Islands Skilled Nursing & Rehabilitation

Inspectors wroteBased on record review and interview the facility failed to submit their staffing information based on payroll data for direct care staffing (including information for agency and contract staff) for fiscal quarter 3 of 2024 (April 1 - June 30), to the Center of Medicare and Medicaid Services (CMS) on the schedule specified by CMS. Findings Include: Review of the CMS Payroll-Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D for fiscal year Quarter 3 of 2024 (April 1 - June 30) revealed the facility Triggered for Failed to Submit Data for the Quarter which states Triggered = No Data Submitted for Quarter. On 04/30/25 at 02:30 PM an interview was conducted with the Administrator and Interim Director of Nursing (DON) in the Administrator's office. Inquired if the facility had submitted the required staffing information based on payroll data to CMS. [...]

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to keep record of dryer lint removal and cleaning. As a result of this deficient practice, the facility did not show that there was any dryer lint removal and/or cleaning being done.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to a dignified existence for four of 15 sampled residents (Resident (R)19, R9, R13 and R16 ) was protected. Specifically, staff were standing over R9, R13 and R16 while assisting them with their meals, and R19's urinary catheter bag was not covered. These deficient practices placed the residents at risk of embarrassment, decreased enjoyment of their environment, and decreased psychosocial well-being with potential negative effects such as decreased social interaction and social isolation.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement comprehensive person-centered care plan (CP) for two of 20 residents sampled for care plan review, Residents (R) 3 and 14. 1. R3 did not have a CP to address his need for bed rail use and interventions to keep him safe. 2. R14 did not have a CP to address his declining Range of Motion (ROM) and interventions that would be used such as Range of Motion exercises to maintain his ROM. Findings Include: 1) On 04/27/25 at 12:13 PM observed R3 lying in his bed and noticed his upper right bed rail was not on the bed. Inquired of Environmental Services Manager (ESM) if he knew where the bed rail was and he said he would search for it, stated he thinks resident's wife removed it. On 04/28/25 at 01:30 PM ESS notified surveyor staff found R3's bedrail in his bathroom and put it back on his bed. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean and homelike environment. Observed a buildup of dust on the back of the ceiling mounted televisions in five rooms. As a result of this deficient practice, there is the potential to cause adverse health conditions to the residents and affect their overall mood and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess one (Resident 18) of four residents reviewed for limitations of range of motion. The deficient practice puts the resident at risk of not having an accurate assessment and proper treatment to maintain his range of motion. Findings Include: Record review of R18's Electronic Health Record (EHR) on 04/28/25 revealed he is [AGE] years old, admitted to the facility on [DATE] and his diagnoses include, but are not limited to, dysphagia, oropharyngeal phase; type 2 diabetes mellitus without complications; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and tracheostomy status. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for Resident (R)33's hyperglycemia (high blood sugar) and use of insulin to control it. The deficient practice could affect all the residents at the facility receiving insulin if a baseline care plan is not developed and implemented to provide effective and person-centered care. Findings Include: On 04/27/25 at 01:58 PM a family interview was conducted at R33's bedside. Inquired if R33 is receiving insulin and Family Member (FM) stated yes he started receiving insulin and his blood sugars have been good. Inquired if resident is diabetic and FM stated no that he started getting insulin when he was in the hospital. [...]

Inspectors wroteBased on record review and interview the facility failed to follow Resident (R) 22's care plan and facility policies/protocols for the prevention/treatment of skin breakdown for one resident of three resident sampled for pressure ulcer/injury. The deficient practice puts the residents at risk for worsening of a pressure ulcer. Findings Include: Record review of R22's MDS with an ARD of 09/20/24 revealed resident was coded for a stage 3 pressure ulcer (PU) that was facility acquired. R22's PU is now coded as a stage 4 PU in the MDS with an ARD of 12/21/24 and continued to have the stage 4 PU for the MDS with an ARD of 03/19/25. Review of R22's care plan revealed she had the following Follow facility policies/protocols for the prevention/treatment of skin breakdown. which was initiated on 05/31/24 and last revision done on 04/10/25. [...]

