Highland Oaks Health Center

Inspectors wroteBased on review of the substitution log and interviews, the facility failed to ensure menus were followed. This had the potential to affect 84 of 84 residents receiving meals from the kitchen. The facility census was 85.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's physician was notified when a medication ordered for the treatment of hypotension (low blood pressure) was not available to be administered as ordered. This affected one (Resident #89) of three residents reviewed for medications. The facility census was 87.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident's baseline care plan was developed and the resident and/ or their representative received a copy of the baseline care plan within 48 hours of admission. This affected one (Resident #89) of three residents reviewed for care plans. The facility census was 87.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure comprehensive care plans addressed bladder and bowel incontinence and toileting assistance for Resident #27, #82 and #89. This affected three (Resident #27, #82, and #89) of three residents reviewed for care plans. The facility census was 87.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure contracted pharmacy services were provided to assure Resident #89's medications were delivered timely and administered as ordered. This affected one (Resident #89) of three residents reviewed for pharmacy services. The facility census was 87.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident's medical record was complete and included all documentation required as part of the resident's admission into the facility. This affected one (Resident #89) of three resident records reviewed. The facility census was 87.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure physician's orders were followed for three (Residents #27, #89, and #91) of seven residents reviewed for physician's orders. The facility census was 88.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to assess, observe, and document care of a left arm fistula site and an external central venous catheter (CVC) dialysis access site for Resident #27. This affected one (Resident #27) of one resident reviewed for dialysis care and services. The facility census was 88.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to obtain a urinalysis for Resident #23 when ordered by the nurse practitioner. This affected one (Resident #23) of five residents reviewed for incontinence. The facility census was 88.

Inspectors wroteBased on observation, record review, review of the facility Abuse and Neglect policy and procedure, and interviews, the facility failed to provide adequate and necessary supervision and intervention to protect Resident #27's right to be free from sexual abuse by Resident #21. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 11/16/24 when Certified Nursing Assistant (CNA) #300 observed Resident #21, who was positive for Hepatitis C engaging in non-consensual sexual intercourse with Resident #27, a cognitively impaired and non-interviewable male resident who lacked the cognition to consent to the interaction. CNA #300 reported the incident to CNA #203 and Registered Nurse (RN) #188 but no investigation was completed, and no interventions were initiated to prevent potential recurrence. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to monitor and administer Resident #31's vancomycin per standards of care, failed to address edema and obtain Doppler testing timely for Residents #59, #85, and #191, failed to communicate orders and care plan with hospice for continuity of care for Resident #54, and failed to address a change in condition for Resident #41 following a fall. This affected six sampled residents (#31, #41, #54, #59, #85, #191) of 20 residents reviewed for quality of care. The facility census was 85. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin assessments/skin checks were completed and to ensure skin integrity issues were reported to the medical provider. In addition, the facility failed to provide treatment to newly developed pressure ulcers for Resident #41 and failed to implement skin interventions for Resident #1 per the resident's plan of care. This affected two residents (#1 and #41) of two residents reviewed for pressure ulcers. The facility census was 85. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement comprehensive, individualized and effective interventions to prevent a fall and wandering behavior resulting in Resident #71 exiting the facility. Actual harm occurred on 07/31/24 when the facility failed to prevent Resident #71 from exiting the building to the patio after the resident reported he was aware he could exit after pushing on the door for 15 seconds to get out. Following this incident on this date, the facility failed to implement additional/new interventions for Resident #71's safety and five hours later, Resident #71 exited the building again, and sustained a fall. The resident complained of pain and was transported to the emergency department where he was diagnosed with a fracture of the shaft of the left femur. [...]

Inspectors wroteBased on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) performance reviews were completed as required at least every 12 months. This had the potential to affect all 85 residents residing in the facility. The facility census was 85. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no annual performance review for 2024. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employee performance review was not completed as required. 2. Review of the employee file for CNA #182 revealed no evidence of annual training for the memory care unit and 12 hours of annual in-services. Interview on 01/22/25 at 5:42 P.M. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the oven was in safe operational condition and failed to ensure the facility had adequate supply of plates and cups. This had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) were provided 12 hours of continuing education per year. This had the potential to affect all 85 residents residing in the facility. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 2. Review of the employee file for CNA #119 revealed a hire date of 08/28/19. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 3. Review of the employee file for CNA #208 revealed a hire date of 02/08/21. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. [...]

