Kennedy Health & Rehab

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (Resident #1) residents reviewed for supervision. The facility failed to ensure the secured unit, 900 hall, door alarm and door lock were functioning properly after a fire alarm was triggered on 7/7/2026 at approximately 4:00 p.m. On 7/7/2026 Resident #1 eloped from the facility and was found 0.5 miles from the facility. On 7/21/2026 at 3:45 p.m. an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to thaw frozen ground meat appropriately on 7/1/2026 that was submerged in a sink with warm water running on top of it. The facility failed to ensure the temperature of the walk-in cooler was at the appropriate temperature of less than 41 degrees on 7/1/2026. The facility failed to ensure the temperature of a refrigerator was at the appropriate temperature of less than 41 degrees on 7/1/2026. The facility failed to ensure the walk-in cooler did not have fifty 1/2 pints of milk that expired 6/26/2026. The facility failed to ensure the milk cooler did not have food debris and a black substance inside at the bottom on 7/1/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 5 halls (Hall 100, Hall 300, and the secure unit) and 1 of 1 kitchen reviewed for environment. The facility failed to ensure the ceiling tiles did not have holes on Hall 100 from 6/29/2026 to 7/1/2026. The facility failed to ensure the baseboards were not detached in the shower room on hall 300 from 6/29/2026 to 7/1/2026. The facility failed to ensure the dining room in the secure unit had adequate lighting on 6/29/2026. The facility failed to ensure the ceiling tiles did not have holes in the kitchen by the food prep area on 7/1/2026. These failures could place the residents at risk of living in an unsafe and uncomfortable environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 Kitchen and 2 of 2 residents (Resident #4 and Resident #8) reviewed for pest control. The facility failed to ensure ants were kept out of the room and bed of Resident #8 on 6/28/2026 and 6/29/2026. The facility failed to ensure ants were kept out of the room of Resident #4 on 6/29/2026. The facility failed to ensure an effective pest control program was in place to keep roaches out of the kitchen on 7/1/2026. These failures could place residents at risk of injury due to an ineffective pest control program at the facility.

Inspectors wroteBased on interviews, and record reviews, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 (Resident # 3) residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NF specialized services in the LTC online portal within 20 business days after the date of the Interdisciplinary Team (IDT) meeting on 12/10/2025 when PT and OT were new services requested. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents' decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 (Resident #1) residents reviewed for supervision. The facility failed to ensure the secured unit, 800 hall, door alarm and door lock was functioning properly. On 10/30/2025 Resident #1 eloped from the facility and was found in the parking lot. An Immediate Jeopardy (IJ) situation was identified on 12/02/2025. While the IJ was removed on 12/03/2025, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 11 residents (Resident #1, Resident #2 and Resident #3) reviewed for abuse and neglect. 1. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/1/2025 when Resident #1 hit Resident #2 twice on the shoulder while cussing him. 2. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/10/2025 when Resident #1 hit Resident #2 on the lower legs while cussing him. 3. The facility failed to protect Resident #3 from abuse from Resident #1 on 11/25/2025 when Resident #1 hit Resident #3 on the right thigh with his fists. The reasonable person concept was applied in determining the psychosocial outcomes. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 entrances (south lobby entrance) and for the dining room chairs in 1 of 2 dining areas reviewed for environmental concerns. 1. The facility failed to ensure the lobby ceiling located at the south entrance (near the secured unit) was in good repair and did not leak water on 12/01/25, 12/02/25 and 12/03/25. 2. The facility failed to ensure the dining room chairs in Hall 900 (secured unit) were in good repair and without damage to the cushions. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when on 9/19/25 Resident # 3 hit Resident #1. The facility failed to protect Resident #5 from abuse when on 9/24/25 Resident # 4 grabbed, pulled, and scratched Resident #5's hand. The facility failed to protect Resident #2 from abuse when on 10/3/25 Resident #6 pushed Resident #2 to the ground, resulting in a lumbar vertebral fracture. The facility failed to protect Resident #1 from abuse when on 10/8/25 Resident #2 punched Resident #1 in the face causing a non-displaced nose fracture. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for abuse policies. 1. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 3 hit Resident #1, on 9/19/25. The facility did not report the incident to the state agency until 9/22/25. 2. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 4 scratched and held Resident #5's hand, on 9/24/25. The facility did not report the incident to the state agency until 9/26/25. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 6 of 11 residents (Residents #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse/neglect. 1. The facility failed to investigate abuse when Resident # 3 hit Resident #1, on 9/19/25. 2. The facility failed to investigate abuse when Resident # 4 grabbed, pulled, and scratched Resident #5's hand, on 9/24/25. 3. The facility failed to investigate abuse when Resident #6 pushed Resident #2 to the ground, on 10/3/25. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 9 resident hallways (Hallway 900 secured unit) and 2 of 3 entrances (north and south lobby entrance) reviewed for environmental concerns, in that:1. The facility failed to ensure the ceiling on the 900 hall was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.2. The facility failed to ensure the lobby ceiling located at the south entrance (near the secured unit) was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.3. The facility failed to ensure the lobby ceiling located at the north entrance was in good repair and did not have a hole and missing sheet rock exposing the frame and insulation on 10/20/25, 10/21/25 and 10/22/25. [...]