Inspectors wroteBased on observation and interview the facility failed to provide an environment free of accident hazards for one of one residents sampled for Accident Hazards, Resident (R) 3. R3's upper right bed rail was removed from his bed which staff were unaware of. This deficient practice could put all residents at the facility, who are dependent upon staff for care, and have bed rails at risk for accidents. Findings Include: On 04/27/25 at 12:13 PM observed R3 resting in his bed. At this time noticed R3's upper right bed rail was missing from his bed. Inquired with Environmental Services Supervisor (EVS), who happened to be in the hallway outside of R3's room, where R3's bed rail could be. EVS went to R3's bed and confirmed the bed rail was missing and stated he would search for it and stated he thinks R3's wife removed it. [...]

Inspectors wroteBased on staff interviews, record review and review of policy, the facility failed to act on a Pharmacist Medication Regimen Review (MRR) recommendation for one resident (R) 2 of five residents sampled for Unnecessary Medication Review. As a result of this deficiency, the facility put R2 at risk for complications related to medications.

Inspectors wrote2) On 04/29/25 at 08:13 AM observed medication cart two near nurse's station with keys left unattended in a disposable cup on top of the medication cart. Inquired of Registered Nurse (RN) 7 if the medication cart keys are supposed to be left on the medication cart and she stated, they told us to put them there. Inquired of RN7 who she meant and she stated manager. Inquired if RN7 is supposed to keep the keys on herself and she stated no that they were told to put the keys near the cups on top of the medication cart or the side of the cart near the medication cups and hide them. Inquired if the set of keys includes the narcotic key and she confirmed it does. Inquired of RN7 if she knew what the facility policy states regarding medication cart keys and she stated she had not seen it. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine was kept in clean and sanitary condition in accordance with professional standards for food service safety. This deficient practice placed the residents at risk for foodborne illness.

Inspectors wroteBased on record review and interview the facility failed to correctly fill out an accurate Physician Orders for Life Sustaining Treatment (POLST) for one of three residents reviewed for Advance Directives, Resident (R) 18. Findings Include: Record review of R18's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] and his diagnoses include, but not limited to, dysphagia, oropharyngeal phase, type 2 diabetes mellitus with other skin complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and tracheostomy status. Continued record review revealed R18's EHR did not have an Advanced Health Care Directive appointing an agent as his Power of Attorney to make health care decisions should he become unable to. [...]

Inspectors wrote5) On 04/27/25 at 11:10 AM observed R31 resting in his bed. At this time observed R31's indwelling urinary catheter tubing and urinary bag, which was covered with a privacy bag, resting on the floor next to R31's bed. Record review of R31's Electronic Health Record revealed he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, chronic pulmonary edema, persistent vegetative state and neuromuscular dysfunction of bladder, unspecified. Review of R31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 revealed he was coded for having a urinary catheter and he is totally dependent upon staff for his care. On 04/30/25 at 02:18 PM a phone interview was conducted with the Interim Director of Nursing (DON). Inquired if it was okay for residents with a urinary indwelling catheter and the urinary bag to rest on the floor. [...]

Inspectors wroteBased on interviews, document and record review, the facility nursing staff did not demonstrate the competency and skill set to provide one Resident (R)1 the services needed to safely care for him. Specifically, when R1 had ongoing symptoms that were not his baseline requiring additional intervention, they did not implement the process to obtain emergency physician services when unable to reach the on call provider. In addition, nursing applied a scopolamine patch (used to control secretions) on R1, that was not ordered by the physician. The patch may have resulted in significant side effects. As a result of these deficiencies, R1 suffered harm and experienced hallucinations, and increased heart rate. He as ultimately transferred to acute care facility, where he was admitted .

Inspectors wroteBased on interviews, record and document reviews, the facility violated federal regulations when they initiated a discharge that did not originate through the Resident's (R)1's Representative's verbal or written request, and was not in alignment with R1's goals for care and preferences. R1 was transferred to an acute care hospital for a medical condition requiring higher level of care. It was R1's Representative's intent to have him return to the facility post hospitalization. Although the facility had the capacity and capability to provide the respiratory specialty services needed, the facility inappropriately made the decision, to deny him the right to return. In addition, the medical record did not contain documentation of the required elements of this discharge. [...]

Inspectors wroteBased on interviews, record and document reviews, the facility did not provide the required notification of transfer/discharge to one Resident's (R)1's representative out of a sample size of four. When R1 was transferred to the hospital for a higher level of care and admitted , it R1's Representatives expectation R1 would be returning to the facility when discharged . While R1 was hospitalized , the facility made the decision to not readmit. The facility failed to provide the Representative or Ombudsman written notice of the facility initiated discharge. As a result of this deficient practice R1's Representative did not have the information needed to exercise their rights to appeal the appropriateness of the facility initiated discharge.

