Imboden Creek Senior Living

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal abuse from facility staff members for one (R2) of five residents reviewed for abuse in the total sample list of six. This failure resulted in R2 being made to feel pressured, outnumbered, and extremely insignificant.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and planned discharge to an appropriate facility for one (R2) of three residents reviewed for inappropriate discharge in the sample list of six.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy related to misappropriation of funds for one (R2) of six residents reviewed for abuse in a sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to investigate misappropriation of property for one (R2) of six residents reviewed for abuse, in a sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan with targeted interventions for one (R8) of three reviewed for care plan interventions following a fall on a sample list of 23 residents. Findings Include: R8's Electronic Health Record (EHR) documented R8 was admitted to the facility on [DATE] and continues to reside at the facility. According to the R8's EHR, R8 has several diagnoses including Chronic Systolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Emphysema, Protein-Calorie Malnutrition, and Unilateral Primary Osteoarthritis, Right Hip, and repeated falls. On 6/9/2026 at 10:34AM, V8, Licensed Practical Nurse (LPN), stated the note V8 authored on 6/6/26 at 2:07PM was due to a conversation with R8's Power of Attorney (POA). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer and supervise three (R8, R19, R22) of four residents reviewed for accidents in a sample of 23 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform incontinence care in a manner to prevent infection and potential skin irritation for three (R8, R19, R23) of three residents reviewed for incontinence care in a sample of 23 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 61 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop. These failures have the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective resident supervision to prevent repeat traumatic falls. These failures resulted in R7 experiencing 14 or more falls between November and December 2025 causing abrasions, skin tears, a hematoma, swelling, pain, and an eyebrow laceration requiring emergency transfer to the hospital for surgical repair. R7 is one of two residents reviewed for accidents on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure over the counter medications were not expired, failed to ensure a bottle of eyedrops was labeled, and failed to ensure insulin pens were dated when opened. This failure affects three of three (R2, R9, R74) residents reviewed for medication storage on the sample list of 29 and has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 79 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food storage areas, food service equipment, and food preparation areas. These failures have the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. This failure has the potential to affect all 79 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications, failed to complete psychotropic medication assessments, failed to track targeted behaviors necessitating use of psychotropic medications, and failed to implement non-pharmacological interventions prior to the use of psychotropic medications. These failures affect one resident (R6) of five reviewed for unnecessary medications on the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects three (R3, R6, and R71) of 18 residents reviewed for care plans on the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to obtain resident diagnostics as ordered by a medical provider. This failure affects one resident (R7) of three reviewed for laboratory diagnostics on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine if a medication was appropriate and safe for self-administration. This failure affects one resident (R59) of 24 reviewed for supervised medication use on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during a procedure by not pulling the curtain for R36. R36 is one of 29 residents reviewed for privacy in a total sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a resident's comprehensive assessment. This failure affects one (R3) of 24 residents reviewed for accuracy of assessments on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure qualified staff applied medicated cream to a resident for one of two (R36) residents reviewed for urinary catheter care in the sample of 29. The EMR (Electronic Medical Record) form titled Medical Diagnosis, dated 1/14/26, documents the following diagnoses for R36: Malignant Neoplasm of the Colon and Secondary Malignant Neoplasm of the lung. R36 requires an indwelling urinary catheter for urination. On 1/7/26 at 10:48 AM, V6, Certified Nursing Assistant/CNA, performed catheter care for R36. After completing the procedure, V6 stated to R36, I am going to put this cream you have on your (buttocks) and on all your red spots. V6 took the cream off of the bed side table and put the cream on her gloves and applied the cream onto R36 buttocks, between his thighs, and also on the glans penis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care with pressure relieving interventions for one of three residents (R53) reviewed for pressure ulcers on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed perform complete urinary catheter/perineal care and failed to prevent cross contamination during catheter/perineal care for one of two residents (R36) reviewed for urinary catheter care in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements as ordered for a nutritionally at-risk resident. This failure affects one resident (R1) of three reviewed for nutrition on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store respiratory care equipment in a sanitary manner. This failure affects one resident (R7) of six reviewed for oxygen therapy on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document administration of resident medication. This failure affects one resident (R59) of 24 reviewed for medications on the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to respond timely to multiple pharmacy requests to reconcile duplicate medication orders resulting in duplicate administration of medication. This failure affects one resident (R7) of eighteen reviewed for medications on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure droplet isolation infection control precautions were utilized for a resident with severe acute respiratory syndrome coronavirus 2 (COVID-19) infection. This failure affects one resident (R2) of 18 reviewed for infection control in the sample list of 29.1. On 1/6/26 at 11 AM, Enhanced Barrier Precaution signage was located on R2's room door and R2's room door was open. R2's Progress Note, dated 1/2/26, documents R2 tested positive for Covid-19 during routine testing and R2 was moved to a private room. On 1/6/26 at 10:08 AM, V1, Administrator, stated, Only one resident (R2) is Covid-19 positive in the facility at this time and the other Covid-19 positive resident (R75) is currently recovering at home. [...]