Inspectors wroteBased on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (Resident #4) of 6 residents reviewed for MDS transmission, in that: The facility failed to complete and transmit an Entry and Discharge MDS assessment for Resident #4 within 14 days of completion. These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 6 residents (Resident #4)reviewed for care plans . The facility failed to complete baseline care plans within 48 hours of admission for Residents #4. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to be free of abuse for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to prevent LVN A from physically abusing Resident #1 on 9/9/2025 witnessed by CNA B and CNA C. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator. The facility failed to report the allegation of abuse within 2 hours. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to in response to allegations of abuse, neglect, exploitation, or mistreatment, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 (Resident #1) residents reviewed for abuse. LVN A physically abused Resident #1 on 9/9/25 and the facility failed to protect residents from further potential abuse when LVN A returned to the facility on the night shift of 9/10/2025 after being suspended at 7:50 a.m. on 9/10/25. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the dietary manager, dietary aide and cook effectively wore a hair net to cover all hair. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled and dated. 3. The facility failed to ensure foods stored in the refrigerator were sealed or in a sealed container. 4. The facility failed to ensure 2 beverage dispensers located in the dining room were dated and labeled. These failures could place residents at risk of foodborne illness and food contamination. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #15) and 3 of 4 staff (CNA B, CNA C, and CNA D) reviewed for infection control. The facility failed to ensure CNA B sanitized her hands between the passing and setting up of residents' meal trays on 6/23/25. The facility failed to ensure CNA C and CNA D wore appropriate PPE for EBP during foley and incontinent care for Resident #15 on 6/24/25. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 9 resident hallways (Hallway 900 secured unit) reviewed for environmental concerns, in that: 1. The facility failed to ensure the secured unit common area, dining room, shower and the 900 hallway did not have soiled floors, soiled walls, chipped paint and holes in the sheetrock on 6/23/25. 2. The facility failed to ensure resident rooms 901, 902, 904, 906, 908, 909 and 910 did not have soiled floors, uncovered electrical outlets, broken faucets, broken paper towel dispensers and broken light covers on 6/23/25. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and home like environment for 1 of 2 dining rooms (the main dining room did not have adequate lighting) observed for environment. The facility failed to ensure there were adequate lighting in the main dining room. This failure could place the residents, who eat in the dining room at risk of injury, and a non-home like dining experience due to inadequate lightening.

