Ivy Park Post Acute

Inspectors wroteBased on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that residents wounds were measured weekly and monitored for one of two residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, closed clinical records, facility documents and staff interviews it was determined that the facility failed to provide a complete copy of a resident's medical records upon request by the resident's next of kin for one of three closed resident records (Closed Resident Record CR1).

Inspectors wroteBased on observations, facility policy, resident interviews, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit [ ]) were provided in the facility for three of seven days (4/13/26, 4/14/26, and 4/15/26). Findings Include: Review of the facility policy Homelike Environment dated 1/9/26, indicated the facility will provide a safe, clean, comfortable, and homelike environment. The facility staff and management maximizes, to the extent possible characteristics that include comfortable and safe temperatures (71-81 ) Review of a Resident representative concern dated 4/13/26, stated This is a nursing home that does not have a functioning air conditioning unit. We have unsafe temperatures for their residents. Review of an additional; [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical closed records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for two of four closed records (Closed Resident Record CR1 and Closed Resident Record CR2).

Inspectors wroteBased on review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for one of 73 residents (Closed Record Resident CR1), resulting in immediate jeopardy.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure consistent care was provided to initiate Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident, which created an immediate jeopardy situation for one (Resident R1) of 131 residents.

Inspectors wroteBased on observations, facility policy, and staff interview, it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (3rd floor) and failed to ensure comfortable air temperature levels were provided for one of three floors (4th floor). Findings Include: Review of the facility policy Safe and Homelike Environment dated 5/20/25, indicated residents are provided a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include:Clean, sanitary and orderly environment;Comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit). [...]

Inspectors wroteBased on a review of the facility's documents and staff interviews it was determined that the facility failed to implement a good faith effort to correct deficiencies cited during the survey ending January 9, 2026, by failing to complete the facility's plan of correction which indicated a direct in-service (training required by the state agency that is presented by an outside vendor) would be provided to all professional nursing staff as required. (all agency professional nursing staff).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of five residents (Resident R1). Review of the clinical face sheet indicated that Resident R1 was admitted to the facility 4/4/24, with diagnoses that included seizures, moyamoya disease (rare blood vessel condition in which the carotid artery in the skull becomes blocked or narrowed) and cerebral infarction. A review of Resident R1's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 6/18/25, indicated the diagnosis remained current. Review of physician orders dated 8/5/25 indicated an order for valproic acid, cbc w/diff, cmp. Facility provided documentation indicated resident refused bloodwork. [...]

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk in cooler and reach in cooler which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment for seven of eight residents (Resident R12, R38, R40, R41, R46, R81, and R120).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of six residents sampled with facility-initiated transfers (Residents R2, R13) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of six resident hospital transfers (Resident R13), and failed to obtain a physician order for discharge for one of three residents ( Closed Record Residents R127).

Inspectors wroteBased on review of policies and clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for three of five residents reviewed (Resident R4, R25, and R120).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to follow physician orders for Blood Glucose levels for one of eight residents (Resident R50), failed to provide parameters of when to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels or notifying physician of results outside parameters ordered for five of eight residents (Residents R25, R34, R53, R75, and R120), failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of eight residents (Resident R53), failed to provide therapeutic lab monitoring for one of three residents (Resident R58) and failed to ensure timely follow up physician appointments were scheduled for one out of three residents (Residents R111).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain residents with behaviors triggering elopement risk were identified timely, failed to assess on an ongoing basis, and failed to provide care plan and physician orders for interventions regarding exit seeking behaviors for three of five residents (Resident R70, R104, and R120).

Inspectors wroteBased on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R2 and R21) and failed to maintain a current dialysis contract with dialysis vendor for two of three (Resident R2, and R61).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three of five nurse aides (NA Employee E17, E18 and E19).

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of three outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one and two).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to ensure that three of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E17, E18 and E19). Review of faciliy policy In-Service Training-All Staff dated 5/20/25 indicated all staff must participate in initial orientation and annual in-service training. Review of facility nurse aide training records revealed that nurse aide Employees E17, E18 and E19 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that the above nurse aide employees had received a minimum of 12 hours of in-service training yearly. During an interview on 6/25/25 , at 1:15 p.m. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of four residents (Residents R120).

Inspectors wroteBased on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of four residents (Resident R5).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of three floors (Fourth floor).

Inspectors wroteBased on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of five residents (Resident R4 and R94).

Inspectors wroteBased on facility policy, review of clinical record, and staff interview, it was determined that the facility failed to provide appropriate foot care to two of five residents (Residents R117 and R120).

Inspectors wroteBased on review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of four residents (Resident R125).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in two of three medications carts (Third floor Low Cart, and Second floor Low Cart).

Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined that the facility failed to provide drinks in a form to meet individuals' needs in one of four residents (Resident R48).

Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for two of five residents (Resident R97 and Resident R104).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R120).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (7/1/24 to 9/30/24).

Inspectors wroteBased on review of facility policy, grievances and staff and resident interviews, it was determined that the facility failed to provide residents with access to their personal funds/petty cash for three of four residents (Residents R1, R2, R4).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person bed mobility assistance for one of four residents (Resident R1) resulting in a fall.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs, resulting in an avoidable fall for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, review of clinical documentation, staff interviews and review of facility reported events, it was determined the facility failed to ensure that physician orders were properly obtained, failed to identify pain or spasms to warrant medication, and failed to notify family for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, review of clinical documentation. observation and staff interview it was determined the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, review of clinical documentation, staff interviews and review of facility reported events, it was determined the facility failed to ensure that orders were properly obtained by a Physician, Physician Assistant, or Nurse Practitioner (NP) for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records and interviews with staff it was determined that the facility failed to implement a safe and orderly discharge from the facility for one of three residents (Closed Record Resident R2).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined the facility failed to properly label and date food products, failed to properly monitor food temperatures, failed to maintain kitchen equipment and dry storage area in a clean sanitary condition, and failed to properly monitor food expiration dates in a manner to prevent foodborne illness in the Main Kitchen.

Inspectors wroteBased on review of facility policy, observations, resident council group interview, and resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff's immediate use on two of three units (second floor and third floor).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R29, R39, R75, and R82).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of five residents (Residents R29, R39, R75, and R82).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of five resident hospital transfers (Residents R29, R39, R75, and R82).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for 17 of 17 new admissions in the past 30 days.

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents (Residents R1, R27, and R41).

Inspectors wroteBased on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for two of three units (third floor medication room and fourth floor medication room).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of two residents (Residents R31 and R97).

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of three quarters (October 2023 through December 2023, January 2024 through March 2024, and April 2024 through June 2024).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a medication pass for two of six residents (Residents R46 and R98), and failed to follow enhanced barrier precautions (EBP) for eight of eight residents with tube feedings (R6, R28, R41, R53, R72, R73, R75, and R109), six of six residents with indwelling urinary catheters (R12, R38, R39, R75, R238, and R240), and two of two residents with indwelling dialysis catheters (R27 and R42).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that an influenza and pneumococcal immunization was offered to four of five residents (Resident R53, R94, R106, and R112).

Inspectors wroteBased on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for three out of five personnel records (Nurse Aide (NA) Employee E25, NA Employee E26, and NA Employee E27).

Inspectors wroteBased on observation, review of facility documentation, resident and staff interviews it was determined that the facility failed to provide a dignified dining experience for meals for one of three units (4th Floor Nursing Unit).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to notify the resident's representative of a change in condition and transfer to the hospital for one of four resident records (Closed Resident Record CR241).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of six medication carts (third floor low hall medication cart assignment two).

Inspectors wroteBased on observations, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for two of three units (second floor shower room and fourth floor nursing unit).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident R125).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of four residents (Residents R19).

Inspectors wroteBased on review of facility policy, observations, resident interview and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two of seven residents (Residents R82 and R100).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities for one of eight residents (Resident R57).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Resident R12) and failed to provide necessary services for one of three residents reviewed (Resident R106).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician orders for maintenance flushing of a enteral-tube for one of four residents (Resident R41), failed to obtain orders for enteral-tube displacement for one of four residents (Resident R53), failed to label tube feeding flush kit with dates on 2 of 8 residents (R28 and R41), and failed to label tube feeding formula and water flush on one of eight residents (R53). Review of the facility policy Enteral Management dated 5/7/24, indicate to provide safe and effective management of enteral tubes (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). Review of the facility policy Enteral Feeding: Administration by Pump dated 5/7/24, indicate to verify order. [...]

Inspectors wroteBased on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R94 and R106).

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two out of five nurse aide personnel records (Nurse Aide (NA) Employee E25 and NA Employee E26).

Inspectors wroteBased on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of three residents (Resident R84).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R106).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's laboratory test results were received for one of seven residents (Resident R75).

Inspectors wroteBased on facility documents, clinical records, observations, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals needs who are ordered easy to chew diet textures for one of five residents (Resident R45).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for two of five residents reviewed for immunizations (Resident R53 and R106).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for two of five NA personnel files (NA Employee E25 and E27) and failed to complete annual training on dementia management for one of five NA personnel files (NA Employee E25) and abuse prevention for two out of five NA personnel files were completed (NA Employee E25 and NA Employee E26).

Inspectors wroteBased on clinical and facility record review, facility submitted documents and staff interview, it was determined that the facility failed to make certain residents were provided appropriate treatment and services for one of forty seven residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide a trauma survivor with trauma centered care for one of two residents (Resident R3).