Inspectors wroteBased on medical record review, review of facility contracts, interviews, and policy review the facility failed to ensure medications were available for administration as ordered. This affected four residents (#1, #31, #85, and #191) of seven residents reviewed for medication review.

Inspectors wroteBased on medical record review, observation, interview and policy review the facility failed to ensure medications were properly stored, medication carts were locked when unsupervised, and insulin medications were dated when opened. This had the potential to affect all 22 of 22 residents on 200 hall, all 14 of 14 residents on 300 hall, and all 22 of 22 residents on 400 hall.

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection in the area of tracheostomy care, dressing change, medication administration and enhanced barrier precautions (EBP). This affected ten residents (Residents #1, #9, #22, #30, #31, #54, #61, #74, #191, #240) of 85 residents who require enhanced barrier precautions and four residents (#1, #10, #67, and #191) of 20 residents reviewed for infection control practices. Additionally, the facility failed to ensure the infection control log was accurate and tracked bacteria from nosocomial infections and infection control polices were reviewed annually. This had the potential to affect all 85 residents residing in the facility. Findings Included: 1. [...]

Inspectors wroteBased on medical record review, review of the concern log, review of personnel files, interviews, and policy reviews the facility failed to ensure residents were treated with respect and dignity by nursing staff. This affected one resident (#9) of six residents interviewed on 300 halls.

Inspectors wroteBased on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#19) of one resident reviewed for notification. The facility census was 85. Findings Include: Review of the medical record for Resident #19 revealed an initial admission date 03/08/16 of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the letter of guardianship dated 10/03/14 revealed the resident was deemed incompetent. A family member of the resident was named the resident's guardian of person only indefinitely. [...]

Inspectors wroteBased on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#19). The facility handled the funds for 52 residents. The facility census was 85. Findings Include: Review of the financial records for Resident #19 revealed the facility managed her funds. Review of the resident's quarterly resident fund statement revealed the balance in the resident's account had been greater than $1800.00 since 10/01/24. On 10/01/24 the balance was $1881.99. The current balance in the account was $1950.97. [...]

Inspectors wroteBased on medical record review, review of the code status binder, interview, and policy review the facility failed to ensure resident code status was consistent and accurate. This affected three residents (#54, #85, and #191) of three reviewed for advance directives.

Inspectors wroteBased on record review and interview, the facility failed to notify legal representatives of changes in orders or medical conditions. This affected two residents (#19, #85) of two residents reviewed for medical provider notifications. The facility census was 85.

Inspectors wroteBased on staff interviews, policy review, and record review, the facility failed to report an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85.

Inspectors wroteBased on staff interviews, policy review, and record review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85.

Inspectors wroteBased on record review, review of email correspondence to the local Ombudsman, and staff interview, the facility failed to ensure the local Ombudsman was notified of a resident's transfer to the hospital as required. This affected one resident (#88) of one residents reviewed for hospitalization.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two residents (#30, #38) in the area of dental and dialysis. This affected two residents (#30, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. [...]

Inspectors wroteBased on record review and staff interview the facility failed to complete a significant change minimum data set ( MDS) for one resident (#40) within 14 days of the resident being admitted to hospice services. This affected one resident (#40) of 20 residents reviewed for assessments. The facility census was 85. Findings Include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including abdominal aortic aneurysm without rupture, malignant neoplasm of prostate, and unspecified dementia. Review of a social services note dated 12/16/24 at 3:28 P.M. revealed Resident #40's family requested a referral be sent to hospice. Review of orders revealed Resident #40 admitted to hospice services on 12/17/24 for a diagnosis of senile degeneration of the brain. [...]

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) was completed when a mental health diagnosis was newly added. This affected one resident (#38) of four residents reviewed for PASARR. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) assessment was correct upon resident admission to the facility. This affected one resident (#85) of four residents reviewed for PASARRs. The facility census was 85.