Inspectors wroteBased on interviews, document review and record review, the facility had an established transfer/discharge policy, but failed to follow and implement that policy and did not comply with regulations that apply to discharges. Specifically, R1 was sent to the Emergency Department (ED) and hospitalized for further care. His Representative had the expectation R1 would return to the facility, but when he was ready for discharge, the facility refused to let him return and resume residence.

Inspectors wroteBased on interviews and record review, the facility failed to update one Resident's (R)1 care plan (CP) of a sample size of four. R1's representative had specific requests/preferences regarding his care, which were not included in the CP. As a result of this deficiency, the CP was not comprehensive or individualized to include agreed upon interventions. This deficient practice could affect all residents and be a barrier to meeting their highest practicable psychological and physical well-being

Inspectors wroteBased on interviews, document review and medical record review, the facility failed to provide availability of physician services 24 hours a day. On 05/31/2024, the nursing staff was unable to reach a physician/provider to discuss a Resident's (R)1 condition. This deficient practice puts any resident requiring emergency physician services at risk of delay in care, which could result in harm or death.

Inspectors wroteBased on observation and interview the facility failed to provide Nursing Staffing Information to include hours worked by Registered Nurses (RNs), Certified Nurse Aides (CNAs) and resident census each day. Findings Include: On 05/15/24 at 08:40 AM, observed facility's Daily Assignment sheet that was posted near the nurse's station on the treatment cart. The posting listed RN and CNA names and area they were assigned to work that day and the shift. No hours worked were posted for the RNs and CNAs and no resident census for the day was included on this posting. On 05/16/24 at 02:06 PM interviewed Director of Nursing (DON). During this interview shared requirements of F732. DON confirmed his posting was missing resident census and total numbers of hours worked by RNs and CNAs.

Inspectors wroteBased on review of the Facility Assesment (FA), the facility failed to conduct, document, and annually review its facility-wide assessment. The facility used a facility assessment tool as a template in place of an up to date and accurate assessment to identify the needs of its residents. The deficient practice placed all residents in the facility at an increased risk of harm.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for three of 34 residents sampled (Resident (R) 4, R12, and R29) with psychotropic and sedative medications. Non-pharmacological interventions and monitored behaviors were not included in the residents' CP.

Inspectors wroteBased on interview and record review the facility failed to update the care plan for one Resident (R) 27 with treatment plans and recommendations. R27 has a tracheostomy and wears a Passy Muir valve (PMV) to improve communication. R27's representative's decision to not have a tracheostomy cap (T-cap) trial were discussed at the interdisciplinary team (IDT) meeting but not included in the care plan. The deficient practice has the potential to dishonor R27 and her representative's rights.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standard of practice for one of 16 residents sampled (Resident (R) 29). The facility did not follow the physician ordered bowel instruction and as a result, R29 was placed at increased risk of avoidable skin breakdown, infection and discomfort.

Inspectors wroteBased on record review and interview, the facility failed to ensure the attending physician documented in the residents' medical record that a review of the medication regimen review (MMR) recommendation from the pharmacist was reviewed and what, if any, action had been taken to address it for three of five residents sampled (Resident (R) 4, R12, and R29).

Inspectors wroteBased on record review and interviews, the facility failed to specify and monitor behaviors related to psychotropic and sedative medications for three of five residents sampled (Resident (R) 4, R12, and R20); and failed to ensure a PRN (as needed) psychotropic medication was limited to 14 days or ensure the physician document their rationale to extend the 14 days in a residents medical record for one of five residents sampled (R4).

Inspectors wroteBased on observations of two of four residents (Resident (R) 17 and R31), record review, one closed record review for R37 and interview the facility failed to ensure its medication error rate was not five percent or greater, an error rate of 38.36 percent (10 errors out of 26 opportunites). This deficient practice could put all residents at risk for medication errors which could include medications given the wrong route and receiving medication when it should be held which could put the residents at risk for harm. Findings Include: 1) On 05/15/24 at 08:50 AM observed Registered Nurse (RN) 80 prepare and pass medication to R17 on the third floor. Prior to medication pass the nurse reported R17's blood pressure was 116/65 and pulse was 67. [...]

