Hill Crest Manor

Inspectors wroteBased on record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect), failed to check the Family Care Safety Registry (FCSR) to ensure that persons caring for children, seniors, or physically or mentally disabled individuals can be screened for employment purposes. The law requires that every child care and elder care worker hired on or after January 1, 2001, and every personal care worker hired on or after January 1, 2002. This affected five of 10 sampled staff. The facility census was 56. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical needs and the services that were to be furnished to attain or maintain the resident's highest practicable wellbeing when the facility failed to include how to care for a catheter as well as supplemental oxygen for Resident #10. This affected one of 14 sampled residents. The facility census was 56. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow standards of practice when they failed to ensure one of the 14 sampled residents, (Resident #28) had a physician's order to have medication at bedside and failed to have a physician's order to self - administer medications. The facility census was 56. Review of the facility policy titled, Self-Administering Medications, dated February 2021 showed the resident was supposed to administer their own medications when the resident's physician and the Interdisciplinary Team (IDT) determined it was safe for the resident. 1. Review of Resident #28's self - administration of medication assessment dated [DATE] showed the resident was capable of self-administering medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident's who required respiratory care, were provided such care consistent with professional standards of practice when the facility failed to ensure oxygen tubing was changed on a regular basis for four resident's (Resident's #8, #10, #49, and #28) of 14 sampled resident's. And when the facility failed to ensure oxygen concentrator filters were cleaned for two resident's (Residents #8 and #49). The facility census was 56. The facility did not provide a policy for respiratory care. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/30/26, showed: -The resident was cognitively intact; -The resident required assistance from staff to carry out activities of daily living; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to post the daily staffing sheets to include the amount of hours scheduled to work for both licensed and non-licensed nursing staff and failed to have it in an area unobstructed from the public view. The facility census was 56. The facility did not have a policy regarding the position of daily census and staffing sheets. 1. Observation and interview on 05/05/26 at 11:22 A.M., showed:- Staffing sheets were only available from 04/28/26 to 05/04/26, - The Regional Nurse Consultant (RNC) said he/she discovered on 04/28/26 the staff had not been filling out the daily staffing sheets. He/She had been unable to locate any staffing sheets for the last year. [...]

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly store, label and monitor food items for expiration dates, failed to properly temperature check cooked food items, failed to use gloves while handling ready-to-eat food items, and failed to properly sanitize between kitchen tasks. This affected all residents in the facility. The facility census was 56. [...]

Inspectors wroteBased on interviews and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services. This failure had the potential to affect all residents who received food from the kitchen. The facility census was 56. Review of the facility job description, Director of Food Services, undated, showed:- The primary purpose of the job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal and state regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free from accident hazards when one resident (Resident #1) eloped from the facility through an unsecured and unalarmed exit door. This affected one of four residents sampled. The facility census was 54. On 6/27/25 the Administrator was notified of the past noncompliance situation which occurred on 6/7/25. On 6/7/25 an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 6/10/25. Review of the facility policy, Wandering and Elopements, revised March 2019, showed: - The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; - The residents' care plan will include strategies and interventions to maintain the resident's safety; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to honor the resident's right to a dignified existence (Resident #11), and additionally when staff failed to assure residents rights to privacy was maintained for five (Resident # 8, #11, #12, #19, #21) of the 15 sampled residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - Employees shall treat all residents with kindness, respect, and dignity; -Staff will maintain a residents right to privacy; -Federal and state laws guarantee certain basic rights to all residents of this facility. 1. Review of the Resident #12's Face Sheet., showed: - Diagnoses included: Stroke and muscle weakness; - Do not resuscitate (No chest compressions for life saving). Review of Resident #12's, undated care plan., showed; - Resident was alert and oriented; [...]

