Kimes Nursing and Rehab LLC

Inspectors wroteBased on closed medical record review, hospital documentation review, facility policy review, and interview, the facility failed to timely identify and obtain necessary medical intervention for Resident #160 following a fall. This resulted in Immediate Jeopardy and Actual Harm on 06/24/26 beginning at 4:00 P.M. when Resident #160 sustained an unwitnessed fall from bed. On 06/24/26 at approximately 6:00 P.M., Certified Nursing Assistant (CNA) #56 reported to Licensed Practical Nurse (LPN) #120 the resident appeared tired. No assessment was conducted, and Resident #160 was left to rest. On 06/24/26 at approximately 9:00 P.M., CNA #56 returned to the resident's room and notified LPN #120 Resident #160 appeared pale. On 06/25/26 at approximately 1:06 A.M., Resident #160's blood pressure was 80/51 mmHg (hypotensive) with a pulse of 52 beats per minute (bradycardic). [...]

Inspectors wroteBased on observation, record review, and interview, the governing body failed to ensure measures were in place to prevent the facility from being without a licensed nursing home administrator who had an active license to practice in the State of Ohio following the resignation of the previous administrator to maintain uninterrupted administrative oversight. This had the potential to affect all 60 residents residing at this facility.

Inspectors wroteBased on closed record review, hospital record review, interview, and facility policy review, the facility failed to investigate an injury of unknown origin when Resident #160 was found to have an abdominal wall hematoma and a closed fracture (fx) of the left fourth cervical vertebrae ( C-4 ). This affected one (Resident #160) of four residents reviewed for injury of unknown origin and change in condition. The facility census was 60.

Inspectors wroteBased on closed record review, fall investigation review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #160 and failed to ensure the resident was fully assessed and provided with timely, updated interventions to prevent additional falls from occurring. This affected one resident (Resident #160) of four residents reviewed for falls. The facility census was 60.

Inspectors wroteBased on closed medical record review, hospital record review, and interview, the facility failed to ensure therapy services were provided as ordered for Resident #160 upon admission. This affected one (Resident #160) of four residents reviewed for therapy services. The facility census was 60.

Inspectors wroteBased on record review, interview, observation, review of hospital records, and review of information from the National Library for Medicine, the facility failed to ensure residents with acute respiratory changes and decline in condition received comprehensive assessment and treatment in a timely manner. This affected two residents (#1,#21) of two residents reviewed for change in condition. The facility census was 56. Actual Harm occurred to Resident #21 on 05/04/26 when the resident was experiencing shortness of breath, had labored breathing, with oxygen levels desaturating into the 70's and 80's around 1:00 A.M. and Licensed Practical Nurse (LPN) #181 failed to complete a comprehensive assessment including checking vitals and lung sounds and failed to provide treatment to the resident. On 05/04/26 at 6:00 A.M. [...]

Inspectors wroteBased on review of employee personnel files, staff interview, and policy review, the facility failed to conduct thorough background checks of employees upon hire to ensure there were no findings of abuse, neglect, exploitation, or misappropriation of property. The facility failed to check the State nurse aide registry for findings of abuse for 30 employees hired since November 2025, failed to conduct an FBI background check for one nurse who had not lived in the the state for the past five years, and failed to check information from previous and/or current employers (reference checks) for 90 of 90 employees hired since November 2025. This affected 56 of 56 residents residing in the facility.

Inspectors wroteBased on review of schedules, director of nursing job description, Staffing Data Report, facility assessment, and interviews, the facility failed to ensure they had Registered Nurse (RN) coverage daily for eight consecutive hours. This had the potential to affect 56 of 56 residents who resided in the facility.

Inspectors wroteBased on review of personnel files, review of the director of nursing job description, and interviews, the facility failed to ensure annual nurse aide performance reviews were completed. This had the potential to affect 56 of 56 residents in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean/ sanitary environment in the dry storage room located in the facility's kitchen used for the storage of dry food goods. This had the potential to affect all residents residing in the facility. The facility's census was 56.

Inspectors wroteBased on record review, review of billing information, review of the facility assessment, review of the Administrator and Director of Nursing (DON) job descriptions, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently. This affected 56 of 56 residents residing in the facility. The facility census was 56.

