lidocaine patches for knee pain. [...]

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1) a pharmacy label's instructions for administration on a medication dispensing card (medication card) matched the physician's order for1 of 19 sampled residents (Resident #4), 2) pre-poured medications were not stored unlabeled in a medication cart for 1 of 19 sampled residents (Resident #61), 3) expired medications were removed from one of three inspected medication carts, 4) insulin pens were correctly labeled and stored in medication carts, 5) medications requiring refrigeration were stored in a refrigerator, and 6) unlabeled and loose medications were not stored in medication carts.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's representative gave consent to the use of a psychotropic medication prior to the medication being administered for 2 of 19 sampled residents (Resident #51 and #32). This deficient practice had the potential for a resident to receive a medication without being fully informed of all potential side effects and adverse reactions or a medication the resident did not wish to receive.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1 of 19 sampled residents' (Resident #44) Minimum Data Set 3.0 (MDS) assessment was accurately completed.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to initiate a submission for a determination of a Preadmission Screening and Resident Review (PASARR) level II for 1 of 19 sampled residents with a mental illness diagnosis of schizoaffective disorder (Resident #37).

Inspectors wroteResident #32 Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic cough, and paroxysmal atrial fibrillation. On 08/19/2024 at 11:01 AM, Resident #32 was seated in a wheelchair with a portable oxygen concentrator hanging on the back of the wheelchair. Next to the resident's bed was an oxygen concentrator. Resident #32 explained being on oxygen continuously at five liters per minute (LPM) because of the resident's heart conditions. A physician's order dated 08/19/2024, documented Oxygen at five LPM via nasal cannula continuous for shortness of breath. Resident #32's Comprehensive Care Plan lacked documented evidence of a care plan for the administration and monitoring of Oxygen. [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to honor an intervention involving a recliner, aimed to aid sleep, for a resident exhibiting resistive care behaviors and who did not sleep in a bed, for 1 of 19 sampled residents (Resident #74).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident dependent upon staff for Activities of Daily Living (ADLs) received showers for 1 of 19 sampled residents (Resident #46).

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to employ a trained Activities Director or a qualified professional to provide oversight to the activities department.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a Physical Therapy (PT) evaluation was completed for a resident identified as a fall risk for 1 of 19 sampled residents (Resident #46). Resident #46 Resident #46 was admitted to the facility on [DATE], with diagnoses including hereditary motor and sensory neuropathy, muscle weakness (generalized), and history of falling. On 08/19/2024 at 10:28 AM, Resident #46 verbalized the resident had a rare hereditary condition that caused weakness of the legs and required the resident to wear braces on both lower legs. The resident had a fall prior to admitting to the facility and had been waiting to receive physical therapy. On 08/21/2024 at 8:45 AM, a Licensed Practical Nurse (LPN) verbalized Resident #46 had issues with their legs and did not have control of them. [...]

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure Oxygen was administered as ordered for 1 of 19 sampled residents (Resident #32).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure 1) pain medications were administered timely when Lidoderm External Patches (Lidocaine patches) were administered late for a resident diagnosed with pain for 1 of 19 sampled residents (Resident #80), and 2) Lidocaine patches were available and administered for 2 of 19 sampled residents (Resident #80 and #79).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a resident was reassessed for risk of entrapment after assessed to have a severe cognitive decline and prior to placing the resident in a bed with side rails for 1 of 19 sampled residents (Resident #52) and ensure residents were assessed for risk of entrapment prior to placing side rails on the residents bed for 2 of 19 sampled residents (Resident #134 and ).

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #8).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was provided dental services timely related to damaged dentures for 1 of 19 sampled residents (Resident #27).

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to honor a resident's meal preferences for a vegetarian diet and provide a meat substitute for meat entrees for 1 of 19 sampled residents (Resident #40). This deficient practice had the potential to deprive the resident of equal nutritional value for a preference of a vegetarian diet.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the administration of physician ordered nutritional shakes (Ensure) was documented for 1 of 19 sampled residents (Resident #27).

Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure medications were correctly labeled and stored, and controlled substances were accurately documented and reconciled.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was not verbally abused by a Certified Nursing Assistant (CNA) for 1 unsampled resident (Resident #17) and a resident was protected from resident-to-resident verbal abuse when a resident yelled racial slurs and profanity for 1 of 19 sampled residents (Resident #79).

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to submit a final Facility Reported Incident (FRI) report to the State Agency (SA) for 1 unsampled resident (Resident #17).

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to investigate an allegation of resident-to-resident verbal abuse and submit a final Facility Reported Incident (FRI) report to the State Agency for 1 of 19 sampled residents (Resident #79). This deficient practice had the potential to allow allegations of abuse to occur and not be investigated by the facility and not reported to the State Agency with the potential for residents to be physically and/or psychosocially harmed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained when an employee was standing over the residents while providing feeding assistance for 3 of 3 residents requiring assistance with eating in the 200 unit dining room.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility neglected to ensure a resident was properly secured for transport in the facility's transport bus resulting in fall with injury for 1 of 24 sampled residents (Resident #11) and failed to ensure two residents were protected from resident-to-resident verbal and physical abuse for 2 of 24 sampled residents (Resident #12 and #13).

Inspectors wroteBased on interview, clinical record review , and document review, the facility failed to ensure reports of suspected abuse toward residents were submitted to the Ombudsman's office from January 2024 through April 2024 for 9 of 19 Facility Reported Incidents (FRI) investigated, and the final FRI investigation was submitted to the State Agency timely for 5 of 19 FRIs investigated. The deficient practice could result in inquiries of abuse not being investigated, allowing potential abuse to occur without being reported to the Ombudsman's office, the State Agency, and /or Law Enforcement.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to thoroughly investigate allegations of abuse and lacked documented evidence of the abuse investigations for 1 of 25 sampled residents (Resident #23).

