Inners Creek Skilled Nursing and Rehabilitation Ce

Inspectors wroteBased on review of facility policy, documentation provided by the facility, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure one of five residents reviewed was free of verbal abuse (Resident 5).

Inspectors wroteBased on facility policies, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs of the resident for one of five residents reviewed (Resident 1).

Inspectors wroteBased on observations, policy review, and staff interviews, it was determined that the facility failed to ensure food is stored, prepared, and distributed in accordance with professional standards for food service safety for one nourishment room observed (Station 3) and observations of two items of equipment in the kitchen (one ice machine and one three-compartment sink). Findings Include: Review of the facility's policy, titled Ice Chests, reviewed July 15, 2025, read, in part, Use an ice scoop to access ice. Grasp the handle of the scoop only and avoid touching the portion that contacts the ice. Store the ice scoop in a clean, uncovered holder. An observation in the Station 3 nourishment room on April 20, 2026, at 9:26 AM, revealed a non-working ice machine. The observation revealed the staff's use of a cooler, sitting on the counter, with melted ice inside. [...]

Inspectors wroteBased on observations, policy review, and staff interviews, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests in two of five resident areas observed (Station 3 and the Rehabilitation area) and one kitchen area observed. Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, reviewed November 14, 2025, read, The resident/patient.has the right to a safe, clean, comfortable and homelike environment. Review of the facility's policy, titled Pest Control, dated February 2025, read, A program will be established for the control of insects and rodents for the Dining Services Department. Also, All preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concern verbally and in writing. [...]

Inspectors wroteBased on observations, policy review, and staff interviews, it was determined that the facility failed to ensure each resident the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely, in one of three shower rooms observed (Station 3). Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, reviewed November 14, 2025, read, in part, The resident/patient has the right to a safe, clean, comfortable and homelike environment. The policy continued, The Center must provide. Housekeeping and Maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. An observation in the shower room on Station 3 on April 20, 2026, at 9:30 AM, revealed one shower head wrapped with tape and a large piece of white linen. [...]

Inspectors wroteBased on observations, policy review, and resident and staff interviews, it was determined that the facility failed to ensure each resident is treated with respect, care, and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of eight residents observed (Resident 6). Findings Include:Review of the facility's policy, titled Resident Rights Under Federal Law, reviewed June 12, 2025, read, in part, that the purpose of the policy is To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth. The policy continued, To protect and promote the rights of the resident. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post the current daily nurse staffing information that included the facility name, current date, resident census, and the total number of direct care hours for licensed and unlicensed nursing staff, for one posted nurse staffing document observed (facility lobby). An observation of the facility's nurse staffing information, on December 29, 2025, at approximately 8:30 AM, revealed the most recent posting with information dated December 27, 2025. An interview with the Administrator in Training (Employee 1), on December 29, 2025, at 9:41 AM, confirmed that the posted information should have been updated by the night shift staff and weekend staff. The interview revealed the posted information would be updated immediately to reflect the current date and other required information.28 Pa. [...]

Inspectors wroteBased on document review, clinical review, and staff interview, it was determined that the facility failed to obtain diagnostic services to meet the needs of its residents and ensure those services are obtained promptly for one of two residents reviewed for falls (Resident 1). Findings Include:Review of Resident 1's clinical record revealed diagnoses that included Right Femur Fracture and Alzheimer's Disease (a progressive brain disease, the most common cause of dementia, that gradually destroys memory, thinking, and reasoning skills, leading to severe memory loss, confusion, and difficulty with daily tasks, behavior changes, and eventual inability to carry out even simple activities). Review of Resident 1's falls, during December 2025, revealed a fall dated December 7, 2025. According to the incident report, staff documented the following immediate action: [...]

Inspectors wroteBased on a clinical record, policy review, and staff interview, it was determined that the facility failed to ensure that residents received routine dental services for one of six resident records reviewed (Resident 4). Findings Include:Review of the facility's policy, titled Dental Services, revised on September 15, 2025, reads, in part, Centers [facility] will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. [...]