Inspectors wroteBased on interview and record review the facility failed to assure that three residents (Resident #12, #25, and #42) had the right to self-determination through support of resident choice, when staff did not honor one resident's request for specific menu food items that had been encouraged by the facility's dietician (Resident # 42) but not not provided to the resident, and additionally failed to honor resident choice for showers for two residents (Resident #12, #25) out of the sampled 15 residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - All residents have the right to choice, and self determination, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of this facility. 1. Review of the Resident #12's Face Sheet., showed diagnoses included a stroke and muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings concerning issues of resident care and life in the facility and failed to communicate how the issues were resolved. The facility census was 58. Review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed: - All grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances; - The Administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; - Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include, as applicable: the date and time of the alleged incident; [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain a surety bond that was equal or greater than one and one-half times the average monthly balance for the residents trust fund (RTF) account for the last 12 consecutive months from January 2024-December 2024. This had the potential to affect all residents who had funds held in the RTF account. The facility census was 58. Review of facility policy, resident trust fund management, revised June 2022, showed: -Transactions are to be handled and records are to be kept in accordance with established directives and in conformance with state and federal requirements. -Facility will have a bond that equals at least one and one-half times the annual average of the fund account. [...]

Inspectors wroteBased on interviews and record review, the facility failed to annually inform the resident's of their rights. This affected 11 of the 11 residents in the group interview. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about his/her rights and responsibilities. 1. Review of the resident council minutes, dated 11/16/24 showed the section for resident rights reviewed was left blank. 2. Review of the resident council minutes, dated 12/4/24 showed the section for resident rights reviewed was left blank. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program that was readily available and could be read by all residents in the facility without assistance. The census was 58. Review of the facility's policy titled, Resident Rights, revised February 2024, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to communicate with outside agencies regarding any matter. 1. During a resident group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents who attended the meeting did not know what the Ombudsman was, what they did or where to find information about the Ombudsman program in the facility. [...]

Inspectors wroteBased on interviews, the facility failed to deliver Saturday mail to facility residents. The facility census was 58. Review of the facility's policy titled, Resident Rights, revised February 2024, showed: - Employees shall treat all residents with kindness, respect, and dignity; - Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to access to a telephone, mail and electronic mail (e-mail). 1. During the resident group meeting on 1/27/25 at 1:07 P.M., 11 of the 11 residents who attended the meeting said the mail is not passed out to the residents on Saturdays. During an interview on 1/27/25 at 4:37 P.M., the Activity Director said: - In the past, a resident used to go out and get the mail out of the mailbox and put it in the office but that has stopped; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 11 of 11 residents who participated in a group meeting, knew how to file a grievance in writing, file anonymously, and obtain a written decision regarding a grievance. The facility census was 58. Review of the facility's policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed: - All grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances; - The Administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer; - Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include, as applicable: the date and time of the alleged incident; [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their own Abuse and Neglect policy, when they did not verify through the employee disqualification list (EDL) verification checks prior to the hire dates of five out of eight employees (Dietary Aide A, Nurse Aide (NA) A, NA B, [NAME] A, Maintenance Director) and additionally failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator ( a marker given by the Federal government to individuals who have committed abuse/neglect) for one of the eight sampled staff (Registered Nurse (RN) A). The facility census was 58. Review of facility policy, Employee Disqualification List (EDL), revised 2/2022, showed: -The employee designated by the administrator to complete the EDL background check will access the EDL website and complete the access to automatic system. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to hold care plan meetings on a quarterly basis or when a resident's significant change in condition occurred. The facility additionally failed to involve residents and/or their representatives in the care planning process for five residents (#24, #32, #42, #16, #21) of the 15 residents sampled. The facility census was 58. Review of the facility's Care Planning Policy, dated 3/2022, showed: -The interdisciplinary team (IDT), in conjunction with the resident and their family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident; -Each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of their plan of care, including the right to: - Participate in the planning process; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff did not follow the manufacturer's guidelines when transferring one (Resident # 8) in a mechanical lift and while pushing residents in their wheelchairs without foot pedals for two (Resident #11 and #30) residents. This affected three (Resident #8, #11, and #30) of the fifteen sampled residents. The facility census was 58. Review of facility policy, Resident Rights, undated, showed: -Safe Environment: Resident have the right to a safe, clean, comfortable, and homelike environment, including while receiving treatment and supports for daily services. Review of facility policy, Resident Handling Policy, Revised in 2000, showed: -Resident handling policy exists to ensure a safe working environment for resident handlers; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides (NA's) met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 58. The facility did not provide a policy regarding hiring and training nurse aides. 1. Review of the facility employee list showed: - NA A was hired on 6/5/24; - NA D was hired on 12/19/22; - NA E was hired on 5/19/23. Record review of personnel files showed no documentation that NA A, NA D and NA E had been certified. During an interview on 1/29/24 at 4:16 P.M., the Administrator said they are no longer hiring NA's, but NAs should have their certification within four months of their hire date.