Inspectors wroteBased on observations, interview and policy review, the facility failed to ensure it established and maintained an infection prevention control program to prevent the spread of infections evidenced by the following: Environmental cleaning of resident's rooms was not being routinely conducted; resident care equipment was not cleaned and left in resident rooms; disposable care equipment was reused; and an infection control and prevention policy was not complete for the provision of infection prevention and control based on recognized guidelines, facility assessment; environmental cleaning and disinfection for resident care areas and equipment; and the kitchen was found with areas where residents food could be contaminated. The deficient practice places all residents in the facility at an increased risk for illness.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were provided privacy and dignity while receiving care in the facility for three of 16 residents (Resident (R) 4, R7 and R26). R4 and R7 had urinary catheter bags that were uncovered and visible to people in the hall. R26 was exposed staff and visitors in the room during personal care. This deficient practice disregarded the resident's right to dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the rights of a resident's representative in a medical treatment decision to insert a tracheostomy cap (T-cap) was exercised. The deficient practice dishonored the resident representative's right to make important decisions in the care and treatment for Resident (R) 27.

Inspectors wroteBased on record review and interviews, the facility failed to ensure written copy of the Notice of Medicare Non-Coverage (NOMNC) form was provided and acknowledged by the beneficiary (resident) or the beneficiary's representative according to the NOMNC instructions for three of three residents sampled (Resident (R) 190, R191, and R192).

Inspectors wroteBased on record review and interviews, the facility failed to report an allegation of abuse immediately but no later than two hours after the allegation was made or allegation of mistreatment and an injury of an unknown origin within 24 hours to the State Survey Agency (SA) for two of two residents sampled (Resident (R) 34 and R10).

Inspectors wroteBased on record review and interviews, the facility failed to prevent further potential abuse or mistreatment while the investigation was in progress for Resident (R) 34. The facility did not remove Certified Nurse's Aide (CNA) 16 from the facility providing access to the resident and/or other vulnerable residents while the investigation was in process.

Inspectors wroteBased on record review and interviews, the facility failed to ensure written notification of transfer/discharge was provided to the resident or resident's representative, as soon as practicable, before transferred or discharged and send a copy of that notice to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for one of three residents sampled (Resident (R) 29).

Inspectors wroteBased on record review and interview the facility failed to re-assess Resident (R) 15 for falls quarterly. The deficient practice puts all residents who are at risk for falls or have had a change in their fall risk if the assessment is not completed and interventions added and implemented to the care plan.

Inspectors wroteBased on record review and interview the facility failed to include Resident (R) 35's daily preferences to her baseline care plan which is to be developed within 48 hours of a resident's admission. Findings Include: On 05/13/24, record review of R35's Electronic Health Record (EHR) found she was admitted to the facility on [DATE]. R35 is a [AGE] year old resident with diagnoses that include, but are not limited to adjustment disorder, unspecified, functional quadriplegia who has a tracheostomy (breathing tube in neck) and uses a ventilator (machine) to help her breath. Review of R35's baseline care plan found it was filled out on 04/23/24. Section 1. General Information and Initial Goals D. Daily Preferences that Resident Prefers was left blank. Resident prefers the following (check all that apply) 1. Choosing clothes to wear. 2. Caring for personal belongings. 3. Receiving tub bath. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with supplies necessary to maintain optimal nutrition, grooming, and personal and oral hygiene for seven residents in the sample (Resident (R) 1, R7, R26, R27, R31, R33, and R4). Six of the seven residents in the sample are receiving enteral nutrition (fed by tube) by gravity instead of a pump due to a shortage of the pump tubing, and R33 had significant weight loss; R27 frequently runs out of suction toothbrushes needed for her increased secretions; and R4 is provided briefs to small for him. The deficient practice places residents who require maximal/ dependent assistance in the facility at risk of achieving maximum physical health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to change a suction cannister half full of red-brown secretions and clots for one of three residents in the sample (Resident (R) 1). The deficient practice placed residents receiving tracheostomy care at an increased risk of illness.