Inspectors wroteBased on interview and record review, the facility failed to employee a Certified Dietary Manager for food services. This failure has the potential to affect all 75 residents currently residing in facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders to use and clean a Continuous Positive Airway Pressure (C-PAP) machine and/or a Bilevel Positive Airway Pressure (BI-PAP) machine for four (R1, R7, R10, R11) residents and failed to obtain and monitor vital signs for three (R1, R10, R11) residents using C-PAP/BI-PAP machines. This failure affects four of four residents (R1, R7, R10, R11) reviewed for Oxygen use in a sample list of eleven residents.

Inspectors wroteBased on interview and record review, the facility failed to provide emergency response resuscitative efforts timely, resulting in a ten-minute delay in life saving services for one (R1) resident out of six residents reviewed for Death in a sample list of eleven residents. On [DATE], R1 was confirmed to be without signs of life ten minutes prior to the initiation of Cardiopulmonary Resuscitation (CPR). R1 subsequently expired at the facility on [DATE] at 9:45 am.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ an Infection Preventionist who remains onsite. This failure has the potential to affect all 70 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a thorough fall investigation, complete post fall neurological assessments, properly transfer a resident after a fall, and implement fall interventions for four of four residents (R2, R4, R5, R9) reviewed for accidents in the sample list of eleven.

Inspectors wroteBased on interview and record review, the facility failed to maintain accessible and complete medical records for five residents (R2, R4, R5, R7, R8) of five residents reviewed for medical records in the sample list of eleven.

Inspectors wroteBased on interview and record review, the facility failed to timely notify the physician of a resident fall for one of four residents (R9) reviewed for falls in the sample list of eleven residents. R9's Nurse Progress Note dated 10/18/25 at 5:10 AM documents R9 was found on the floor. This same note documents staff assessed R9 with no injuries and R9 denied pain. This same note documents staff assisted R9 back to bed and then informed V33 Licensed Practical Nurse (LPN), R9's nurse. This same note documents V33 LPN then assessed R9 in her room with no findings and no obvious injuries. R9's Progress Note dated 10/18/25 at 7:14 AM documents R9 had swelling to her Right Leg from Hip to Knee noted when staff assisted R9 to get dressed for the day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an undisturbed environment following the death of a resident prior to the arrival of the coroner for one of six residents (R1) reviewed for death in the sample list of eleven residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess wounds/skin and complete wound treatments for two of three residents (R1, R2) reviewed for pressure sores in the sample of five residents.

Inspectors wroteBased on interview and record review, the facility failed to notify a family member of an accident for one of three residents (R1) reviewed for resident injury in the sample list of 12.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one (R3) resident of three residents reviewed for abuse in a sample list of 12.

Inspectors wroteBased on interview and record review, the facility failed to timely review and revise comprehensive care plans. This failure affects three residents (R1, R2, R3) of three residents reviewed for care plans in the sample list of 12 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall intervention for one resident (R1) of three residents reviewed for resident injury in the sample list of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dependent resident, at risk for pressure ulcers, timely repositioning and incontinence care to prevent pressure ulcers. R9 is one of 13 residents reviewed for pressure ulcers on the sample list of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care, free of cross contamination for a one (R9) of thirteen-resident reviewed for hygiene needs on the sample list of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise medication administration for one resident (R11) of two residents reviewed for supervision of medication administration in the sample list of 15.