Inspectors wroteBased on observations, interviews and record review, the facility failed to discard expired medications and biological's stored within the medication cart and medication room, failed to date an opened vial of tuberculin (TB) purified protein derivative (PPD, skin test used to help diagnosed tuberculosis infection), failed to ensure to insulin pens had a pharmacy label to indicate who they belonged to, failed to ensure there were no loose pills in the medication carts and failed to ensure staff did not leave medications at bedside for Resident #26. The facility census was 58. Review of the facility's undated policy titled, Medication Storage in the Facility, showed: - Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to label and date all foods, seal all foods after opening, use proper hand washing, record refrigerator temperatures, properly store food storage containers and dishes, and failed to temperature check foods before serving food from steam table. The facility census was 58. 1. Facility's policy titled, Handling Leftover Food, dated 10/23 showed: -Leftover foods stored in the refrigerator should be wrapped and labeled with a use by date no later than 72 hours from the time of first use; -Leftover foods stored in the freezer should be dated and labeled. A policy regarding safe food handling was requested but not provided. Continuous observation of the kitchen on 1/26/25 at 9:15 A.M.- 9:52 A.M., showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain resident wheelchairs in safe operating condition when resident wheelchairs had ripped and peeling arm rests. This affected three of fifteen sampled residents (Resident #11, #57, and #60). The facility census was 58. Review of facility policy, wheelchair policy, undated, showed the facility may provide residents with wheelchairs for mobility when such need is established either by evaluation or request of the resident. Review of facility policy, Resident Rights, undated, showed: -Safe Environment: Resident has right to a safe, clean, comfortable, and homelike environment, including to receiving treatment and supports for daily services; -Facility shall exercise reasonable care for protection of resident's property from loss or theft; -Maintenance services to maintain a sanitary, orderly, and comfortable interior. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure they transmitted all Minimum Data Set (MDS, a federally mandate resident assessment tool) assessments within the federally mandated timeframe for one of the 15 sampled residents, (Resident #49). The facility census was 58. The facility did not provide a policy regarding MDS assessment transmittals. 1. Review of Resident #49's medical record showed: - admission date: 7/27/24; - Discharge assessment completed on 8/15/24; - No transmission accepted date listed for the assessment. During an interview on 1/28/25 at 3:16 P.M., the MDS/Care Plan Coordinator said: - He/she had been in the current position for two years but worked on the floor a lot during the first year; - The resident was discharged to home on 8/15/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained routine orders for prothrombin time (PT, a blood test to measure how long it takes blood to clot) and international normalized ratio (INR, a standardized measure of the clotting ability of blood, used to monitor the risk of bleeding when taking anticoagulation medication). Staff continued to administer the the anticoagulant medication in the absence of orders to monitor the effect of the medication. This affected one of the 15 sampled residents, (Resident #16). The facility census was 58. Review of the facility's undated policy titled, Coumadin Use, showed: - A Coumadin (Warfarin) policy for long-term care facility would typically outline guidelines and procedures to ensure the safe and effective use of this anticoagulant medication for residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care by assisting one resident (Resident #32) out of the 15 sampled residents when the facility failed to replace their prescription eyeglasses that had been reported missing for several weeks by the family representative. The facility census was 58. Review of facility undated Resident Rights policy showed residents have the right to services and/or items included in plan of care. 1. Review of Resident #32's Significant Change MDS, dated [DATE], showed: -Severe cognitive impairment; -They had no impairment in upper or lower extremities; -Impaired vision; -Required corrective lenses; -Diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide shaving to care to one of three sampled resident (Resident # 1), failed to ensure showers were completed for two of three sampled residents (Resident #1 and Resident #3) and failed to ensure nail care was completed for one resident (Resident #2). Facility census was 56. Review of facility policy, care of fingernails/toenails, revised February 2018, showed: -Purpose of procedure are to clean nail bed, keep nails trimmed, and prevent infections; -Review resident care plans to assess for any special needs of resident; -Nail care included daily cleaning and regular trimming; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision, identify an elopement risk, implement safety measures and prevent one resident (Resident #1),from eloping from the facility through the front door, and exiting from the building for approximately one hour. The facility census was 50. Review of the facility provided policy Elopement Precautions/Missing Resident, revised July 2017 showed: -Prevention of residents leaving the facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing. [...]