Inspectors wrote3) On 05/15/24 at 09:45 AM, inspected medication cart RN80 was using. While checking narcotics reviewed Narcotic Endorsement Log and found two blank spaces dated 05/03/24 0700-1900 ON and 1900-0700 OFF. Inquired of RN80 why these were left blank and RN80 stated someone forgot to sign the form. On 05/17/24 at 03:40 PM interviewed DON and inquired if nurses are expected to sign the Narcotic Endorsement Log after the narcotic count is done and he confirmed this. Showed DON the May 2024 Narcotic Endorsement Log and he stated staff forgot to sign the form. Based on observation, record review and interview, the facility failed to label medications in accordance with acceptable professional standards, including expiration date, and store medications in a locked compartment when left unattended by authorizing administering nursing staff for three residents sampled (Resident (R) 1, R4, and R14) . [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nurses accurately documented in two sampled residents' record (Resident (R) 17 and R14). The nurse did not accurately document the route Resident (R) 17 received his medications and a cup full of medications left on R14's bedside table unattended was documented in the Medication Administration Record (MAR) as administered. This deficient practice could put all residents at risk for incorrect documentation of medications administered to them. Findings Include: 1) Cross reference to F759 . The facility failed to assure it was free of medication error rate of five percent or greater with a nurse incorrectly documenting medications given the wrong route resulting in medication administration errors and documentation errors for Resident (R) 17. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure pneumococcal vaccination was offered to one of the six residents (R) 3 in the sample. This deficient practice placed the resident at risk for acquiring, transmitting and developing possible complications from pneumococcal disease. Findings Include: On 09/06/23 at 11:38 AM, review of R3's electronic health record (EHR) conducted. R3 is a [AGE] year-old resident admitted on [DATE]. Diagnoses include but not limited to amyotrophic lateral sclerosis (disease that affects nerve cells in the brain and spinal cord causing loss of muscle control), chronic respiratory failure, severe protein-calorie malnutrition, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition and often accompanied by depressive symptoms and impaired immune function). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one resident (R), R28, out of the six residents sampled, had the appropriate documentation for the administration or refusal of the COVID-19 vaccination. This deficient practice fails to ensure that residents and/or their representatives were educated about the COVID-19 vaccine and that the COVID-19 vaccination could be administered while in the facility. Findings Include: Record review of R28's electronic health record (EHR). The Medical Diagnosis tab revealed that R28 was admitted for a stroke on 08/15/23. The Immunization tab did not have an entry for the administration of the COVID-19 vaccine. An admission Summary progress note for 08/15/23 at 3:36 PM documented by a nurse stated, . COVID: NEGATIVE. COVID vaccine TBD [to be determined] by ID [Infectious Disease] RN [Registered Nurse]. [...]

Inspectors wroteBased on resident interviews and record reviews, the facility failed to ensure the resident's right to an environment that promotes enhancement of his or her quality of life, as evidenced by staff speaking a foreign language while providing care to residents was honored by staff members.

Inspectors wroteBased on observations and interviews, the facility failed to post the results of the facility's most recent State survey, that is easily accessible to residents, legal representatives, and family members.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide written notice of discharge to the resident or residents' representative for three residents (R) sampled, R6 and R38 who were discharged to an acute care hospital for a higher level of care, and R22, who was discharged home. The facility also failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (LTCO).

Inspectors wroteBased on record reviews and staff interview, the facility failed to provide written notice of the facility's bed-hold policy for two residents (Residents 6 and 38) in the closed record sample. This deficient practice has the potential for miscommunication with residents that are discharged or transferred out of the facility.

Inspectors wroteBased on observations, record review, and interviews with staff, resident, and resident's representative, the facility failed to: 1) provide services for a resident that had a craniectomy (neurosurgical procedure that involves removing a portion of the skull to relieve pressure on the underlying brain) related to a motor vehicle accident, including scheduling of follow up appointments with the nuerosurgeon or development a care plan to address precauations while caring for this vulnerable resident; and 2) ensure nursing care provided for residents with gastrostomy tube (g-tube) met the needs of two residents in the sample (R19 and R189), and were in alignment with standards of good clinical practice and/or facility policy and procedure. as evidenced by nurses not verifying proper placement of the G-tube prior to use.