Inspectors wroteBased on review of the facility assessment, policy and procedure, and interviews, the facility failed to maintain an adequate quality assurance and program improvement program. This affected 56 of 56 residents residing in the facility. The facility census was 56.

Inspectors wroteBased on record review, observations, staff interview, policy review, and review of Legionella prevention maintenance records, the facility failed to implement their infection prevention and control program (standard precautions, enhanced barrier precautions and Legionella prevention) to prevent the spread of infection. This affected three residents (#2, #21, #57) of 27 residents reviewed for infection control concerns and had the potential to affect all 56 residents residing in the facility.

Inspectors wroteBased on review of personnel files and interviews, the facility failed to ensure facility staff received a minimum of 12 hours of in-services per year. This affected 56 of 56 residents living in the facility.

Inspectors wroteBased on review of resident financial records, staff interview, and policy review, the facility failed to ensure residents had access to petty cash on an ongoing basis to include evenings and weekends. This could affect the seven residents whose personal funds were handled by the facility (#2, #6, #13, #25, #26, #27, and #43) of the seven residents reviewed for funds. The facility census was 56.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, to include the resident and resident representative and individuals who have knowledge of the resident and his/her needs, after each comprehensive and quarterly assessment. This affected four residents (#3, #5, #9, and #10) of 27 sampled residents reviewed for plans of care. The facility census was 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs including drugs used without adequate indication for use. This affected four residents (#7, #22, #53, #72) of five residents reviewed for unnecessary medications. The facility census was 56.1. Review of the record for Resident #7 revealed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, hypertension, anxiety disorder, morbid obesity, and status post pneumonia. Record review revealed a physician's order 05/04/26 for Prednisone ( a steroid medication) 40 milligrams in the morning for seven days for cold symptoms. Review of the medication administration record for May 2026 revealed the Prednisone 40 milligrams was given daily from 05/05/26 to 05/20/26 (16 days instead of 7). [...]

Inspectors wroteBased on observation, review of meal tickets, review of the facility's menu/ spreadsheet for specialty diets, review of diet orders, interview, and policy review, the facility failed to ensure all residents receiving a carbohydrate controlled diet (CCD) received the appropriate serving size of the dessert food item served during the lunch meal on 05/19/26. This affected two residents (Resident #58 and #65) and had the potential to affect 19 other residents (Resident #1, #3, #4, #5, #6, #13, #16, #21, #26, #27, #29, #31, #39, #40, #42, #50, #53, #56, and #57), who the facility identified as receiving a carbohydrate controlled diet.

Inspectors wroteBased on record review, interview, observations, and policy review, the facility failed to ensure documentation in the medical record was completed accurately to reflect residents' status. This affected four residents (#4, #5, #13, and #56) of 27 residents reviewed for accuracy of medical records. The facility census was 56.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident receiving an anti-depressant received education on the risks and benefits of taking that medication to allow them to provide informed consent. This affected one resident (#44) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on review of resident financial records, record review, staff interview, and family interview, the facility failed to maintain a system that assured a full and complete accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. This affected one resident (#25) of seven residents whose funds were handled by the facility. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident's medical provider was notified regarding change in condition. This affected two residents (#1 and #21) of two residents reviewed for change in condition. The facility census was 56.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure proper notices were given to residents when skilled services were ending. This affected three residents (#1, #4, and #69) of five residents reviewed for beneficiary notices. The facility census was 56.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the resident/resident representative was provided written notice, at the time of transfer for hospitalization, that specified the duration of the bed-hold policy. This affected one resident (#62) of one resident whose closed record was reviewed for hospitalization. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of vision/ corrective lenses and medications received during the assessment period. This affected three residents (#6, #7, and #44) of 27 residents reviewed for MDS assessments.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Pre-Assessment Screenings and Resident Reviews (PASARRs) were accurate and updated to reflect new mental health diagnoses. This affected three residents (#6, #40, and #53) of four residents reviewed for PASARRs. The facility census was 56.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident with known edema to her bilateral lower extremities (BLE) had a care plan developed to address her edema and another resident's care plan for being at risk for falls was implemented. This affected two residents (#28, #44) of 27 residents reviewed for care plans.