Inspectors wroteBased on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that residents were free from sexual abuse, which resulted in actual harm as evidenced by emotional distress and a vaginal wound for one of four residents reviewed for abuse (Resident 1).

Inspectors wroteBased on facility document review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide physician ordered enriched diet and nutritional supplements for four of five residents reviewed (Resident 1, 3, 4, and 5).

Inspectors wroteBased on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility to ensure that each resident is free from abuse for two of six of residents reviewed (Residents 2 and 3). Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following:Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Injuries of unknown source are defined as an injury with both of the following conditions: [...]

Inspectors wroteBased on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility failed to ensure that an injury of unknown origin was investigated for one of two residents (Resident 4). Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following: 6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected;8. The Center will protect patients from further harm during an investigation.8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.8.2 Assign a representative from Social Services or a designee to monitor the patient ' s feelings concerning the incident, as well as the patient ' s involvement in the investigation;9. [...]

Inspectors wroteBased on clinical record review, facility provided documentation review, and staff interviews it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of three residents reviewed (Resident 4). Review of facility policy titled NSG215 Falls Management with a last revision date of March 15, 2024, revealed 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes. 4. Educate staff, patient, and/or patient representative(s) as appropriate to increase awareness of 'at risk' patients and to provide possible strategies to minimize risk for falls. [...]

Inspectors wroteBased on policy review, staff interview, and other documents review, it was determined that the facility failed to ensure food is served at a safe and appetizing temperature for one meal test tray completed (lunch meal). Findings Include: Review of the facility's policy, titled Food Handling, revised January 26, 2024, read, Foods are stored, prepared, and served in a safe and sanitary manner. The purpose of the policy read To prevent bacterial contamination and the possible spread of infection. The policy continued, food must remain at 135 [degrees] or above. Review of the facility's document titled Resident Council Minutes, dated May 1, 2025, revealed that residents reported concerns about the temperatures of food, and residents reported trays are cold. [...]

Inspectors wroteBased on policy review, resident and staff interviews, and clinical record review, it was determined that the facility failed to ensure its residents the right to exercise his or her rights as a resident of the facility and as a citizen of the United States for voting in one election (local election) for three of four residents interested in voting (Residents 2, 5, and 6). Findings Include: Review of the facility's policy, titled Resident Rights Under Federal Law, revised February 1, 2023, revealed a purpose to Treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the resident's goals, preferences, and choices into care. To recognize each resident's individuality as well as honor and value his/her input. [...]

Inspectors wroteBased on facility policy review, job description review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled NSG122 Change in Condition: Notification of, revised July 1, 2024, revealed A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); . or A decision to transfer or discharge the patient from the Center. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident recieves adequate supervision and assistance to prevent accidents and hazards for one of three residents reviewed (Resident 1). Findings Include: Review of the facililty's policy, titled Elopement of Patient, recently revised October 24, 2022, defined elopement as .any situation in which the patient leaves the premises without the facility's knowledge and supervison . Review of Resident 1's clinical record revealed diagnoses that inlcuded Post Traumatic Stress Disorder (PTSD - A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the physician reviews the resident's total program of care, including medications, for one of three residents reviewed (Resident 1). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included bilateral knee osteoarthritis (a degenerative joint disease that causes the cartilage and bone in your joints to break down over time. It's the most common type of arthritis and can affect the hands, hips, knees, back, and other joints) and muscle weakness. A review of Resident 1's consultation form dated November 13, 2024, with an Orthopaedic Surgery Specialist ([NAME]), revealed recommendations that included a new order for Tylenol 1000 mg (milligrams) Q (every) 8 hours. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident for one of three residents reviewed (Resident 1). Findings Include: A review of the facility's Registered Nurse Job Description, revised June 16, 2017, read, in part, The Registered Nurse [RN] delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act . The RN manages patient care by performing nursing assessments and collaborating with the nursing team and other disciplines .to develop effective plans of care. [...]