Inspectors wroteBased on interviews, observation and record review, the facility failed to maintain resident rights and respect of those rights when a facility staff made a derogatory religious statement to one resident (Resident #1) of 4 sampled residents. The facility census was 50. Review of the facility provided, undated policy Resident Rights showed: -The resident has the right to a dignified existence. -The facility must treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintence or enhancement of the quality of life, recognizing each resident's individuality. -The facility must ensure that a resident can exercise their rights without interference, coercion, discrimination or reprisal from the facility. -The resident has the right to be treated with dignity and respect. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure adequate nursing department staffing was in place to meet the needs for 4 of 14 sampled residents (Resident #5, #29, #14, #205); related to adequate grooming, providing showers, and prevention of pressure ulcers and skin breakdown for dependent residents. The facility census was 53. Review of the facility's Payroll Based Journal, dated fiscal year quarter one 1/1/23 to 3/31/23, showed: -One star rating for staffing -Excessively low weekend staffing Review of the facility provided policy, Staffing, Sufficient and Competent Nursing, dated August 2022 showed in part: -Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours, seven days per week. The facility census was 53. Review of the Staffing, Sufficient and Competent Nursing Policy, dated August 2022, showed: - A RN provides services at least eight consecutive hours every 24 hours, seven days per week; - The Director of Nursing (DON) may serve as the charge nurse only when the daily occupancy of the facility is 60 or fewer residents. Review of the facility's staffing sheets showed the following: - 1/4/23- six hours of consecutive RN coverage; - 1/19/23- six hours of consecutive RN coverage; - 1/28/23- six hours of consecutive RN coverage; - 3/4/23- four hours of consecutive RN coverage; - 3/16/23- six hours of consecutive RN coverage; - 4/6/23- seven hours of consecutive RN coverage; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 53. The facility did not provide a policy addressing food storage, kitchen cleaning and sanitation of the kitchen. Observation of the kitchen on 09/10/23 at 8:57 A.M., showed: -The paper towel dispenser above the hand washing sink covered in dirt and grime; -There were no paper towels in the paper towel dispenser at the hand washing sink; -The hand washing sink had black film in the basin; -The top of a plastic hamper with dirty towels in it covered in dirt and debris and had a brown sticky substance on the lid; -The floor of the kitchen was covered with dirt and debris throughout; [...]