Inspectors wroteBased on record review and interview, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) contained correct developmental disability diagnoses. This affected one resident (#23) of four residents reviewed for PASARR assessments. The facility census was 85.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for three residents (#30, #31, #38). This affected three residents (#30, #31, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure comprehensive care plans were up to date. This affected two residents (#21 and #71) of three residents reviewed for care planning. The facility also failed to complete quarterly care conferences. This affected one resident (#1) of three residents reviewed for care planning. The facility census was 85.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. This affected one resident (#87) of one resident reviewed for discharge. The facility census was 85. Findings Include: Review of the closed medical record for Resident #87 revealed an initial admission date of 10/11/24 with the diagnoses including but not limited to traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, hyperlipidemia, hypertension, benign prostatic hyperplasia, obesity, diverticulosis, osteoarthritis, incisional hernia, dysphagia, generalized muscle weakness and disorders of kidney and ureter, renal mass. The resident was discharged to his own home on [DATE]. [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#57) of two residents reviewed for activities of daily living (ADL's). The facility census was 85. Findings Include: Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the plan of care dated 01/06/23 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. [...]

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to treat one resident (#11) for a urinary tract infection (UTI) in a timely manner. Additionally, the facility also failed to provide one resident (#1) with routine indwelling urinary catheter care. This affected two residents (#11, #1) of three residents reviewed for catheter or UTI. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 05/07/21 with the latest readmission of 07/05/22 with the diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, Major depressive disorder, irritable bowel syndrome, hypertension, dysphagia, acute failure to thrive, insomnia, anxiety and palliative care. Review of Resident #11's progress notes dated 10/01/24 at 10:53 A.M. [...]

Inspectors wroteBased on record review, Registered Dietician (RD) recommendation review, interview and facility policy review, the facility failed to implement dietary recommendations and obtain physician ordered daily weights for one resident (#30). This affected one resident (#30) of two residents reviewed for nutrition. The facility census was 85. Findings Include: Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. [...]

Inspectors wroteBased on medical record review, review of hospital records, observation, interview, and policy review the facility failed to ensure residents had oxygen orders, respiratory medications were administered as ordered, respiratory supplies were stored properly, and emergency tracheostomy supplies were readily available. This affected three residents (#57, #67, #191) of three residents reviewed for respiratory care and medication observation.

Inspectors wroteBased on medical record review, observation, interviews and facility policy review, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#30) of one resident reviewed for dialysis. The facility census was 85.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to assess, implement and monitor one resident (#38) with known post traumatic stress disorder (PTSD) for triggers and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. This affected one resident (#38) of five residents reviewed for behavioral-emotional needs. The facility census was 85. Findings Include: [...]

Inspectors wroteBased on medical record review and interviews, the facility failed to ensure a resident received referrals for psychiatric services and failed to ensure a resident had interventions in place to address aggressive behaviors. This affected one resident (#71) of one reviewed for choices and one resident (#85) two reviewed for dementia care.

Inspectors wrote2. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The assessment indicated dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were active diagnoses. The resident received antipsychotic, antianxiety, antidepressant and hypoglycemic medications. [...]

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents were free from unnecessary medications when pain medication failed to have parameters and failed to ensure sliding scale insulin was followed per orders. This affected three residents (#74, #85, and #191) of six reviewed for unnecessary medication review. The facility census was 85.

Inspectors wroteBased on medical record review, review of hospital records, interviews, and policy review the facility failed to ensure psychotropic drugs were administered as ordered, properly assessed, and had appropriate diagnoses. This affected three residents (#19, #85, and #191) of six reviewed of unnecessary medication review.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to ensure physician ordered laboratory tests were obtained as ordered. This affected two residents (#19, #38) of five residents reviewed for unnecessary medications. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure one resident (#38) received routine dental care. This affected one resident (#38) of one resident reviewed for dental services. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's admission observation and data collection dated 02/02/23 revealed the resident had her own natural teeth. [...]