Inspectors wroteBased on facility contract review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner consistent with physician's orders for two of three residents reviewed (Residents 1 and 2).

Inspectors wroteBased on facility policy and procedures reviews, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician was promptly notified of abnormal x-ray results for one of three residents reviewed (Resident 2).

Inspectors wroteBased on facility policy review, observations, clinical record review, review of facility master menu diet guide sheets, and staff and resident caregiver interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for nine residents (Resident's 37, 41, 57, 59, 78, 112, 155, 162, and 167) observed. This failure placed 31 residents that had similar diet needs at a high risk for death, and resulted in an Immediate Jeopardy (IJ) situation for Residents 1, 3, 4, 5, 6, 7, 9, 10, 13, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 30, 31, 32, 33, 34, 36, 38, 39, 58, and 92.

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner which promoted resident dignity in one of four dining areas (Station 3 Dining Room).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for restraint use, including consent, physician orders, initial and ongoing evaluations, and scheduled removal, for one of one residents reviewed for restraints (Resident 126).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that physician's orders were implemented for one of 35 residents reviewed (Resident 49); and failed to ensure assessments were completed for three of 36 residents reviewed (Residents 162, 228, and 522).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of hydration and nutritional status for two of seven residents reviewed for nutrition or hydration (Residents 92 and 157); and failed to notify the physician of a significant weight loss for one of five residents reviewed for nutritional status (Resident 72).

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of five nurse aide documents reviewed (Employees 11, 12, 13, 14, and 15). Findings Include: A review of Employee 11's documents revealed a hire date of December 10, 2022. A continued review of Employee 11's information revealed no recent performance evaluation. A review of Employee 12's documents revealed a hire date of December 10, 2022. A continued review of Employee 12's information revealed no recent performance evaluation. A review of Employee 13's documents revealed a hire date of September 28, 2023. A continued review of Employee 13's information revealed no recent performance evaluation. A review of Employee 14's documents revealed a hire date of August 17, 2023. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four or five residents reviewed for unnecessary medications (Residents 12, 15, 25, and 72). Findings Include: Review of facility policy, titled Section 1.3 Organization Aspects Consultant Pharmacist Services Provider Requirements, last reviewed July 2024, read, in part, Regular and reliable consultant pharmacist services are provided to residents. 4. The consultant pharmacist or designee, provides pharmaceutical care services, including but not limited to the following: .d. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure adequate monitoring of psychotropic medications to ensure that resident were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 15).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and four of four pantry areas.

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure implementation of Enhanced Barrier Precautions to prevent the spread of infection by wearing required PPE (personal protective equipment) and hanging correct signage for six of 37 residents observed (Residents 2, 47, 58, 71, 91, and 159). Findings Include: Review of facility policy, titled Enhanced Barrier Precautions, revised January 8, 2024, revealed that enhanced barrier precautions are to be used to reduce the risk of epidemiologically important microorganisms by direct or indirect contact. Additionally, Enhanced Barrier Precautions is based on the Centers for Disease Control & Prevention (CDC) guidance. Further review of the policy failed to reveal any expectation that residents with indwelling medical devices should be placed on Enhanced Barrier Precautions. [...]

Inspectors wroteBased on employee file review and staff interview, it was determined that the facility failed to ensure the required nurse aide in-service training be no less than 12 hours per year and include dementia management training and resident abuse prevention training for three of five nurse aide documents reviewed (Employees 12, 13, and 15). Findings Include: A review of Resident 12's training information revealed a total of 6:13 hours documented and did not include the required dementia management or resident abuse prevention training. A review of Resident 13's training information revealed a total of 9:00 hours documented and did not include the required resident abuse prevention training. A review of Resident 15's training information revealed a total of 3:08 hours documented and did not include the required dementia management training. [...]

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure a clean, comfortable, homelike environment, as evidenced by soiled wheelchairs, for three of 35 residents reviewed (Residents 53, 72, and 96).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's representative were provided the bed-hold notice upon transfer for two of five residents reviewed for hospitalizations (Residents 71 and 157).