Inspectors wroteBased on record review and interview, the facility failed to have care plans readily accessible to pertinent staff. The facility census was 53. Review of the undated medical record regulations policy showed: - The medical record must contain sufficient information to identify the resident and a comprehensive plan of care and services provided. Observations from 9/11/23 through 9/13/23 showed: - The residents' care plans were not in their medical records; - The care plans were not in the nurses office or on the medical records cart; - The care plans were not available to be reviewed by the staff. During an interview on 9/12/23 at 1:02 P.M., Nurse Aide (NA) B said: - He/She worked at the facility for six days and was not shown where to find supplies to be able to do his/her job; - He/She did not know what a care plan was; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 53. The facility did not provide an Antibiotic Stewardship policy. 1. The facility did not provide Antibiotic Stewardship Program documentation that should include: - Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic; - Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, and comfortable, homelike environment. The facility had a census of 53. 1. Observations starting on 09/10/23 11:44 A.M. through 9/13/23, showed the following: - The main hall light fixture had a cracked cover. - Multiple ceiling tiles in the main hall were warped with dark brown water stained corners. - The light fixture, at the end of 301 hall, had a broken cover with missing plastic pieces. Dried cut grass built up in the corners of the exit door and hallway. Black, thick, crusted material at edges of threshold and baseboards. - Broken floor tile at the exit measured approximately 6 inches (in) by 2 in. - Baseboards in the main hall were peeling away from the wall that exposed sheetrock underneath. - The vertical blinds, of the 301 hall, at the window by the exit door were broken with a missing slat. [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to develop and implement resident centered care plans for five of 14 sampled residents (Residents #5, #13, #24, #29, and #43), when facility staff failed to update Resident #5's care plan when a wound was discovered, the facility staff failed to develop Resident #13's care plan with interventions for a contracture (a condition when the muscles become shortened and hardened, causing the area to not be able to be opened properly) to his/her left hand and foot, when the facility staff failed to develop a care plan for Resident #24's contracture of his/her right hand, when the facility staff failed to update Resident #29's care plan after he/she was found on the floor, and the facility failed to develop a care plan to address Resident #43's Alzheimer's Disease. The facility census was 53. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of 14 sampled residents who required staff assistance (Resident #23, #34, #5, #24, #14, and #205) received the necessary assistance with grooming, bathing and incontinence care. The facility census was 53. Review of the facility provided policy Bath, Shower/Tub, dated February 2018, showed in part: -The purposes of this policy are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Review of the facility provided policy Perineal Care, dated February 2018, showed in part: -The purposes of this policy are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #23 Quarterly Minimum Data Set (MDS: [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed prevent further decrease in range of motion (ROM) for two resident's (Resident #13 and #24) of 14 sampled residents when the facility staff failed to provide ROM exercises to both residents who had contracture's of their hands. The facility census was 53. Review of the mobility and ROM policy, dated July 2017, showed: - Residents will not experience an avoidable reduction of ROM. - Resident with limited ROM will receive treatment, appropriate treatment, cares and services to increase and/or prevent a further decrease in ROM. 1. Review of Resident #13's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility staff), dated 5/10/23, showed: - He/She had a brief interview for mental status (BIMS) score of 14, indicating no cognitive impairment. - Diagnoses included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two sampled residents when using a gait belt (Residents #205 and #24). The facility census was 53. Review of the undated Resident Handling Policy showed: - Mandatory transfer belt use for all resident handling. Review of the Assessing Falls and Their Causes Policy, dated March 18 showed: - When a resident has an unwitnessed fall, evaluate for possible head, neck, spine, and extremity injuries. - Observe for delayed complications of a fall for 48 hours after a suspected fall and document the findings in the medical record. 1. Review of Resident #205's MDS (Minimum Data Set, A federally mandated assessment completed by facility staff), dated 6/19/23, showed: -Moderate cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 53. The facility did not provide the requested job description for the dietary manger. During an interview on 09/12/23 at 1:36 P.M., the DM said: -He/she has been the DM for a year; -He/she just got thrown into it because everyone quit; -He/she has worked in the dietary department for about three years, but never managed the kitchen; -He/she was responsible for ordering food on a budget, ensuring the kitchen was staffed to meet the needs of the residents and managing the day to day activities of the kitchen; - The facility had not provided him/her with any dietary management training; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared foods in a form designed to meet the needs of individual residents when they did not ensure the pureed (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected three residents identified by the facility as having orders for a pureed diet (Residents #14, #18, and #34). The facility census was 53. The facility did not provide the requested policies on therapeutic diets and pureed food preparation. 1. Review of Resident #14's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 8/8/23, showed: -The resident had severe cognitive impairment; -The resident required the assistance of one staff with transfers and activities of daily living (ADL's); [...]