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure a complete and accurate record. This affected three residents (#57, #11, #85) of 20 sampled residents. The census was 85. Findings Include: 1. Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the resident's plan of care revealed no care plan addressing the resident's oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had not utilized oxygen therapy. Review of the resident's monthly physician orders identified no orders for oxygen use. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure an appropriate reason for the use of an antibiotic for one resident (#11). This affected one resident (#11) of three residents reviewed for antibiotic use. The facility census was 85. Findings Include: Review of the closed medical record for Resident #11 revealed an initial admission date of 07/05/21 with the latest readmission of 05/07/22 with the admitting diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, irritable bowel syndrome, hypertension, malignant neoplasm of female genital organ, dysphagia, tract infection, insomnia, unspecified, palliative care, and anxiety disorder. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the influenza vaccine, pneumonia vaccine and COVID-19 vaccine. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the COVID-19 vaccine. Review of the resident's medical record revealed no documented evidence the resident received the requested COVID-19 vaccination as requested. [...]

Inspectors wroteBased on record review, resident interview, staff interview, and policy interview, the facility failed to ensure a resident received appropriate wound care to a surgical site and to a non-pressure ulcer on his right foot. They also failed to ensure wounds were assessed upon admission and weekly thereafter to monitor for healing. This affected one (#56) of three residents reviewed for wounds/ dressing changes.

Inspectors wroteBased on record review, review of an Omnicell (medication dispensing system) Inventory list, and staff interview, the facility failed to ensure a resident identified as having a urinary tract infection received antibiotic therapy timely, after it was ordered. This affected one (#91) of three residents reviewed for urinary tract infections.

Inspectors wroteBased on record review, resident representative interview, staff interview, and policy review, the facility failed to ensure appropriate care and treatment was provided to a resident that had a gastrostomy tube. This affected one ( #91) of one residents reviewed for gastrostomy tubes.

Inspectors wroteBased on record review, review of controlled drug use records, staff interview, and policy review, the facility failed to ensure controlled medications administered to a resident, as indicated on the medication administration records, were also properly documented on controlled drug use record sheets for reconciliation purposes. This affected one (#91) of three residents reviewed for controlled medication use.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were properly dated when first accessed/ used. This involved three of four medication administration carts and affected a total of eight residents (#30, #32, #50, #54, #55, #63, #75, and #77). The facility's census was 87.

Inspectors wroteBased on record review, observations and interviews, the facility failed to follow infection control protocols. This affected 18 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) of 26 residents residing on the memory care unit. The facility census was 95.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to investigate an allegation of misappropriation within the required five days. This affected one resident (#20) of one resident reviewed for misappropriation. The facility census was 95.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to ensure food was properly stored in the dry food storage area to prevent spoilage/ possible contamination from insects and/ or rodents. This had the potential to affect all residents in the facility who received food from the kitchen. The facility's census was 95.

Inspectors wroteBased on observation, review of quotes for equipment replacement, review of a facility issued check, review of the administrator's notes, review of daily temperature log sheets, review of correspondence with the facility's chemical supplier, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the washers or utilize appropriate bleach or bleach alternative products to properly disinfect/ sanitize linens and residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95.

Inspectors wroteBased on observation, review of quotes for equipment replacement, review of a facility issued check, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the facility's washing machines to be able to properly disinfect/ sanitize linens and the residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95.