Inspectors wroteBased on review of facility policy, record review, observation, and staff interviews, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of two residents reviewed with pressure injuries (Resident 91). Findings Include: Review of facility policy, titled Wound Dressings: Aseptic, Revised December 1, 2021, revealed in step 1. Verify order. Review of Resident 91's clinical record revealed diagnoses of pressure ulcer of left heel (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time) and pressure ulcer of the left buttock (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time). [...]

Inspectors wroteBased on clinical records review, policy review, facility document review, and resident and staff interviews, it was determined that the facility failed to ensure that the medications ordered by the physician were available for one of 35 residents reviewed (Resident 229); and failed to provide documentation of disposition of medications for one of three closed records reviewed (Resident 170).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to place opened dates on medications in one of four medication carts (100 hall) and one of two medication storage rooms (Station 1) observed. Findings Include: Review of facility policy, titled Section 4.1 Storage of Medication, last reviewed July 2024, read, in part, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Procedures 12. Note the date on the label for insulin vials and pens when first used. Review of facility policy, titled Section 9.10 Appendix of Resources Medication with Shortened Expiration Dates, last reviewed July 2024, stated, in part, Tuberculin PPD .discard vials in use after 30 days. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of nine residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included end stage renal disease (ESRD- when the kidneys no longer work as they should to meet the body's needs) and idiopathic pulmonary fibrosis (a condition in which the lungs become scarred and breathing becomes increasingly difficult). Review of Resident 2's clinical record revealed a progress note, written by Employee 1 (Licensed Practical Nurse [LPN]) on August 10, 2024, at 1:14 AM, stating that Resident 2 was anxious, diaphoretic (excessive sweating), and was stating that he was not getting oxygen from his nasal cannula. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interview it was determined that the facility failed to provide food and beverage that were at a safe and appetizing temperature for one of one meal observed on the short-stay rehabilitation unit.

Inspectors wroteBased on clinical record review, and staff interviews it was determined that the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administration of drugs to meet the needs of each resident for one of 6 residents reviewed (Resident 4).

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure its Facility Assessment addresses the resources necessary to care for its residents, including staff competencies necessary to provide the level and types of care needed for its resident population, for one facility assessment reviewed (Dated November 16, 2023-December 7, 2023). Findings Include: The intent of the Facility Assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of the information documented in the Facility Assessment revealed no information outlining the staff competencies necessary to care for the facility's resident population. [...]

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 34 residents reviewed (Resident 60) and one of three dining rooms observed (The Bread Basket).

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 34 residents reviewed (Residents 42, 98, 114, and 136); and failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for three of 34 residents reviewed (Residents 23, 81, and 103).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide routine assessments of pressure ulcers for two of four residents reviewed for pressure ulcers (Residents 98 and 114). Findings Include: Review of facility policy, titled Skin Integrity and Wound Management, revised February 2023, revealed, Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Review of Resident 98's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]). Review of a physician evaluation for Resident 98 from June 2, 2023, revealed that Resident 98 had a stage 4 pressure ulcer of the sacral region. [...]

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for five of five employee files reviewed (Employees 7, 8, 9, 10, and 11). Findings Include: Review of Employee 7's personnel record revealed a hire date of September 8, 2008, and no evidence of a recent annual performance review. Review of Employee 8's personnel record revealed a hire date of April 27, 2018, and no evidence of a recent annual performance review. Review of Employee 9's personnel record revealed a hire date of October 6, 2008, and no evidence of a recent annual performance review. Review of Employee 10's personnel record revealed a hire date of July 22, 2015, and no evidence of a recent annual performance review. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure one of 34 residents reviewed were free of unnecessary psychotropic medications (Resident 25).

Inspectors wroteBased on observation, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in one of four nourishment pantries (Station 4 nourishment pantry).