Inspectors wroteBased on record review and interview the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility census was 53. Review of the facility policy Quality Assurance Program, dated 2019, showed in part: -The committee shall include, at a minimum, the Administrator, the Director of Nursing, the Medical Director or his/her designee, at least three other members of the staff, and the Infection Control and Prevention Officer. The committee shall include a representative from each department. The Medical Director is a required member of the committee and shall attend no less than quarterly. Record review of the facility's QAA meeting minutes for the year 2023 showed: -January attendees were the Activity Director, Director of Nursing, and Administrator; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain hand rails in good repair or firmly affixed to the wall, in the following areas: the corridor of hall 301, the bathing room [ROOM NUMBER], and outside room [ROOM NUMBER]. The facility census was 53 residents. Observation on 9/10/23 at 12:42 P.M., showed: -The 301 hall, north wall handrail was loose and pulling away from the wall. - The handrail outside room [ROOM NUMBER] on the east wall was loose and pulling away from the wall. - Shower room [ROOM NUMBER] toilet rail was rusted with chipping paint. During an interview on 9/13/23 at 5:00 P.M., the Director of Nursing said: -She was not sure checking hand rails was done. -Maintenance had a list of things he checks regularly. -She would expect the rails to be in good condition and fixed to the wall.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities based on resident needs and preferences for one resident (Resident #34) in a review of 14 sampled residents. The facility census was 53. Review of the facility's Activity Director job description, showed: -The purpose is to assure that an ongoing program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well being of each resident. The facility did not provide a policy for the activities program. Review of the facility's activity calendar for August 2023 showed: -Every Saturday and Sunday: movie and snacks at 3:00 P.M.; -Every Sunday: worship or music services; -Mondays-Wednesdays-Fridays: bedside activities; -Monday: manicures. Review of the facility's activity calendar for September 2023 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one full-time Nurse Aide (NA) completed the required competency exam for certification within four months of hire. The facility census was 53. The facility did not provide an NA training policy. 1. Review of NA A's personnel file showed: - He/She was hired at the facility on 3/30/23 as an NA. Review of the staffing sheets showed the following: - His/Her first shift as an NA was 3/30/23; - He/She worked at least five days per week from 3/30/23 to 9/13/23; - He/She worked 6:00 P.M. to 6:00 A.M. primarily until 7/16/23 when he/she began working 6:00 A.M. to 6:00 P.M. primarily. During an interview on 9/13/23 at 10:28 A.M., NA A said: -He/She has worked at the facility for six months and was not yet enrolled in a nurse aide training or competency evaluation program (NATCEP); [...]

Inspectors wroteBased on record review and interview, the facility failed to provide necessary services to maintain psychosocial health for one resident (Resident #29) of 14 sampled residents when the facility failed to provide continuing professional mental health services to the resident after he/she attempted suicide while in the facility and returned from the behavioral health unit (BHU). The facility census was 53. Review of the behavioral health services policy, dated February 2019, showed: - The facility will provide all residents with behavioral health services as needed to attain or maintained the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive plan of care. - Behavioral health services will be provided as needed to residents as a part of the person- centered approach to care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide services and care for a resident with dementia to attain and/or maintain his/her highest practicable mental and psychosocial well-being for one of 14 sampled residents (Resident #43). The facility census was 53. The facility did not provide a dementia care policy. Review of the behavioral health services policy, dated February 2019, showed: - The facility will provide all residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive plan of care; - Behavioral health services will be provided as needed to residents as a part of the person-centered approach to care; [...]