Inspectors wroteBased on record review, observations, interviews, and policy review, the facility failed to ensure residents requiring assistance with hygiene services received showers, facial hair removal, and nail care. This affected three residents (#13, #30, and #40) of five residents reviewed for activities of daily living (ADLs). The facility census was 56.

Inspectors wroteBased on record review, staff interview, resident interview, and contract review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision abilities by assisting with making appointments and/or arranging for transportation to and from practitioner's offices. This affected two residents (#7, #13) of three residents reviewed for communication/sensory impairment. The facility census was 56.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a resident, who was at risk for falls and had a history of falls, had their fall prevention interventions implemented as per their plan of care and failed to ensure facility staff who are knowledgeable of resident transfers attended an appointment with a resident. This affected two residents (#21, #44) of two residents reviewed for falls.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure residents received necessary respiratory care and services. This affected two residents (#21, #56) of four residents reviewed for respiratory care. The facility census was 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pharmacy recommendations that were generated from irregularities noted during residents' monthly medication regimen reviews were addressed and/ or responded to timely by the attending physician. This affected two residents (#6, #25) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure lab results were obtained as ordered. This affected one resident (#1) of one resident reviewed for low hemoglobin. The facility census was 56.

Inspectors wroteBased on record review, staff interview, policy review, and review of infection surveillance reports, the facility failed to implement the antibiotic stewardship program to ensure the appropriate use of antibiotics. This affected three residents (#22, #40, and #72) of 27 residents reviewed for infection control concerns. The facility census was 56.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to provide education for and then offer the influenza and pneumonia vaccines for a resident. This affected one resident (#6) of five residents reviewed for vaccines. The facility census was 56.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to provide education for then offer COVID-19 vaccines for a resident. The is affected one resident (#6) of five residents reviewed for vaccines. The facility census was 56.

Inspectors wroteBased on record review, review of an Emergency Medical Service (EMS) run report, review of the facility's incident and accident log for the past six months, review of a facility investigation, interview, and policy review, the facility failed to ensure Agency Licensed Practical Nurse (LPN) #100 followed proper medication administration procedures when preparing and administering medications to Resident #42 resulting in a significant medication error. This resulted in Immediate Jeopardy and Actual Harm on [DATE] at 8:23 P.M., when Resident #42 was erroneously given medications that included Xanax 2 milligrams (mg) by mouth (po), Oxycodone 10- 325 mg po, and Gabapentin 800 mg po during an evening medication administration pass that were physician ordered and intended for his roommate (Resident #15). [...]

Inspectors wroteBased on record review and interview, the facility failed to update the state agency regarding a change in administration. This affected all 59 residents residing in the facility. The facility census was 59.

Inspectors wroteBased on record review and interview, the facility failed to maintain and effective training program for staff. This affected all 59 residents residing in the facility. The facility census was 59.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident's change in condition was timely identified, properly correlated to a suspected medication error, and promptly reported to the physician for necessary medical intervention. This affected one resident (#42) of three residents reviewed for medication administration errors.

Inspectors wroteBased on record review, review of a grievance investigation, and interviews, the facility failed to ensure allegations of misappropriation were reported. This affected one resident (#10) of one resident reviewed for misappropriation. The facility census was 59.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure residents who were not able to carry out of activities of daily living independently were provided with showers. This affected three residents (#35, #53, and #62) of five residents reviewed for showers. The facility census was 59.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure wound care treatments were completed as ordered. This affected one resident (#62) of one resident reviewed for non-pressure wound care. The facility census was 59.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure residents, who were at risk for falls, had their fall prevention interventions implemented as per their plan of care. This affected two residents (#6 and #19) of three residents reviewed for falls.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure a staff nurse donned appropriate personal protective equipment (PPE) before entering the room of a resident in transmission based precautions for Covid-19. This affected one resident (#30) of two residents reviewed for medication administration pass.

Inspectors wroteBased on observations, staff interview, record review, and policy review, the facility failed to maintain an infection and prevention and control program designed to help prevent the development and transmission of communicable disease, including COVID-19. This affected 55 of 55 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure residents received showers per their preferred shower schedule. This affected three (#5, #8 and #47) of four residents reviewed for showers. The facility census was 54.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy review, the facility failed to ensure residents with pressure ulcers received appropriate and timely treatment and services to promote wound healing. This affected two (Residents #22 and #58) of three residents reviewed for pressure ulcers. The facility census was 55 residents.