Inspectors wroteBased on observation, review of work invoices, review of quotes for plumbing work that needed to be done, and staff interview, the facility failed to ensure the basement area utilized for food storage was maintained in a clean/ sanitary manner as a leaking sewer pipe was not timely repaired. This had the potential to affect all residents residing in the facility. The facility census was 95.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure residents received laboratory testing as ordered by the physician. This affected one (Resident #34) of three residents reviewed for laboratory services. The facility census was 91.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure timely and necessary care and services were provided to meet the total care needs of all residents. Actual Harm occurred on 09/24/23 at 10:00 P.M. when the facility failed to timely treat and seek medical intervention for Resident #44 following a fall with left hip fracture. On 09/24/23 at 10:30 P.M. Resident #44 was assessed to have an elevated blood pressure of 216/68, followed by multiple other elevated blood pressures. On 09/25/23 at 2:28 A.M. the resident exhibited groin pain and on 09/25/23 at 1:04 P.M. the resident exhibited pain not controlled by Tylenol. The facility did not notify the physician of the pain until 09/25/23 at 6:12 P.M. when an order was given for left hip and femur x-rays and Percocet (a narcotic analgesic) was ordered for pain. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide comprehensive and individualized interventions to Resident #188 to prevent the deterioration of a pressure ulcer. The facility also failed to ensure pressure ulcer assessments were comprehensive and completed weekly. Actual Harm occurred on 12/06/23 when Resident #188, who was admitted with a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the buttocks was identified to have deterioration to the ulcer which was now assessed to be unstageable (obscured full-thickness skin and tissue loss) related to the lack of comprehensive and individuated interventions being in place and lack of ongoing monitoring and timely identification of the wound deterioration. This affected one resident (#188) of one resident reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an effective and comprehensive plan to address the dementia/behavioral health care needs of Resident #47 to prevent a resident to resident altercation resulting in harm to Resident #29. Actual harm occurred on 11/23/23 when Resident #47 physically pushed Resident #29 after Resident #29 tried to take a paper away from Resident #47. As a result of the altercation, Resident #29 fell to the ground, hitting her head on a wheelchair, leaving a laceration which required three staples. This affected two residents (#47 and #29) of six residents reviewed for abuse. The facility census was 85.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications were appropriately packaged, labeled, and secured. This affected three medication carts of three medication carts (Connections 300 Hall, Front 500 Hall and Back 500 Hall) observed and one medication room (Connections 300 Nurses' Station) of one medication room observed. The facility census was 85.

Inspectors wroteBased on observation, facility policy review and interview, facility failed to prepare foods in a sanitary manner and failed discard food items that were out of date/expired. This had the potential to affect 84 of 84 residents who received meal trays from the kitchen. The facility census was 85.

Inspectors wroteBased on interview, resident record review, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were updated appropriately. This affected four residents (#13, #16, #26, #63) of nine residents reviewed for PASARR. The facility census was 85.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure residents had comprehensive care plans in place to address pressure ulcers, schizophrenia, anxiety, and insomnia. This affected four resident's (#4, #13, #30, and #188) of 26 residents reviewed for care plans.

Inspectors wroteBased on record review and interview the facility failed to ensure residents and representatives were invited to participate in care conferences and care plans were updated to reflect residents' current conditions. This affected four residents (#8, #29, #47, and #68) of five residents reviewed for care planning. The facility census was 85.

Inspectors wroteBased on observation, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed when passing residents their meals in their rooms and failed to ensure a glucometer was cleaned and disinfected after use. This had the potential to affect eight residents (#2, #14, #16, #27, #52, #57, #193, and #195) observed during lunch service and three residents (#11, #44, and #57) who required blood glucose monitoring using the shared glucometer from the 500 front medication cart. The facility census was 85.

Inspectors wroteBased on record review, review of invoice documents, facility policy review and interview, the facility failed to ensure immunizations were provided timely and as requested. This affected two residents (#9 and #34) and had the potential to affect 38 additional residents identified on a facility log to have consented to receiving a pneumococcal vaccine in September 2023 without evidence of administration. The facility census was 85.

Inspectors wroteBased on interview, resident funds documentation review, and facility policy review, the facility failed to ensure staff were not witnesses for Resident #32's and #62's account and failed to ensure money was dispersed timely upon the death of Resident #288. This affected three residents (#32, #62, and #288) of five residents reviewed for personal funds. The facility census was 85.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review the facility failed to ensure the resident's code status/advance directives were consistent in the medical record and failed to include the resident in the decision-making process related to his code status. This affected one resident (#34) of 24 residents reviewed for advanced directive.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide adequate supervision and effective/necessary intervention for Resident #68 to prevent potential incidents of resident to resident sexual abuse toward Resident #77. This affected two residents (#68 and #77) of six residents reviewed for abuse. The facility census was 85.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to report and/or investigate an injury of unknown origin for Resident #29. This affected one resident (#29) of one resident reviewed for reporting requirements. The facility census was 85.