Inspectors wroteBased on interview and record review (RR), the facility failed to ensure there was enough staff to provide services and respond to each resident's needs in a timely manner, as evidenced by a complaint of long waits for call light response, and staffing ratios on both the second and third floor that were not in alignment with the Facility Assessment. As a result of this deficient practice, at least one resident experienced a decreased quality of life, was placed at risk of physical decline, and was unable to attain his highest practicable well-being. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure that the drug regimen of each resident was reviewed once a month by a licensed pharmacist, and that recommendations made by the licensed pharmacist were acted upon by the attending physician. The Medication Regimen Review (MRR) for the month of October 2022 was missing for four of the five residents (R) sampled for psychotropic medications (R26, R17, R21, and R20), and the physician failed to act upon recommendations for two of the five residents sampled (R26 and R17). As a result of this deficient practice, the residents were placed at risk of avoidable complications related to their medications. This deficient practice has the potential to affect all the residents in the facility taking psychotropic medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all medications used in the facility were securely stored in locked compartments. Proper storage and labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors and diversion of resident medications.

Inspectors wroteBased on observations and staff interview, the facility failed to provide a clean area to prepare food for the residents. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility with food-borne illnesses.

Inspectors wroteBased on record review, the facility failed to maintain accurate medical records for seven residents, physician progress notes were documented in the wrong record. This deficient practice has the potential to affect the medical care residents receive at the facility.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to prevent the possible spread of infectious illnesses to other residents. The facility failed to follow airborne precautions put in place for one resident (R) 189. This deficient practice has the potential to spread infectious illnesses to other residents in the facility. Findings Include: On 05/22/23 at 09:18 AM, initial observation conducted on the second-floor unit. room [ROOM NUMBER] is occupied by four residents, including R189. A sign outside of the room indicated that R189 was on droplet precautions and the following personal protective equipment were required when providing care: mask, gown and gloves. Registered Nurse (RN) 22 was observed entering room [ROOM NUMBER] wearing only a mask holding a medicine cup filled with liquid and an empty cup. [...]

Inspectors wroteBased on observations and interview, the facility failed to identify and support one resident's (R)17 preference to not be placed in a yellow gown. As a result of this deficient practice, R17 did not have his needs met and was placed at risk of not attaining his highest practicable well-being.

Inspectors wroteBased on observations and staff interview, the facility failed to provide safe, clean, and homelike environment for the residents. The facility failed to repair damaged linoleum floor, and ripped privacy curtain for one of the residents (Resident (R) 20) sampled and in two additional rooms.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement person-centered Comprehensive Care Plans (CPs) for 2 of 12 residents in the sample (Residents 19 and 21). As a result of this deficient practice, both Resident (R)19 and R21 were placed at risk for avoidable injury and/or declines in their quality of life and were prevented from attaining their highest practicable well-being.

Inspectors wroteBased on record reviews and interviews with staff members, the facility failed to revise the care plan for 2 (Residents 33 and 13) of 12 residents in the sample.

Inspectors wroteBased on record review and interviews with staff, residents, and resident representatives, the facility failed to ensure residents remained free from accidents for 2 (Residents 33 and 13) of 3 residents in the sample. The facility did not complete an initial fall risk assessment to develop interventions for fall prevention and did not assure monitoring for effectiveness and modifying interventions were done as necessary.

Inspectors wroteBased on record review and interviews with resident and staff member, the facility failed to assure a resident who is incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for 1 (Resident 13) of 2 residents in the sample.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide nutritional care and services to address significant weight loss for one of two residents sampled, Resident (R)32. The attending physician and facility dietitian was not notified when R32 had a 9.24% weight loss within one month of admission to the facility. As a result of this deficient practice, the resident was placed at risk for potential complications due to impaired nutrition.

Inspectors wroteBased on observations, record review, and interview with staff member, the facility failed to use infection control precautions to ensure syringe used for gastrostomy tube (G-tube) was discarded according to the facility's practice and sanitarily stored to prevent infections. This deficient practice has the potential to expose the resident to infections.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure two (Residents 20 and 17) of five residents sampled for medication review were free from unnecessary medications. The PRN (as needed) order for a psychotropic medication (drugs affecting behavior, mood, thoughts or perception) for R20 was not limited to 14 days and reordered indefinitely without a rationale for continuance. Also, the facility failed to assure a gradual dose reduction for R17 as recommended by the pharmacist was done.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide food that accommodates a resident's food allergies. Resident (R)190 was served food that contained an ingredient that she was allergic to placing her at risk for an adverse health condition.