Inspectors wroteBased on record review, staff interviews, review of the facility Self-Reported Incident, review of facility witness statements, and review of facility policy, the facility failed to ensure an allegation of physical abuse was reported timely and appropriately. This affected one resident (#39) of the three residents reviewed for abuse during the complaint survey. The facility census was 55.

Inspectors wroteBased on review of medical records, resident vaccination consent forms and staff interview the facility failed to offer each resident a pneumococcal immunization. This affected four (Residents #10, #36, #37 and #46) of five residents sampled for influenza, pneumococcal and COVID-19 immunization review. The census was 51.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident and or their resident representative was provided a bed-hold notice as required, when the resident was transferred out to the hospital. This affected one (Resident #32) of two residents reviewed for hospitalization. The facility census was 51.

Inspectors wroteBased on staff interview and record review the facility failed to to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected one (Resident #4) of one resident reviewed for PASARR documents. The census was 51.

Inspectors wroteBased on staff interview, and record review the facility failed to develop comprehensive care plans for Resident #36's anticoagulant use and Resident #10's anxiety care plan was not specific and patient centered. This affected two (Resident #10, and #36) of 20 residents reviewed for care plans. The facility census was 51.

Inspectors wroteBased on record review and interview, the facility failed to ensure hospice records were available for continuity of care for one resident. This affected one (Resident #109) of one resident reviewed for hospice. Additionally, the facility failed to ensure compression stockings were applied as physician ordered. This affected one resident (#32) of one resident reviewed for edema. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's comprehensive admission assessment dated [DATE] revealed the resident had a severe cognitive deficit. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician ordered pressure reduction devices were implemented as ordered. This affected two residents (#45 and #109) of four residents reviewed for pressure ulcers. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's admission nursing assessment dated [DATE] revealed the resident was admitted to the facility with a stage I pressure ulcer to the right outer ankle measuring 2.0 centimeters (cm) by 2.0 cm. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the plan of care for residents who were at risk for and/ or had a history of falls. This affected two (Resident #33 and #38) of four residents reviewed for falls. The census was 51.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one resident (#37) identified by the facility as having PTSD/trauma. The facility census was 51.

Inspectors wroteBased on observation, record review, policy review, and staff interview the facility failed to follow infection prevention guidelines when they failed to wear appropriate personal protective equipment for enhance barrier precautions when doing would care for Resident #36. This affected one (Resident #36) of five residents reviewed for infection control. The facility census was 51.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (#21) was not treated with an antibiotic prior to the return of the culture and sensitivity (C&S) results. This affected one (Resident #21) of two residents reviewed for urinary tract infection (UTI). The facility census was 51. Findings Include: Review of the medical record for Resident #21 revealed an initial admission date of 02/13/23 with the latest readmission date of 04/07/23 with the diagnoses including but not limited to neurocognitive disorder with Lewy bodies, repeated falls, anxiety disorder, dementia, Alzheimer's disease, mood disorder, hypertension, osteoarthritis, metabolic encephalopathy and osteoporosis. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to serve food in a safe and sanitary manner. This affected 46 of 46 residents who utilized the kitchen for meals (Resident #249 received nothing by mouth). The census was 47. Findings Include: Observation on 07/06/23 at 12:36 P.M. revealed [NAME] #163 touching the cornbread from the pan three times with gloves and placed them on the meal plates. Also, she touched one breaded pork chop with the same gloved hand and placed it on the meal plate. In between touching the cornbread and pork chop with the same gloved hands, she touched the counter top, drawer handle for utensils, three different food utensils, multiple plates, and the plate warmer lid to lift it up. Observation on 07/06/23 at 12:44 P.M. revealed [NAME] #163 touching four pork chops with her gloved hand. [...]

Inspectors wroteBased on review of infection control records and infection control policies and procedures review the facility failed to appropriately monitor resident infections as per infection control policy and procedures for the month of July, August and September of 2022. In addition the facility failed to implement and perform their Legionella Precautionary Maintenance and Inspections per their Legionella Water Management Program. This affected all residents in the facility. The census was 47. Findings Include: 1. Review of the the facility monthly infection control logs from 07/2022 to 07/2023 revealed for the months of 07/2022, 08/2022 and 09/2022 the monthly infection control log form did not include the resident symptoms, indicate if the resident had a chest x-ray or culture done with results , any type of necessary treatments and if the resident required Isolation. [...]