Inspectors wrote2. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia without behavioral disturbances and bipolar disorder. A review of Resident #4's PASARR Identification Screen dated 07/07/23 revealed the PASARR was completed for a Preadmission Screening (PAS) from the community. Section (E.) of the PASARR was to document all the diagnoses the resident had of any mental disorders that were listed below. The diagnoses listed below included mood disorder, but mood disorder was not marked despite the resident's diagnoses including bipolar disorder (which was a mood disorder). The PASARR result notice indicated the resident did not have any indications of a serious mental illness and/ or developmental disability based on the PASARR Identification Screen that was submitted. [...]

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to ensure effective fall interventions were in place for Residents #29 and #44, and the facility failed to ensure 15-minute checks were completed for Resident #19 when he made statements of self-harm. This affected three (Residents #19, #29, and #44) of five residents reviewed for accidents and hazards. The facility census was 85.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure a bowel protocol was followed for Resident #9, failed to ensure adequate and proper urinary catheter care was documented and orders were followed for a trial removal of a urinary catheter for Resident #186 and failed to ensure proper infection control measures were maintained during urinary catheter care to prevent Resident #13 from developing a urinary tract infection. This affected one resident (#9) of one resident reviewed for dialysis and two residents (#186 and #13) of two residents reviewed for urinary catheters.

Inspectors wroteBased on medical record review, observation, and interviews the facility failed to ensure residents received nutritional supplements as ordered. This affected one resident (#9) of one resident reviewed for dialysis and one resident (#68) of two residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, resident record review, and facility policy review, the facility failed to ensure Resident #39's enteral tube placement was confirmed prior to administering medications. This affected one resident (#39) of one resident reviewed for tube feeding. The facility census was 85.

Inspectors wroteBased on observation, interview, resident record review, and facility policy review, the facility failed to ensure oxygen was administered per physician's order, oxygen tubing was changed per physician's order, and tubing and nebulizer equipment was maintained in a sanitary manner. This affected three residents (#13, #44, and #58) of three residents reviewed for respiratory care. The facility census was 85.

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to ensure residents had an effective pain management program. This affected two residents (#186 and #188) of three residents reviewed for pain.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to maintain communication with the dialysis center. This affected one resident (#9) of one resident reviewed for dialysis.

Inspectors wroteBased on record review and interviews, the facility failed to provide medically related social services to ensure Resident #19 maintained the highest practicable psychosocial well-being. This affected one resident (#19) of one resident reviewed for medically necessary social services. This facility census was 85.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure antibiotic medication to treat an infection for Resident #186 was properly ordered/transcribed following a hospitalization to ensure the resident received all doses ordered of the medication. This affected one resident (#186) of five residents reviewed for medication review.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations made as part of the residents' monthly medication regimen review were addressed by the physician and/or addressed timely. This affected three residents (#4, #19, and #25) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to ensure Resident #189's pulse (heart rate) was obtained prior to the administration of Digoxin, a cardiac glycoside medication, as ordered by the physician to ensure the medication was only administered when necessary. This affected one resident (#189) of three residents observed for medication administration. The facility census was 85.

Inspectors wroteBased on record review, review of a medication error report, staff interview, and policy review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were performed on a resident receiving antipsychotic medications to identify any side effects related to their use. They also failed to ensure a resident did not receive an extra dose of an anti-anxiety medication that was outside the orders given by the physician. This affected two residents (#4 and #28) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, resident record review, policy review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 7.69% and included three medication errors of 39 medication administration opportunities. The facility also failed to ensure inhalation medications were administered following manufacturer recommendations for proper use and to prevent compliacations. This affected three residents (#39, #66, and #189) of three residents observed for medication administration. The facility census was 85.