Inspectors wroteBased on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #56) reviewed for assessments. The facility failed to reassess Resident #56 following a hospice admission (specific care for the sick or terminally ill) on 05/27/25. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Residents #21 and #2) in that: The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #21 and #2. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 3 resident's (Resident #40) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator for Resident #40 was clean, defrosted and did not contain unidentifiable food items in the freezer on 6/23/25. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 refrigerator in the facility kitchen. The facility failed to assure a refrigerator door latch adequately closed and sealed in the kitchen on 06/23/2025. These failures could affect residents who eat food from the kitchen placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 1 of 6 residents (Resident #12) reviewed for call lights. The facility failed to ensure Resident #12's bathroom call light pull string was not wrapped up and inaccessible from the floor on 06/23/2025. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the governing body failed to appoint an Administrator licensed by the state who was responsible for management of the facility for 1 of 1 facility reviewed for governing body. The governing body failed to designate a person in the role of an Administrator from 3/25/2025, through surveyor exit on 5/1/2025. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents had the right to be free from verbal abuse by staff for 2 (Resident #1 and Resident #2) of 10 residents reviewed for abuse. The facility failed to prevent verbal abuse by CNA A. On 3/3/2025 CNA A told Resident #1 She was stinky and needed to take a shower. The facility failed to prevent verbal abuse by the Cook. On 4/6/2025 the [NAME] cussed Resident #2 in a verbal altercation. This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the governing body failed to appoint an Administrator licensed by the state who was responsible for management of the facility for 1 of 1 facility reviewed for governing body. The governing body failed to designate a person in the role of an Administrator from December 13 2024, to February 12, 2025. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 8 residents reviewed for ADLs (Residents #6 and Resident #7) 1. The facility failed to give Resident #6 a bath as scheduled or clean/groom her fingernails. Resident #6 had long fingernails with a brown substance underneath them, her skin was dry, and she had unwanted facial hair on her chin on 3/5/2025. 2. The facility failed to give Resident #7 a bath as scheduled and remove unwanted facial hair on her chin on 3/5/2025. Thes failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity, and poor health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #6 and Resident #8) and 3 of 5 staff (Hospice Aide, CNA B, and CNA D) reviewed for infection control. Hospice aide failed to wear a gown while giving Resident #8, who was on enhanced barrier precautions, a bed bath, on 3/5/2025. CNA B and CNA D failed to wash or sanitize their hands before, during, and after performing incontinent care for Resident #6 and CNA B failed to change her gloves during care provided for Resident #6 on 3/5/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (Resident #1 and Resident #4) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 4/26/2024 when he climbed out of a window in the secured unit. The facility failed to keep Resident #2 in a safe environment to prevent an elopement on 8/23/2024 when he walked out an unlocked door in the secured unit. An Immediate Jeopardy (IJ) situation was identified on 12/10/2024 at 1:32 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 1 (Hall 400) of 4 hallways (Hall 100 and 300 and 400 hallways) and 11 of 11 (Residents #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for call light response. The facility failed to ensure hallway 400's call lights were visible and audible to staff. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 1 of 2 entrance foyers (foyer for 800/900 hallways) shower room on the 100 hallway, 300 hallway, 500 hallway and 800/900 hallways reviewed for physical environment. The facility failed to maintain the 800/900 foyer entrance ceiling. The facility failed to clean the 100 hall shower room and maintain the hall 100 shower room door. The facility failed to secure cleaning agents in the shower room on the 100 hallway. The facility failed to maintain walls, doors and doorways on the 300 hallway. The facility failed to secure nursing supply storage rooms on the 500 hallway and 800/900 hallway.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 16 residents (Resident #4 and Resident #5) observed for resident environment. The facility failed to ensure the baseboard in the room of Resident #4 and #5 was attached to the wall from 12/9/2024-12/11/2024. This failure could place residents at risk for an unsafe environment.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #3) reviewed for clinical records. The facility failed to ensure the medication administration records (MAR) for Resident #3 reflected discontinuation of medications on 10/09/2024 and non-administered medications when Resident #3 was out of the facility on 10/10/24 and 10/14/2024. This failure could place residents at risk of improper care due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to ensure LVN C did not reuse a single use suction catheter with Resident #1 on 10/31/24. The facility failed to ensure LVN C employed sterile technique during suctioning and tracheostomy care with Resident #1 on 10/31/24. The facility failed to ensure LVN C did not use tap water when performing tracheal suctioning for Resident #1 on 10/31/24. The facility failed to ensure LVN C used intermittent suctioning during care on 10/31/24. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 of 4 staff (CNA A, CNA B, LVN C, and LVN D) reviewed for competent nursing care. CNA A failed to clean Resident # 2's penis properly during incontinent care provided on 10/26/24. CNA A and CNA B failed to wear PPE for enhanced barrier precautions during incontinent care for Resident #2 on 10/26/24. LVN D failed to wear PPE for enhanced barrier precautions during wound care on Resident # 3 on 10/28/24. LVN C failed to utilize sterile technique when performing trach care and suctioning on Resident #1 on 10/31/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 2 hallways, 1 of 1 nurses station, 2 of 8 residents (Resident #1 and Resident #8), and 1 of 1 ice chest reviewed for pest control. The facility failed to ensure the 100 and 300 hallways and the common nurse's station between the 2 hallways were free of gnats and pests on 10/30/31 through 11/2/24. The facility failed to ensure Resident #8's room was free on gnats on 10/30/24. The facility failed to ensure the Ice Chest located at nurses' station for 100 and 300 hallway residents did not have a gnat inside it on 10/30/24. The facility failed to ensure Resident #1's room was free of gnats on 10/31/24. This failure could place residents at risk of a diminished quality of life due to an unsanitary environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infections prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident #2, and Resident #3) and 4 of 4 staff (CNA A, CNA B, LVN C, and LVN D) reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B wore appropriate PPE for enhanced barrier precautions when providing incontinent care to Resident #2 on 10/26/24. 2. The facility failed to ensure CNA B sanitized or washed her hands between glove changes while providing incontinent care to Resident #2 on 10/26/24. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 2 of 3 residents (Resident #1 and Resident #5) observed for care in that: The facility failed to ensure Resident #1's and Resident #5's urinary drainage bag (a bag at the end of an indwelling catheter that drains urine from the bladder) had a privacy cover in place on 10/26/24. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs (Residents #1 and Resident #6) 1. The facility failed to give Resident #6 a bath as scheduled or clean/groom his fingernails. Resident #6 had long, overgrown fingernails with skin buildup and a black substance underneath them and his skin was dry and scaly from 10/30/2024-11/1/2024. 2. The facility failed to give Resident #1 a bath as scheduled or clean/groom his fingernails. Resident #1 had long fingernails that had brown substance underneath them from 10/30/2024-11/1/2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated it was unavoidable and residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (Resident #6 and Resident #7) reviewed for pressure ulcers. The facility failed to ensure Resident's #6 and #7 received accurate and weekly skin assessments to prevent the development of or worsening of pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Resident #2 and Resident #5) reviewed for incontinent care and catheter care. The facility failed to ensure CNA A and CNA B properly cleaned the penis of Resident #2 during incontinent care. The facility failed to ensure Resident #5's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor her catheter. The facility failed to ensure Resident#5's urinary catheter drainage bag tubing did not touch the floor. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed. The Facility Assessment had not been updated since February 2023. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed orally, of their rights, for 8 of 8 residents interviewed during a group meeting. Resident #s #15, #16, #25, #29, #31, #40 and #303. Residents were not provided on going communication of their rights, during their stay in the facility. This failure could place the residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals reviewed for menus and nutritional adequacy. (Lunch meals 04/22/24, 04/23/24). Resident # 21 did not receive pureed bread on her lunch tray on 04/22/24. Incorrect utensils were used for serving food during lunch on 04/23/24 resulting in improper portion sizes. Cook A served the lunch meal on 04/23/24 in a haphazard manner inadequately filling the serving utensils with food and did not deliver the required amount of foods consistently. Pureed diets did not receive pureed bread during lunch on 04/23/24. Regular and mechanical diets received a half portion of bread during lunch on 04/23/34. These failures could place residents who eat foods from the kitchen at risk of not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. The microwave had food debris and splatters. The bulk flour bin had a measuring cup inside. The DM dropped a thermometer into the pureed meat and served the food. Cook A touched the inside of the plates and food with her gloved hands. She was not wearing an apron and used her body to keep the plates with food on the tray line. DA B touched the inside of the plates with her bare hand and placed bread on top of the food using her hand and not a utensil. Cook A returned food that had spilled onto the prep area to the pan of food on the steam table. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 2 of 12 residents reviewed for PASRR (Residents #33 and #35). The facility failed to ensure Residents #33 and Resident #35 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to post accurate daily information that included the total number and actual hours worked by registered nurses and licensed practical or licensed vocational nurses directly responsible for resident care per shift for the 6-2 shift on 3 of 3 days reviewed for posted nursing staff information. The facility did not post the accurate actual number and hours worked by registered nurses and licensed practical nurses directly responsible for resident care per shift on 04/22/2024, 04/23/2024, and 04/24/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to accurate information regarding staffing data.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received mail for 7 of 8 residents reviewed for rights to privacy and confidentiality. (Residents #1, #11, #15, #16, #34, #39 and #103) The facility did not implement a system for delivering mail on Saturdays. Residents #1, #11, #15, #16, #34, #39 and #103 said the mail was not delivered to them on Saturdays The facility failed to ensure mail was unopened when delivered to Residents #16 and #39. These failures could place the residents at risk of not receiving mail in a timely manner, the right to privacy and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 2 of 24 residents (Resident #24 and #49) reviewed for ADLs. Resident #24 missed 7 scheduled baths in February 2023. Resident #49 missed 8 scheduled baths in February 2023 These failures could cause all residents not to receive daily personal hygiene services and cause the resident to have health, social, and emotional issues.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 3 medication carts (nurse cart for locked unit) reviewed for pharmacy services. The facility did not dispose of expired insulin pens from the nurse medication cart for the locked unit. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.