Inspectors wroteBased on record review, review of the facility's shower schedule, resident interview, staff interview, and policy review, the facility failed to ensure a resident's frequency in which they were showered was honored in accordance with their preference. This affected one (Resident #10) of one residents reviewed for choices.

Inspectors wroteBased on record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure a thorough investigation was competed for an alleged allegation of abuse. This had the potential to affect all 47 residents residing in the facility and specifically affected Resident #39. Findings Included: Review of the SRI dated 04/01/23 revealed Resident #39 reported Licensed Practical Nurse (LPN) #210, the agency nurse who worked through the night threw something and hit her in the nose with it and woke her up. The SRI indicated the resident was alert and oriented and was emotionally distressed at the moment, but no physical injuries were present. The Administrator immediately reported LPN #210 to the agency and banned the nurse from returning to the facility in any role. [...]

Inspectors wroteBased on record review ,staff interview, policy and procedure review the facility failed to issue a bed hold notification letter to one resident (#47) out of one resident reviewed for hospitalizations. The census was 47. Findings Include: Review of Resident #47's medical record revealed an admission date of 4/28/23 with no cognitive deficits. Diagnoses include atherosclerosis, muscle weakness, surgical aftercare following surgery on the circulatory system, and atherosclerotic heart disease of natives coronary artery without angina pector. Resident #47 was discharged on 05/18/23 to the hospital. Review of Resident #47's medical record nurses progress notes from 05/01/23 to 05/18/23 confirmed resident was discharged to the hospital on [DATE] with no bed hold notification given. Interview on 07/05/23 at 4:09 P.M. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete comprehensive assessments as required. This affected three (Residents #9, #250, and #40) of 17 resident assessments reviewed. The census was 47. Findings Include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, Alzheimer's disease, repeated falls, cognitive communication deficit, muscle weakness, heart failure, generalized anxiety disorder, congestive heart failure, osteoporosis, cerebrovascular disease, kyphosis, anemia, osteoarthritis, atherosclerosis, anemia, chronic kidney disease, major depressive disorder, dermatitis, insomnia, disorder of thyroid, hypertension, delirium, atrial fibrillation, hyperlipidemia, dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 02/22/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Record review revealed Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident's (#40) hospice continuity of care. This affected one of one resident reviewed for hospice. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 02/22/23 with the admitting diagnoses including Alzheimer's disease, anxiety disorder, restlessness and agitation, chronic obstructive pulmonary disease, diabetes mellitus, anemia, insomnia, peripheral vascular disease, chronic kidney disease, hyperlipidemia and depression. Review of the resident's clinical admission assessment dated [DATE] indicated the resident was admitted to the facility with hospice services. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received hospice services. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the physician ordered off-loading to one resident's (#15) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident reviewed for pressure ulcers. Findings Included: Review of the medical record for Resident #15 revealed an initial admission date of 08/12/21 with the diagnoses including dementia, altered mental status, adult failure to thrive, nonrheumatic aortic valve insufficiency, cardiac murmur, generalized muscle weakness, schizoaffective disorder, metabolic encephalopathy, dysphagia, hypertension, disorder of kidney and ureter, gastro-esophageal reflux disease, insomnia and presence of cardiac pacemaker. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for a resident with a known history of falls and considered to be at risk for falls. This affected one (Resident #2) of two residents reviewed for accidents.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean, sanitary homelike environment. This affected one (#40) of 15 sampled residents. Findings Included: On 07/03/23 at 9:57 A.M., observation of Resident #40's room revealed a strong odor of urine. The resident's bed side chair had peeling leather and a rip in the cushion. The resident's wall behind the headboard was also marred. On 07/05/23 at 1:20 P.M., observation of Resident #40 revealed the resident was quiet at bedrest with eyes closed. No signs of incontinence noted, however the resident's room continued to have a strong odor of urine. On 07/05/23 at 10:45 A.M., interview with Registered Nurse (RN) #142 verified the resident's room had a persistent strong odor of urine and the disrepair of the chair and wall. [...]