Inspectors wroteBased on record review and interview the facility failed to appropriately communicate dental concerns involving Resident #30. This affected one resident (#30) of four residents reviewed for dental services. The facility census was 85.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #84 who was being transferred to the local emergency department received a notice of transfer/discharge. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure a resident who was being transferred to the local emergency department received a notice of bed hold. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure the daily staffing data was posted daily and included the facility name per the regulation. This had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on record review, staff interview and facility policy and procedure review the facility failed to ensure resident financial accounts were maintained within the appropriate limits. This affected two residents (#25 and #43) of six residents whose financial records were reviewed. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident who utilized Medicaid may not keep more than $2000.00 in a trust account. Also, the same guidelines confirmed the COVID-19 stimulus checks (three total) did not count as monthly income; so it would not affect a resident's medical coverage. However, a resident who utilized Medicaid and received stimulus payment(s) had 12 months to spend that money from the time they received it to stay within the allowable limit. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacy recommendations were timely and appropriately addressed. This affected four residents (#29, #322, #36 and #62) of six residents reviewed for unnecessary medication use. Findings Include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, Anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes, and old myocardial infarction. [...]

Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to ensure Resident #27's bathing preference for showers was honored. This affected one resident (#27) of one resident reviewed for choices. Findings Include: Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. Review of the life enrichment assessment, dated 06/09/21 it was somewhat important for the resident to choose the type of bathing she received. The assessment indicated she preferred showers. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a beneficiary notice was provided to Resident #70 in a timely manner. This affected one resident (#70) of three residents reviewed for beneficiary notices. Findings Include: Resident #70 was admitted to the facility on [DATE] with diagnoses including encephalopathy, nontraumatic intracerebral hemorrhage, hypertensive emergency, atrial fibrillation, chronic kidney disease, cardiomegaly, benign prostatic hyperplasia, osteoarthritis, coagulation defect, age related physical debility, hypertension, hyperlipidemia and cerebral infarction. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/13/22 revealed Resident #70 had intact cognition. Review of Resident #70's beneficiary notice, dated 03/01/22 revealed his last day of covered of rehabilitation and skilled nursing services was on 03/01/22. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #29's Preadmission Screening and Resident Review (PASARR) was accurate at the time of the resident's admission. This affected one resident (#29) of two residents reviewed for PASARR. Findings Include: Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes mellitus, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes and old myocardial infarction. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to ensure Resident #27, Resident #31 and Resident #46, who required staff assistance for activity of daily living (ADL) care received adequate and timely assistance with showers, dressing and/or oral care to maintain proper grooming and hygiene. This affected three residents (#27, #31 and #46) of six residents reviewed for ADL care. Findings Include: 1. Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. [...]

Inspectors wroteBased on observation, record review, interview and facility policy and procedure review the facility failed to ensure comprehensive and individualized collaboration of care with the Hospice provider for Resident #31 including changes to guardianship and advance directives and failed to ensure a skin tear and bruising was monitored and treated. This affected one resident (#31) of one resident reviewed for Hospice services and non-pressure related skin conditions. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastro-esophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. [...]

Inspectors wroteBased on observation, record review, interview and facility policy and procedure review the facility failed to ensure interventions were in place to prevent falls for Resident #23. This affected one resident (#23) of six residents reviewed for accidents. Findings Include: Review of Resident #23's medical record revealed an admission date of 12/13/21 with diagnoses including vascular dementia without behavioral disturbances, psychosis and repeated falls. Review of the plan of care, initiated 12/24/21 revealed the resident was at risk for falls related to being unsteady at times, dementia and medications. Interventions included a Dycem (a non-slip, rubber-like plastic material used to stabilize surfaces) to the seat of the resident's wheelchair implemented on 04/06/22. [...]

Inspectors wroteBased on observation, record review, interview, meal ticket review and facility policy and procedure review the facility failed to ensure Resident #1 and Resident #36 were provided a diet as ordered during the dinner meal on 04/13/22 and failed to ensure weights were documented in the electronic health record and weight loss was reported timely to the dietician as necessary for Resident #11. This affected three residents (#1, #11 and #36) of five residents reviewed for nutrition.

Inspectors wroteBased on record review and interview the facility failed to ensure psychotropic medications were only administered to residents with clinical justification and as needed psychotropic medications were evaluated for duration of use. This affected three residents (#32, #62 and #272) of six residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, staff interview and facility policy and procedure review the facility failed to ensure fluids were readily available for Resident #31 for independent fluid consumption. This affected one resident (#31) of two residents reviewed for hydration. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the plan of care, dated 11/19/21 revealed the resident was on hospice with potential for unavoidable weight loss and nutritional decline and wanted to remain comfortable. [...]