Inspectors wroteBased on record review and interviews, the facility failed to maintain complete and accurate medical records for one (R9) of 14 residents reviewed for medical records on the sample list of 16.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify a physician of a resident's change in condition and significant decline in mobility, which resulted in prolonged discomfort/pain for one cognitively impaired resident (R1). More than twenty-four hours after the initial change of condition was noted, an x-ray was obtained and R1 was sent to the Emergency Room, admitted , and had surgical repair of a left intertrochanteric hip fracture. R1 is one of three residents reviewed for falls in the sample of four. Findings Include: R1's Medical Diagnosis List, dated June 2025, documents R1 is diagnosed with Falls, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, and Anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer timely toileting assistance, implement fall interventions, and complete thorough fall investigations for three of three residents (R1, R2, R3) reviewed for falls in the sample list of three. Failing to provide R1 with timely toileting assistance resulted in R1 falling, after attempting to toilet independently, and suffering a hematoma to R1's head and a femur fracture requiring surgery and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely meals and without serving an evening snack. This failure has the potential to affect all 69 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident verbal abuse to the Abuse Coordinator for two of three residents (R23 and R29) reviewed for Abuse in a sample list of 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide weight management services for residents experiencing unplanned weight loss for two of three residents ((R13, R69) reviewed for weight loss on the sample list of 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to attempt nonpharmacological intervention prior to implementing psychotropic medications, failed to identify target behaviors for the use of psychotropic medications, and failed to assess use of psychotropic medications for one resident (R6) of eight residents reviewed for Psychotropic medications in a sample list of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications for three residents (R5, R49, R67) out of four residents reviewed for medication administration in a sample list of 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program by failing to assess criteria for determining an infection for one of one residents (R9)reviewed for antibiotic stewardship in the sample of 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate Advanced Directive for one (R5) of three residents reviewed for Advanced Directives from a total sample list of 16 residents. Findings Include: The facility provided Advanced Directives Policy, dated [DATE], documents that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if her or she chooses to do so. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was maintained by failing to provide timely bowel and bladder incontinence care, for one of three residents (R13) reviewed for incontinence care on the sample list of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately measure food portions during of meals service for residents in the dining room and residents that dine in their rooms. This failure affects three residents (R1, R4, R18) and has the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound treatments as ordered by the physician and failed to have a pressure sore plan of care for two (R1, R2) of three residents reviewed for pressure sores in the sample list of three.

Inspectors wroteBased on record review and interview, the facility failed to provide physician ordered wound care for a surgical incision. This failure affects one resident (R1) on a sample of three reviewed for wound care in the sample list of 37. This failure resulted in R1 experiencing a wound infection which required being sent to the hospital for a surgical debridement and multiple intravenous antibiotics. This past non-compliance occurred from 8/14/24 when the facility failure to monitor and treat R1's surgical incision through 8/22/24 when R1 was discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent the potential for foodborne illness by serving undercooked hamburgers. This failure affected one resident (R2) of three reviewed for food safety in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to provide safe and effective supervision of R1 during incontinence care to prevent a traumatic fall. This failure resulted in R1 falling from R1's bed, striking R1's head on an adjacent nightstand, and landing on the floor resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to update R2's care plan subsequent to a fall. This failure affects one resident (R2) of three reviewed for care plans in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure mechanical lifts are routinely inspected and maintained in good working order. This failure has the potential to affect 18 (R2, R3, R5-R20) out of 18 residents reviewed for mechanical lifts in the sample list of 20.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical and mental abuse by an employee. This failure affects one of five residents (R1) reviewed for abuse in the sample list of 20.

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of staff to resident abuse to the administrator. This failure affects one (R1) of five residents reviewed for abuse in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate abuse allegations and maintain accurate documentation of the investigations for two residents (R1, R4), and failed to document a thorough investigation into a resident incident/injury for one (R2) of five residents reviewed for abuse in the sample list of 20.

Inspectors wroteBased on interview and record review, the facility failed to provide Dementia Management training for staff. This failure affects one (R1) of five residents reviewed for abuse in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow weekly menu's and the corresponding spreadsheets for appropriate serving sizes. This failure has the potential to affect all 68 residents who reside at the facility. Findings Include: 1.) On 10/30/23 at 9:20 am, V4 (R1's family) stated on 10/22/23, R1 was not served what was on the menu, and hardly any food, explaining R1 was only served a small spoonful of mashed potatoes, small spoonful of soup, and a slice of bread. V4 stated the Dietary staff was confronted and the cook, later identified as V11, reported V11 didn't know what to do, because V11 was a dishwasher, not a cook, but V11 was just cooking that night. The Week At A Glance, Week 4 Menu, documents on 10/22/23 for supper, the facility was to have; chicken and rice soup, crackers, stuffed baked potato, seasoned spinach, fruit cup, and ice cream. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely toileting assistance to one of three residents (R2) reviewed for toileting assistance on the sample list of three. Findings Include: The Facility Resident Council Minutes dated 8/19/23, documents, There is still a delay getting assistance to the restroom. On 10/30/23 at 10:53 am, V8, CNA (Certified Nursing Assistant) responded to R2's activated call light. R2 stated R2 had to use the restroom, and V8 instructed R2 to come to the shower room for toileting. Once R2 went to the shower room, V8 along with V9, CNA, assisted R2 to stand, and removed R2's incontinence brief, which was wet with urine, and placed R2 onto the toilet. R2 voided and had a bowel movement while on the toilet, then requested V8 to apply two incontinence briefs onto R2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a restraint assessment and obtain an order for restraints prior to restraining one of three residents (R1) reviewed for abuse on the sample list of nine. Findings Include: R1's ongoing Diagnosis listing documents Diagnoses of Alzheimer's Disease, Dementia with Behaviors, and Unspecified Convulsions. R1's Abuse Investigation by V1, Administrator, dated 8/24/23, documents it was reported V4, CNA (Certified Nursing Assistant), used a device to help keep R1 in R1's chair while feeding R1. R1 has a BIMS (Brief Interview for Mental Status) of 0, {indicating R1 has severe cognitive impairments}, and due to increased Dementia behaviors, R1 has been assigned to one on one care. Facility staff attempted to interview R1, however, due to R1's cognitive status/diagnosis, R1 was unable to participate in an interview. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide morning cares, breakfast, and toileting timely for one of five residents (R7) reviewed for Activity of Daily Living assistance on the sample list of nine. Findings Include: On 9/12/23 at 9:50 am, R7 stated sometimes it takes staff awhile to answer the call light, sometimes up to 45 minutes, causing R7 to be incontinent of urine. R7 stated, It's embarrassing, nobody wants to wet themselves. R7 also stated in August, R7 was supposed to have an insurance interview and was still in bed when it was supposed to happen. R7 explained V17 (R7's family) was at the facility and had to help R1 with the call/interview because R7 had not been gotten up yet out of bed, gotten ready, or eaten breakfast at that time, which was a little before 9:00 am. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for the prevention of indwelling catheter associated urinary tract infections of residents by failing to provide supplies to ensure for hygienic perineal care, failing to securely maintain indwelling urinary catheter tubing, and failing to ensure use of residents catheter drainage bags in a dignified and sanitary manner. These failures affect three (R6, R4, R47) of seven residents reviewed for urinary catheter and urinary tract infections (UTIs) from a total sample list of 40. These failures resulted in R6 feeling humiliated by having to sit in feces for over an hour in the dining room, due to a lack of supplies, while being treated for a urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to complete yearly performance reviews of Certified Nursing Assistants. This has the potential to affect all 72 residents residing at the facility. Findings Include: The Facility's Employee Summary Report, dated 8/22/23, document the following CNA's and their dates of hire: V30 - 6/7/22; V31 - 3/1/22; V32 - 3/1/22; V33 - 3/1/22; V22 - 3/1/23; V34 - 3/1/22; V35 - 3/1/22; V37 - 3/1/22; V38 - 8/18/22; V39 - 3/1/22; V40 - 3/1/22; V26 - 6/7/22; V41 - 3/1/22; V42 - 3/1/22; V13 - 3/1/22; and V43 - 3/1/22. There was no documentation provided by the facility, of CNA's listed above, yearly performance reviews being completed. On 8/22/23 at 12:43 PM, V2, DON (Director of Nursing), stated V2 has only been DON since June 2023, but V2 has not completed any CNA performance reviews since taking over the position. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to have a certified Dietary Manager on staff. This failure has the potential to affect all 72 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean and hygienic kitchen. This failure has the potential to affect all 72 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to establish an Infection Prevention and Control Program. This failure has the potential to affect all 72 residents residing at the facility. Findings Include: The Facility's Surveillance for Infections Policy, dated September 2017, documents, The Infection Preventionist will conduct ongoing surveillance for Health-Associated Infections and other epidemiologically significant infections that have substantial impact on potential resident outcome an that may require transmission-based precautions and other preventative interventions. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI (Quality Assurance Performance Improvement) Committee may be involved in interpretation of the data. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility's dryers in a safe operating condition. The failure has the potential to affect all 72 residents who reside at the facility. Findings Include: On 8/22/23 at 10:35 AM, one of the two dryers has the upper door covering the heating element of the dryer open, so the gas flames were visible. With the door being open, there was a horizontal platform that had a thick layer of lint and debris on it. This lint was approximately 5 inches away from the open flames. At this time, V15, Regional Director of Operations, and V49, Housekeeping/Laundry Supervisor, were present, and both stated the lint with the open flames was a fire hazard. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain consents, abnormal involuntary movement scales, and assessments for psychotropic medications for four (R6, R67, R54, R64) of five residents reviewed for psychotropics from a total sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to offer and/or administer Pneumococcal Immunizations for four of five residents (R13, R30, R38, R61) reviewed for immunizations on the sample list of 40. Findings Include: R13, R38, and R60's ongoing Immunization Logs do not document they have received the Pneumococcal Immunization. Their Medical Records do not contain an Influenza and Pneumococcal Consent/Decline Authorization Form. R30's undated Influenza and Pneumococcal Consent/Decline Authorization signed by V28 (R30's family) documents V28 wants R30 to receive the Pneumococcal Immunization. R30's ongoing Immunization Log does not document R30 has ever received the Pneumococcal Immunization. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's Advanced Directives were consistent throughout the medical chart for 3 of 4 residents (R11, R69, R12) reviewed for Advanced Directives in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the use of body pillows as a restraint, assess for the restraint, care plan the restraint and accurately code the Minimum Data Set for one of one residents (R56) reviewed for restraints on the sample list of 40. Findings Include: R56's MDS (Minimum Data Set), dated 5/26/23, documents R56 does not use any restraints while in bed, but does use restraints daily when up in the chair and out of bed. R56's Care Plan dated 8/1/23, does not document any restraint use. R56's Physical Restraint Assessment, dated 5/26/23, documents R56 does not use any restraints at this time. On 8/20/23 at 8:00 AM, R56 was lying in a low bed, with body pillows placed under the fitted sheet on both sides of the bed. The pillows were approximately 9 inches tall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R6) of one residents with a serious mental illness and reviewed for PASARR level II screenings from a total sample list of 40 residents reviewed. Findings Include: The facility's Behavioral Assessment, Intervention and Monitoring policy, dated March 2019, documents new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. R6's level I PASARR, dated 11/17/21, documents a level II PASARR is not required, due to R6 not having an SMI (Severe Mental Illness) Diagnosis and admission to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a baseline care plan for staff to reference for one of six residents (R174) reviewed for pressure ulcers on the sample list of 40. Findings Include: R174's Progress Notes document R174 was admitted to the facility on [DATE]. On 8/21/23, R174 did not have a baseline care plan in R174's medical record. On 8/21/23 at 11:00 AM, V3, QA (Quality Assurance)/IP (Infection Preventionist)/LPN (Licensed Practical Nurse), stated V10, MDS (Minimum Data Set)/Care Plan Coordinator, just started last week and has no MDS/Care Plan experience, so V10 probably did not know she needed to complete a baseline care plan. On 8/21/23 at 2:22 PM, V21, Regional Clinical Nurse, produced a Baseline Care Plan, dated 8/18/23. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to assess a laceration upon admission and obtain wound treatment orders for one of one residents (R174) reviewed for non-pressure wounds on the sample list of 40. B. Based on observation, interview and record review, the facility failed to coordinate care with hospice for one of one resident (R174) reviewed for hospice services on the sample list of 40. Findings Include: A. R174's Progress Notes document R174 was admitted to the facility on [DATE]. On 8/20/23 at 9:48 AM, R174 was lying in bed, slightly on R174's left side. V47, R174's family, stated R174 has a head laceration on the upper back of the head with sutures from a fall at home. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a treatment order upon admission, complete treatments as ordered, maintain a dressing over a pressure ulcer, perform hand hygiene to prevent potential cross contamination during pressure ulcers treatments, utilize an appropriate mattress for the stage of pressure ulcer, and implement pressure relieving/preventing interventions for two of six residents (R47, R174) reviewed for pressure ulcers in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check the placement of a gastrostomy tube prior to giving medications, and failed to allow medications and water to infuse by gravity for one of one residents (R16) reviewed for gastrostomy tubes on the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a medication before breakfast per manufacturers directions for one (R38) of five residents reviewed for medication administration on the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label insulin vials and pens when opened for three (R16, R43, and R223) of four residents reviewed for insulin on the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a closet with working closet doors that allowed access to residents clothing. This failure affects two of 24 residents (R7, R13) reviewed for environment on the sample list of 40.