Inspectors wroteBased on clinical record review, document review, and staff interviews, it was determined the facility failed to ensure coordination of necessary service for one out of two residents reviewed receiving Hospice services. (Resident 25)

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure nurse aides complete annual training, including dementia management and resident abuse prevention, and all training hours be no less than 12 hours per year for four of five nurse aide files reviewed (Employees 7, 8, 9, and 11). Findings Include: Review of Employee 7's personnel file revealed no documentation of dementia management or resident abuse prevention training. The file also revealed Employee 7 did not receive the minimum 12 hours of required annual training. Review of Employee 8's personnel file revealed no documentation of dementia management or resident abuse prevention training. The file also revealed Employee 8 did not receive the minimum 12 hours of required annual training. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the listed emergency contact person (Resident's Representative) of the transfer to the hospital for one of four residents reviewed for hospitalizations (Resident 136).

Inspectors wroteBased on observations, review of facility policy, and staff interview, it was determined that the facility failed to post the required information of the Grievance Official for two of four identified areas (Station 4 nursing area and Station 2 lobby area)

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to notify the Resident/Resident Representative and the Representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for two of 34 resident records reviewed (Residents 40 and 136).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the Resident and/or Resident Representative received written notice of the facility bed-hold policy at the time of transfer for one of four residents reviewed for hospitalizations (Resident 136). Findings Include: Review of Resident 136's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 136's nursing progress notes revealed that on August 29, 2023, Resident 136 went to an outside orthopedic appointment and was then transferred to the hospital from that appointment. Resident 136 was admitted to the hospital on [DATE]. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 34 residents reviewed (Resident 25). Findings Include: Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of a client coordination notes report from Memorial [NAME] Home Health and Hospice received on November 29, 2023, at 2:00 PM, revealed Resident 25 was discharged from hospice on November 7, 2023, and their last date of service was on November 3, 2023. [...]

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission that would include the instructions needed to provide effective and person-centered care of the resident and meet professional standards of quality of care for one of 34 residents reviewed (Resident 42).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that outlines resident goals for admission and desired outcomes for one of 34 resident records reviewed (Resident 25). Findings Include: Review of the facility's policy, titled OPS416 Person-Centered Care Plan, last reviewed and revised on October 24, 2022, reveals that care plans include measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. [...]

Inspectors wroteBased on clinical record review, document review, and resident and staff interviews, it was determined that the facility failed to provide services that meet professional standards of practice for three of 34 residents reviewed (Residents 25, 103, and 136).

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for one of 34 residents reviewed (Resident 114). Findings Include: Review of Resident 114's clinical record revealed diagnoses that included retention of urine (difficulty urinating and completely emptying the bladder) and Stage 3 pressure ulcer to the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; stage 3 is full-thickness skin loss; sacrum-a triangular bone located at the base of the spine). [...]

Inspectors wroteBased on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder or suprapubic area to drain urine into a bag) care for one of 34 residents reviewed (Residents 49 and 114).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to act on a pharmacy recommendation in a timely way, and failed to ensure that the physician documented a rationale for declination of a pharmacy review recommendation for one of 34 residents reviewed (Resident 25).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to post nurse staffing information on a daily basis, include the resident census and the total number of actual hours worked by licensed and unlicensed staff; and failed to maintain the posted daily nurse staffing data for a minimum of 18 months for one area observed (facility lobby) two days reviewed (November 27-28, 2023) and one week data requested (July 9-16, 2023). Findings Include: Review of the facility's daily nurse staffing information forms dated November 27-28, 2023, revealed the forms to not document the resident census on each shift and the actual hours that were worked on each shift to reflect any changes in the schedule. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 29 residents reviewed (Resident 40). Findings Include: Review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe) and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). Review of Resident 40's Annual MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated October 14, 2022, revealed that Section O0100c, Oxygen was marked NO, signifying that Resident 40 did not receive supplemental oxygen during the 14-day look-back period. [...]

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 30 residents reviewed (Residents 29 and 107).