Inspectors wroteResident #3 Resident #3 , was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified (Primary), major depressive disorder, recurrent, severe with psychotic symptoms, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, other symptoms and signs involving cognitive functions and awareness, and insomnia, unspecified. The Care Plan for Resident #3 lacked documented evidence the resident's comprehensive care plan was updated after a resident to resident altercation occurring on [DATE] and [DATE]. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure there were eight hours of consecutive Registered Nurse (RN) coverage for 1 of 30 days reviewed for staffing and the facility had a full time Director of Nursing (DON). This deficient practice could have allowed all 77 residents residing in the facility on the affected date to go without proper assessments or certain cares RNs can perform and compromise the supervision of nursing care due to lack of oversight.

Inspectors wroteBased on observation, interview, and document review, the facility failed to 1) ensure staff used appropriate hand hygiene when working in the kitchen and serving resident food items, and 2) ensure staff used appropriate hand hygiene when providing feeding assistance to residents. The deficient practice could impact the sanitary conditions of the working area for preparing resident food and meals and the potential to cause the spread of food borne illness to residents in the facility.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure the Social Services department assessed and monitored residents for signs and symptoms of adverse outcomes following a resident-to-resident altercation for 3 of 15 Facility Reported Incident (FRI) sampled residents (Resident #50, #60, and #7). The failure to assess and monitor the residents had the potential for adverse outcomes and contributing behaviors to go unidentified resulting in the residents having increased or continued behaviors and/or adverse psychosocial outcomes.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 1 of 15 Facility Reported Incident (FRI) residents (Resident #25).

Inspectors wroteBased on observation, record review, document review, and interview the facility failed to prevent the misappropriation of funds for 1 of 15 Facility Reported Incident (FRI) residents (Resident #8).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a care plan was developed 1) regarding the misappropriation of a resident's funds by a staff member for 1 of 15 Facility Reported Incident (FRI) investigated residents (Resident 8), and 2) following resident to resident abuse allegations for 2 of 15 FRI investigated residents (Resident #25 and #7). The failure had the potential to delay implementation of appropriate resident care interventions.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure care plans were completed and up to date for 15 of 18 sampled residents (Resident #30, #37, #8, #35, #65, #7, #23, #49, #60, #25, #44, #74, #71, #284, and #25), and 1 of 5 residents for closed record review (Resident #22). The failure had the potential to delay implementation of appropriate resident care interventions.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure residents' rights to use silverware instead of plastic utensils was maintained for 21 of 21 residents located in the 100 hall and failed to provide the preferred shower scheduled to a resident requiring assistance for 1 of 18 sampled residents (Resident #20). On 06/06/23 at 2:30 PM, during the Resident Council Interview, 2 of 14 residents verbalized the residents had been eating with plastic utensils and wanted to know when the facility would serve the residents regular silverware. Another resident verbalized they hated eating with plastic spoons and forks because they break. The resident explained the resident had chewed on plastic when eating due to the tines of the forks breaking. The plasticware was not professional and screamed cheap. [...]

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident had been informed of the possible side effects and risks of psychotropic medication and had been given the opportunity to consent or refuse the medication prior to administration for 1 of 5 residents selected for medication review (Resident #37).

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure residents' rights to a homelike environment when the facility used silverware instead of plastic utensils for 21 of 21 residents located in the 100 hall.

Inspectors wroteBased on interview and clinical record review, the facility failed to ensure a resident's discharge status was accurately documented on a Minimum Data Set 3.0 (MDS) assessment for 2 of 5 closed resident records (Resident #58 and #59).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was created timely for the treatment and care needs for 1 of 5 residents selected for medication review (Resident #30) and 1 of 18 sampled residents (Resident #74).

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure a resident's gastric tubing was secured prior to transferring a resident, resulting in the gastrostomy feeding tube (G-tube) being pulled out with the inflated balloon intact for 1 of 18 sampled residents (Resident #25).

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to maintain a completed dialysis communication transfer form for 1 of 18 sampled residents (Resident #21).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure residents with bedrails initiated had appropriate alternatives implemented and attempted prior to usage for 1 of 18 sampled residents (Resident #65).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure medication was available and administered timely and an error rate of less than 5 percent (%). The medication administration error rate was 5.26%

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure expired medications were removed from 1 of 1 sampled medication storage room and 2 of 2 sampled medication carts, and medications were secured for 1 of 4 medication carts.

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 18 sampled residents (Resident #8).

Inspectors wroteBased on observation, interview, and clinical record review, the facility failed to ensure an assistive device was provided to assist with eating for 1 of 18 sampled residents (Resident #49).

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store food in a manner to prevent pests.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen facing a public area for 1 of 26 residents residing in a unit (Resident #69) and a list of resident names and vital sign measurements were not visible and left unattended on the top of a medication cart.

Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure 1) residents' homelike environment was maintained by not serving plasticware with meals, and 2) person centered care plans were developed to address the identified care needs of each resident.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 3 of 4 residents on Transmission Based Precautions (TBP) (Resident #10, #25, and #44) had the appropriate infection control signage posted at the entrance of the residents' rooms and failed to ensure the facility Infection Prevention and Control Plan (IPCP) was reviewed and/or updated annually and included a plan to address staff with communicable diseases.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #60) was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #54) was screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined.