Hilltop at Blue River, the

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent physical abuse for one sampled resident (Resident #1) out of four sampled residents. On 4/26/26 at approximately 11:00 A.M. Resident #2 who has a history of being physically aggressive to residents and staff, struck Resident #1 on the head with a chair resulting in a red and raised area on his/her head and a small scratch on the bridge of his/her nose which required first aid. The facility census was 143 residents. The Administrator was notified on 5/1/26 of Past Non-Compliance which occurred on 4/26/26. An all-staff in-service on Abuse and Neglect and Resident's Rights. Both residents were also set up for additional psychiatric services and therapy. The deficiency was corrected by 4/27/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the dignity of one sampled resident when on 12/19/25 Certified Medication Aide A forced Resident #2 to get out of bed against his/her will out of six sampled residents. The facility census was 143 residents. The Administrator was notified on 1/2/26 of the past noncompliance which began on 12/19/25. The facility immediately completed education for the violation of residents' rights and choices. The deficiency was corrected on 12/20/25. Review of the facility's policy entitled Resident Rights and revised on 8/20, showed:-Purpose: To promote and protect the rights of all residents at the facility.-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #3) representative/power of attorney was able to exercise his/her rights to make financial decisions on behalf of the resident out of four sampled residents. The facility census was 145 residents. Review of the facility Resident Rights Policy dated 8/2020 showed: -Promote and protect the rights of all residents at the facility. -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in the policy. -The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staff on the weekends to provide care and services for residents and for one sampled resident (Resident #10) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Staffing, Scheduling, and Posting, dated 06/2020 showed: -Staffing an adequate number of nursing service personnel, scheduling would have been done as needed to met the residents' needs and would have accounted for the number, acuity and diagnoses of the facility resident populations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use the liquid to maintain the nutritive value of pureed carrots and pureed chicken for residents who received pureed diets. This deficient practice potentially affected residents who received pureed diets. The facility also failed to ensure the temperature of carrots and ham was maintained throughout the meal service for residents who consumed food out of the kitchen. The facility census was 140 residents. Review of the facility's Therapeutic Diet policy and procedure dated 12/2020, showed the purpose was to ensure that the facility provided therapeutic diets to residents that meet nutritional guidelines and physician orders. It showed: -The Nutrition Service Manager was responsible for ensuring the correct type and amount of food is purchased to meet the needs of residents receiving therapeutic diets. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen was kept clean and kitchen devices were free from caked on grease, soil and food debris. This deficient practice potentially affected all residents who ate out of the kitchen. The facility census was 140 residents. 1. Observation on 3/12/25 at 10:21 A.M., showed: -The dishwasher had yellowish, dried on food debris on outside of washer. -The tray containing covered bowls of dry cereal on the prep table in front of the oven showed spilled cereal debris on and around the tray and floor. -The toaster on top of the prep table had dried food debris and grease on the outside of the toaster. The mechanical parts inside the toaster had food debris that was caked on the roller mechanism. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility transfer/discharge notice was completed in detail and provided to the resident and the resident's responsible party for one closed record sampled resident (Resident #142) out of three closed record sampled residents. The facility census was 140 residents. Review of the facility Transfer and Discharge policy and procedure, revised dated 6/2020 showed: -The purpose is to provide the residents with reasonable advance notice of the transfer or discharge before it occurs if possible. -Documentation of written or telephone acknowledgment of the resident ' s transfer by the residents personal representative may occur after the transfer in emergency situations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold agreement was completed in detail and provided to the resident and resident's responsible party for one closed record sampled resident (Resident #142) out of three closed record sampled residents. The facility census was 140 residents. Review of the facility bed hold policy and procedure, revised dated 6/2020 showed: -The purpose was to advise residents or his/her representatives in writing that the facility has a bed hold policy and will hold the resident's bed for the state specified period, if the resident is transferred to a general acute care hospital, as long as the resident or their representative notifies the facility within 24 hours of the transfer that they wish to have the facility hold the bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an individualized activity plan that was goal directed and incorporated the interest and ability of two sampled residents with dementia (Resident #22 and #90) out of 29 sampled residents. The facility census was 140 residents. Record review of the facility Activity policy and procedure dated 6/2020, showed: -The purpose was to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -The facility provides and activity program designed to meet the needs, interests and preferences of residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident(Resident #104) did not keep smoking materials including cigarettes and a lighter in his/her room, and failed to ensure the resident was only smoking in the smoke area not in his/her room; and failed to ensure to protective oversite and supervision to maintain a safe environment during smoking breaks, and to failed ensure resident assigned smoking area was free of potential hazards including wood, nails and broken equipment for one sampled resident (Resident #103) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Smoking by Residents, dated November 2023 showed: -Smoking was not allowed anywhere inside the facility. -The facility permits smoking only in the areas designated by the facility's Safety Committee. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve the physician ordered texture and portion size to one sampled resident (Resident #22) with swallowing difficulties and who was at risk for weight loss out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Therapeutic Diet policy and procedure dated 12/2020, showed: -The purpose was to ensure that the facility provided therapeutic diets to residents that meet nutritional guidelines and physician orders. -Therapeutic diets would not be given without a physician's order. -The therapeutic diet would be reflected on the resident's diet tray card. -The Nutrition Services Manager was responsible for ensuring each food item was pureed and served separately for a pureed diet per the menu and recipe and food portions are equal to the written portion sizes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nebulizer (a machine that turns liquid medicine into a mist that could have been easily inhaled) was available for respiratory treatments for one sampled resident, (Resident #10); failed to ensure the Continuous Positive Airway Pressure (CPAP a machine that delivers enough air pressure to a mask to keep the upper airway passages open during sleep) mask was correctly placed for one sampled resident, (Resident # 126) and failed to ensure oxygen equipment was stored in a sanitary manner for two sampled residents, (Resident #68 and Resident #126) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Oxygen Administration, dated 6/2020 showed: -A physician's order was required to intiate oxygen therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 12) had received dental care out of 29 sampled residents. The facility census was 140 residents. Review of the facility's undated policy, Dental Services, showed: -All residents would receive appropriate oral cares if applicable on a daily basis. -It was the responsibility of each staff member within the nursing department to have ensured good oral care for each resident. -Assessment of the oral cavity and teeth was to have been performed upon admission and as necessary. -Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. -Note any such condition in the resident's chart and report the problem to the charge nurse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) by expanding the use of gowns and gloves during high-contact resident care activities) were implemented for one sampled resident (Resident #82) with a foot wound and receiving intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into a vein) antibiotic therapy; and out of 29 sampled residents. The facility census was 140 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sample resident (Resident #3) out of 12 sampled residents. The facility census was 137 residents. Review of the facility's policy titled Resident Self-Admin Meds Clinically Appropriate dated August 2020 showed: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility during the care planning process. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Transportation Driver (TD) A followed protocol related to safely securing a resident's wheelchair according to facility policy and training, affecting one sampled resident (Resident #3), who fell backwards in his/her wheelchair during transport, out of seven sampled residents. The facility census was 134 residents. On 11/8/24, the Administrator was notified of the past noncompliance which took place on 10/18/24. TD A reported the accident to his/her supervisor who provided immediate training. Drivers received documented education on 10/21/24 related to wheelchair safety during transport. The facility did an investigation and found TD A did not follow facility policy, protocols, and training related to securing the resident's wheelchair and the employee was disciplined. The deficiency was corrected on 10/21/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled substances (is generally a drug or chemical whose manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law) were counted during change of shift or when keys were transferred to another responsible party resulting in a total of 60 tablets Oxycodone Immediate Release (a narcotic pain medication) 30 milligram (mg) that were not accounted for for one sampled resident (Resident #3) out of the three sampled residents. The facility census was 126 residents. On 9/20/23, the Administrator was notified of the past noncompliance which took place on 9/1/23. Licensed Practical Nurse (LPN) reported unaccounted for controlled substances to Human Resources (HR) on 9/1/23. HR then informed the Director of Nursing (DON). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to put measures in place to prevent further injury following an incident in which one sampled resident (Resident #120) out of 27 sampled residents knocked over a large, heavy metal activity cabinet, resulting in the resident sustaining a fractured wrist. The facility also failed to complete a smoking assessment and care plan for one sampled resident (Resident #15) who smoked cigarettes to ensure a safe smoking plan out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Accidents and Incidents - Investigating and Reporting policy statement, undated showed: -All accidents and incidents involving residents, employees, visitors, vendors, etc, occurring on the premises shall be investigated and reported to the administrator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor weights upon admission for one sampled resident (Resident #10) who had a significant weight loss of 28 pounds, a 13.96% loss in 3 1/2 weeks, to notify the resident's physician of the Registered Dietician's (RD) recommendations in a timely manner so the recommendations could be implemented before the resident's weight loss became significant, and to have an individualized comprehensive dietary care plan; to monitor and record weights and notify the resident's physician in a timely manner for one sampled resident (Resident #11) with a gradual significant weight loss; and to ensure hydration opportunities and assistance were provided to three sampled residents (Residents #6, #120, and #104) who were dependent upon staff for their hydration needs out of 27 sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's dietary staff failed to sanitize their work areas before, during and after preparing food; to take food temperatures at the foods' heat source; to sanitize the juice and beverage apparatuses nozzle; and to wear the appropriate hair restraints while in the kitchen. The facility census was 125 residents. 1. Observations on 7/17/23 between 5:03 A.M. and 7:55 A.M. in the kitchen showed: -At 5:05 A.M. the beverage/juice gun was not disassembled, soaking in a sanitizing solution mixture. -The beverage/juice gun's nozzle appeared to have various beverage and juice sediment stuck to the inside and out and, was actually sticky to the touch. -The Dietary [NAME] (DC) had a full beard with sideburns and a mustache, and did not have his/her entire facial hair covered. -At 5:10 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids of the dumpster's were closed for two days during the survey. The facility census was 125 residents. 1. Observations on 7/17/23 at 8:33 A.M., 9:30 A.M. and on 7/19/23 at 9:37 A.M., and 1:06 P.M., showed: -The facility had two dumpster's for trash, each with two lids attached to them. -One lid on each dumpster was open. -On 7/19/23 at 1:06 P.M. two employees placed trash bags into the dumpster and did not close the lid. During an interview on 7/21/23 at 10:33 A.M., the Assistant Dietary Manager said : -Each and every individual person that uses the dumpster is responsible for closing the lids after they use the dumpster to discard trash. -There are several people and facility departments that use the dumpster's for trash. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community based risk assessment. A total of 27 residents were sampled. The facility census was 125 residents. Facility Assessment policy was requested and not received by day of exit 7/21/23. Review of the facility's Resident Census and Condition dated 7/17/23 showed the following resident demographics in the building: -Six residents with indwelling catheters (a tube with retaining balloon passed through the urethra into the bladder to drain urine). -85 residents were frequently incontinent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff treated one sampled resident (Resident #102) with dignity when two staff members used disrespectful profanity towards the resident and around other residents out of 27 sampled residents. The facility census was 125 residents. Review of facility policy Resident Rights revised 8/2020 showed: -All residents have the right to a dignified existence. 1. Review of Resident #102's Face Sheet showed an admission to the facility on 3/19/22 with diagnoses of: -Dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). -Cognitive communication deficit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six sampled residents (Resident #52, #119, #50, #41, #15, #47) were offered the right to formulate and/or obtain existing advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's policy Advanced Directives revised 8/2020, showed: -At the time of admission, admission Staff or designee would inquire about the existence of an Advanced Directive. -If no Advanced Directive exists, the Facility provided the resident with the opportunity to complete the Advance Directive upon resident request. -Assistance was provided as necessary to execute an Advance Directive. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected a resident), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) in accordance with the state and federal regulation prior to hire on ten out of ten employees sampled. The facility census was 125 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four sampled residents (Residents #6, #12, #104, and #120), who were dependent upon staff for activity participation, had opportunities for activities of personal interest on a daily basis out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Activities Program policy and procedure, dated 6/2020 showed: -Residents will be encouraged to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -A variety of activities should be offered on a daily basis, including weekends and evenings. -Activities are developed for individual, small group and large group participation. [...]

Inspectors wrote2. Review of Resident #5's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of hallucinations (hearing, seeing, feeling, smelling, or tasting things that are not real), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and paranoid schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others and in which a person has an extreme fear and distrust of others). Review of the resident's Pharmacy Note dated 5/20/22 showed please ensure target behavior and side effect monitoring are in place in order to evaluate the continued appropriateness of the resident's antipsychotic medication - Clozapine (antipsychotic medication) . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident #10, #119, and #120) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) after this was explained in a manner they understood and the resident had the right to communicate with state officials out of three sampled residents out of three sampled residents for arbitration. The census was 125 residents. Record review of the facility Arbitration Agreement policy revised 10/24/22 showed: -To provide a lawful opportunity for a provider of health services and residents/responsible parties to enter into an enforceable written contract to settle a dispute outside the court through and arbitration process. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident #10, #119, and #120) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) that contained the selection of a neutral arbitrator would be agreed upon by both parties (resident and facility) out of three sampled residents for arbitration. The census was 125 residents. Record review of the facility Arbitration Agreement policy revised 10/24/22 showed: -To provide a lawful opportunity for a provider of health services and residents/responsible parties to enter into an enforceable written contract to settle a dispute outside the court through and arbitration process. -The healthcare arbitration agreement should comply with federal and state laws. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they failed to ensure they implemented appropriate interventions to correct on-going, systemic issues regarding weights not being completed or correctly completed and fall interventions not being implemented; and to complete effective audits for weights and falls after issues were determined in QA. The facility census was 125 residents. Review of the facility's policy QAPI Program, revised 10/24/2022, showed: -The facility implemented and maintained an ongoing, facility-wide QAPI program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolved identified problems. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections. The facility census was 125 residents. Review of the facility Infection Prevention and Control Program, revised October 24, 2022 showed: -The facility must establish an Infection Prevention and Control Program under which it identifies, investigates, controls, and prevents infections in the facility and maintains a record of incidents and corrective actions related to infections. -The Infection Preventionist (IP) collects, analyzes, and provides infection data and trends to nursing staff, physicians. -The IP will determine specific sites and pathogen trends. -The IP will at least on a monthly basis conduct an infection control audit to identify trends. -Infection data is analyze to identify trends. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they completed an antibiotic stewardship program over the past 12 months. The facility census was 125 residents. Review of the facility Antibiotic Stewardship Program revised June 2020 showed: -The Antibiotic Stewardship Program (ASP) was designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and reduce the possible adverse events associated with antibiotic use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #47 and #104) received teaching regarding the benefits and risks of influenza and pneumococcal vaccination, and that the resident's consent/declination was retained in the resident's medical record for two of five residents selected for review for vaccination. The facility census was 125 residents. Policies were requested for resident influenza and pneumococcal vaccination were requested and not received. 1. Review of Resident #47's electronic medical record (EMR) dated 8/23/22 through 7/21/23 showed: -His/her Immunization Report showed that he/she had refused the pneumococcal and influenza vaccines with no documented dates of his/her refusal refusals. -No documentation regarding teaching regarding the benefits and risks of influenza and pneumococcal vaccination. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents and/or family/representative of care plan (written out plan for the care of the resident) meetings or have care plan meetings for one sampled resident (Resident #52) out of 26 sampled residents. The facility census was 125 residents. Review of the facility's policy titled Care Planning Nursing Manual-Nursing Administration dated 6/2020 showed: -The facility would invite the resident, if capable, and the resident's family to care plan meetings and used its best efforts to have scheduled care planning meetings at times that are were convenient for the resident and family. -When a resident did not have family, or if the resident/family requested it, the Interdisciplinary team (IDT) would invite the Ombudsman to attend the care planning meeting. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed notify the physician when behaviors became excessive for one sampled resident (Resident #15) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Change of Condition policy updated 6/2020 showed: -The nurses were responsible for notifying the residents' physician of a significant change including a deterioration in mental health. -The physician should be notified timely with a change of condition. 1. Review of Resident #15's admission Record showed he/she had the following diagnoses: -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of a resident discharge from the facility for one sampled resident (Resident #41) and two closed sampled residents (Resident's #126 and #129) and to ensure that written notice of transfer or discharge was provided to the resident and/or family for one sampled resident (Resident#41) and for one closed sampled resident (Resident #126) out of three closed record sampled residents. The facility census was 125 residents. Review of the facility policy and procedure Transfer and Discharge, revised 8/2020 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of the facility's bed-hold policy before transferring or discharging the resident to the hospital for one sampled resident (Resident #41) out of 33 sampled residents. The facility census was 125 residents. Record review of the facility's Bed Hold policy revised 6/2020 showed the facility would notify the resident or his/her representative in writing of the bed hold policy any time a resident was transferred to an acute care hospital. 1. Review of Resident #41's discharge MDS dated [DATE] showed the resident was sent to the hospital return anticipated. Review of the resident's Nurses Notes dated 5/1/23 showed: -The resident was found unresponsive. -The resident's physician was notified. -The resident was sent to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to include one sampled resident's (Resident #5) diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) in his/her comprehensive care plan out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Care Planning policy revised June 2020 showed: -The facility would develop a comprehensive person-centered care plan for each resident. -The care plan would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform restorative nursing services, and to apply a therapeutic splint for one sampled resident (Resident #52) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's policy titled Restorative Nursing Program Guidelines dated 6/2020 showed: -A resident would be started on a Restorative Nursing program when a resident was discharged from formulized physical, occupational, or speech rehabilitation therapy. -General restorative nursing care was that which did not require the use of a qualified professional therapist to render such care. -Basic restorative nursing categories include: --Active range of motion. --Passive range of motion. --Splinting or bracing. --Dressing or grooming. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and the dialysis (a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure) center was maintained to ensure the continuum of care for one sampled resident (Resident #47) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Dialysis Care undated policy showed: -The facility would communicate and collaborate in writing with the dialysis clinic. -This should include any medication changes, changes of condition and tolerance of the resident's procedure. 1. Review of Resident #47's admission Record showed the resident had the following diagnoses: -End stage renal disease (the gradual loss of kidney function). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, monitor behaviors, and intervene when behaviors became excessive for one sampled resident (Resident #15) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Behavior Management policy revised 6/2020 showed: -The purpose of the policy was to implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that were distressing to the resident. -The staff were to identify residents with behaviors that may pose a risk to self or others. -Develop individual and practical care strategies based on assessed needs. -Implement a behavior management program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff consistently and accurately documented resident behaviors and/or monitored the effectiveness of interventions for two sampled residents (Residents #120 and #6) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Behavior Management policy revised 6/2020 showed: -The purpose of the policy was to implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that were distressing to the resident. -The staff were to identify residents with behaviors that may pose a risk to self or others. -Develop individual and practical care strategies based on assessed needs. -Implement a behavior management program. -Complete on-going assessments, monitoring, and evaluation of the effectiveness of medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to attain the highest practical physical, mental and psychosocial well-being of one resident by not providing supportive services for one sampled resident (Resident #15) who exhibited changes in behaviors, such as excessively stacking belongings all over his/her room and bed, using Rubber Maid totes and a plunger to wash clothing, believing he/she had gone blind for a few days, and sweeping up mice droppings daily which were not present in the room. In addition, the facility failed to monitor and provide practical care strategies based on assessment needs out of 27 sampled residents. The facility census was 125 residents. Review of the facility Social Services policy revised 08/2020 showed: [...]

Inspectors wroteBased on interview and record review,the facility failed to ensure one sampled resident's (Resident #5) drug regimen was free from antipsychotic (a type of medication used treat a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) medication without adequate indications for use as demonstrated by identification of and monitoring of target behaviors, and by monitoring for adverse reactions for use and without monitoring for adverse effects, out of 27 sampled residents. The facility census was 125 residents. A policy for antipsychotic medications was requested and not received. 1. Review of Resident #5's admission Record showed: -He/she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 34 observed medication opportunities, two errors occurred resulting in an error rate of 5.88%. One error involved an eye drop medication (Resident #16), one error involved an inhaler medication (Resident #33). The facility census was 125 residents. Review of facility policy and procedure for Eye Drop Administration, revised 8/2020 showed: -Put on examination gloves. -Remove the cap, taking care to avoid touching the dropper tip. Place the cap on the barrier or a clean, dry surface. -Tilt the resident's head back slightly. -With a gloved finger, gently pull down the lower eyelid to form a pouch while instructing the resident to look up. Place your other hand against the resident's forehead to steady. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with activities to meet the interests and abilities of four sampled residents (Residents #4, #18, #62, and #153) out of four residents sampled for activities. There were 21 residents sampled overall. The facility census was 105 residents. Record review of the facility's Activities Program policy dated June 2020 showed: -Instructions to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -Provide an activity program to meet the needs, interests and preferences of the residents. -Complete an initial activity assessment within seven days of admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications with dates when they were first opened; failed to maintain cleanliness of medication bottles; failed to remove a medication that was discontinued from the medication cart, and dispose of it appropriately; and failed to ensure the medication refrigerator was maintained and clean. The facility census was 105 residents. Record review of facilities undated Medication Storage policy showed: -Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperature and humidity. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain consent prior to the administration of the coronavirus disease 2019 (COVID-19-a respiratory disease caused by a new coronavirus, named SARS-CoV-2 and the disease it causes has been named coronavirus disease 2019) vaccine from the resident's Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for one supplemental resident (Resident #11) out of seven residents sampled for vaccinations. The overall sample was 21 residents. The facility census was 105 residents. The facility did not have a policy regarding obtaining consent. 1. Record review of Resident #11's care plan initiated 2/5/20 showed the resident was cognitively impaired. [...]