Inspectors wroteBased on review of facility documentation, and staff interviews it was determined that the facility failed to have enough staff to supervise and prevent incidents for one of forty-seven residents.

Inspectors wroteBased on review of facility policy, clinical record, facility documentation and staff interview it was determined that the facility failed to make certain medications were administered as ordered by physician for one of four residents reviewed (Resident R3).

Inspectors wroteBased on facility documents, observations, and staff interview, it was determined that the facility failed to have appropriate personal protective equipment (PPE) to prevent cross-contamination for two of two residents in Covid-19 isolation (respiratory infection Resident R1 and R2) and two of two residents in other isolation precautions (Resident R3 and R4) and failed to clean consistently to prevent infectious spread from items or environment to residents and or staff on three of three units (2nd, 3rd, and 4th floors).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen creating the potential for food-borne illness (Main kitchen).

Inspectors wroteBased on facility policy, documents submitted by the facility, and staff interview it was determined that the governing body of the facility failed to ensure consistent appointment of an administrator licensed by the state for three out of seven days (8/4/23, 8/5/23, and 8/6/23).

Inspectors wroteBased on review of facility policy, facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually (January 2022 to August 2023).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for three of three units (second and fourth floor's solariums, third floor shower rooms and solarium) and seven of nine resident rooms observed (Residents R31, R41, R71, R72, R81, R94, and R270). Findings Include: Review of facility policy Accommodation of Needs dated 2/1/23, indicated the resident has a right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Observation of the second floor nursing unit, on 8/7/23, at 8:45 a. m. revealed debris on the hallway floors, solarium floors, and tables appeared sticky with food debris (dirt, crumbs, tissues). Review of admission record indicated Resident R270 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to make certain anonymous grievance forms are readily accessible for resident use throughout the facility for three of three nursing units (Second floor, Third floor, and Fourth floor).

Inspectors wroteBased review of facility provided documents and clinical records, observations and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans for two of 16 residents (Resident R40 and R41).

Inspectors wroteBased on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for six of 16 residents (Residents R40, R25 R48, R60, R71 and R97).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for four of seven residents reviewed (Resident R41, R69, R83, and R271).

Inspectors wroteBased on review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for six out of ten nursing personnel (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, Nurse Aide Employee E17, Licensed Practical Nurse (LPN) Employee E21, and Licensed Practical Nurse (LPN) Employee E22).

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five nurse aide personnel records (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, and Nurse Aide Employee E17).

Inspectors wroteBased on policy review, record review, observation, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a clean environment, failed to handle soiled linens properly, and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for seven of twelve months (January, February, March, April, May, June, July 2023). Findings Include: A review of facility policy Infection Control dated 8/8/23, previously dated 8/30/22, indicated the facility will maintain a safe, sanitary environment for residents. [...]

Inspectors wroteBased on review of infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist, for three of twelve months (September, October, and November 2022). Review of the Pennsylvania Department of Health notice PAHAN #626, dated 2/15/22, PAHAN #663, dated 10/4/22, PAHAN #694, dated 5/11/23, indicated long-term care facilities should Assign one or more individuals with training in IPC (infection preventions and control) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents . Review of the QAPI (Quality Assurance and Performance Improvement) committee meeting sign-in sheets indicated that the Director of Nursing had the role of Infection Preventionist from September through November 2022. [...]

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual training on dementia management and resident abuse prevention for four out of five nurse aide personnel records (Nurse Aide (NA) Employee E14, Nurse Aide Employee E15, Nurse Aide Employee E16, and Nurse Aide Employee E17).

Inspectors wroteBased on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of eight residents (Resident R27).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a State background check prior to hire for one out of five personnel records (Cook Employee E12).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order, and failed to provide as needed medications for constipation for two of five residents (Resident R29 and R40).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of three residents reviewed (Resident R72 and R317).

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 18 of 32 residents. (Resident R4, R13, R20, R25, R33, R40, R48, R53, R60, R71, R89, R96, R97, R109, R217, R300, R301, and R302) and for two of five confidential group residents. Findings Include: Review of facility policy Nursing Scheduling and Timekeeping Process dated 8/8/23, previously reviewed 8/30/22, indicated the facility will staff according to budgeted staffing levels and adjust schedules based on census. Budgeting and adjusted staffing levels are based on a combination of census, acuity levels, and regulatory requirements. During an interview on 8/7/23, at 9:32 a.m. [...]

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to schedule ordered appointments for one of two residents (Resident R93).

Inspectors wroteBased on review of facility documents, resident clinical record and staff interview it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of a resident lacking capacity to understand the agreement terms for one of four sampled residents (Resident R53).