Kittanning Health & Rehab Center

Inspectors wroteBased on review of facility policy, clinical record review, resident interview, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of six residents reviewed (Resident R31, and R53) which resulted in actual harm (a medication overdose that caused unresponsiveness and required the administration of Narcan- a medication used to reverse overdoses of opioids [pain medication with a high risk of addiction] that is administered via a nasal spray) for Resident R31.

Inspectors wroteBased on review of facility documents, and 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 of eleven of 16 residents (Group Resident (GR)1, GR2, GR3, GR4, GR5, GR6, GR7, GR8, and GR9, R51, and R88). Findings Include: Review of Payroll Based Journal (PBJ- a mandatory reporting system for nursing homes in which staffing information is reported on a quarterly basis) dated 1/1/25, through 3/31/25, indicated that the facility has a one star rating out of five stars, and that they have excessively low weekend staffing. Review of PBJ dated 7/1/25 through 9/30/25, indicated that the facility has a one star rating out of five stars, and that they have excessively low weekend staffing. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews it was determined that the facility failed to ensure that fit testing of NIOSH-approved N-95 masks (a respirator mask used to care for residents with suspected or confirmed Covid-19) was completed to care for residents with suspected or confirmed Covid-19 (an infectious disease caused by a virus) during an outbreak in order to prevent the transmission of communicable diseases and infections during a COVID-19 outbreak from 12/29/25 through 1/9/26, and failed to properly monitor residents refrigerator temperatures for one of two residents (Resident R88).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Common Room and Memory Impaired Unit) and two of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Common Room and Main Dining Room).

Inspectors wroteBased on clinical record review and family and staff interview, it was determined that the facility failed to provide quarterly resident trust fund statements for four of four sampled residents (Residents R11, R31, R80, and Residents R88).

Inspectors wroteBased on review of facility policy, closed clinical 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 three out of three closed resident records (Closed Resident records CR110, CR111, and CR112).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Resident R13, R36, and R100).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure a physician response for medication regimen reviews (MRR) for four of six sampled resident records (Resident R2, R5, R9, and R71).

Inspectors wroteBased on review of facility in-service documentation, personnel files, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for three out of five personnel files reviewed (Licensed Practical Nurse (LPN) Employee E10, Nurse Aide (NA) Employee E11, and LPN Employee E12).

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R77).

Inspectors wroteBased on review of clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents reviewed (Resident R99).

Inspectors wroteBased on a review of facility policy, facility documents, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of two residents (Resident R88).

Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of five residents (Resident R2 and R9).

Inspectors wroteBased on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for one of five personnel files reviewed (Licensed Practical Nurse (LPN) Employee E9).

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an incident of neglect for two of five residents (Resident R71, and R88).

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, including bed hold policy for two of four residents sampled with facility-initiated transfers (Residents R1 and R5).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide care and treatment as ordered by physician for one of three residents (Residents R71).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of two residents (Resident R10). Review of facility policy Splint Issuance Policy dated 6/18/25, indicated that the patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to make certain each resident received adequate supervision which resulted in a resident ingesting a skin cleanser for one of four residents (Resident R71).

Inspectors wroteBased on review of facility policy, resident clinical record, and staff interview, it was determined that the facility failed to maintain a complete record of pre and post dialysis assessments for one out of three sampled resident records (Resident R11).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for two of five nurse aide (NA) personnel records (NA Employees E11 and E19).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being as required (Resident R99).

Inspectors wroteBased on review of facility policy, clinical documentation and staff interview it was determined that the facility failed to provide sufficient and timely social services to one of three residents reviewed (Resident R99).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one of six residents (Resident R71).

Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of five residents (Resident R2).

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 two of four quarters (January 2025 through March 2025 and July 2025 through September 2025).

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 the COVID-19 (a respiratory disease) vaccine for two of five residents (Resident R83, and R95).

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 one of five NA personnel records (NA Employee E11).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was available at the beginning of each shift.

Inspectors wroteBased on review of facility policy, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on two of two medication carts reviewed (Unit One Medication Cart and Unti 2B Medication Cart) and failed to ensure accurate administration of medications, resulting in a medication error for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of three residents reviewed (Residents R1 and R2).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies, documentation, observations, resident and staff interviews and state and federal guidance it was determined that the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance for 95-101 residents from 11/29/24, through 1/15/25. The facility failed to adhere to state return to work guidance for staff. These failures placed all residents in the facility in an Immediate Jeopardy situation. [...]

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store, label and date food products in the Main Kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Storge of Refrigerated Foods last reviewed 1/12/25, and previously reviewed 1/2/24, indicated that employee lunches shall not be stored in dietary refrigerators. During an observation in the Main Kitchen Back Reach-in Cooler, on 1/12/25, at 9:35 a.m. an opened bottle of Pepsi, and an opened bottle of Dr. Pepper were observed with no name, or date. During an observation in the Main Kitchen Walk-in Freezer, on 1/12/25, at 9:37 a.m. an opened bag of mixed vegetables and an opened package of sausage patties had no date or label. During an observation in the Main Kitchen Dry Storage, on 1/12/25, at 9:45 a.m. [...]

Inspectors wroteBased on 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 three of three residents with facility-initiated transfers (Resident R21, R30, and R78).

Inspectors wroteBased on review of facility policy, clinical records, 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 three of three resident hospital transfers or therapeutic leave of absence (Resident R21, R30 and R78). Findings Include: Review of the facility policy Bed Hold Notice dated 1/12/25, and previously dated 1/2/24, indicated that the bed hold policy will be provided to residents at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 hours. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed for three of three residents reviewed (Resident R4, R26, and R78).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to properly store medications in two out of two medications carts (2B and Unit 1 Medication Carts) and failed to properly store a medication on one of two medication rooms (Unit Medication Room).

Inspectors wroteBased on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of four residents (Resident R21, R87, and R199)

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for one of six residents as required (Resident R4).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of two residents (Resident R87).

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three sampled residents (Resident R47).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of abuse in the required timeframe one of four residents (Resident R80).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R30).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of four residents (Resident R4).

Inspectors wroteBased on a review of facility policy and documents, resident interviews, 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 four of five weeks (12/10/24 through 12/21/24, and 12/26/24 through 1/16/25).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to monitor and ensure proper treatment of resident wounds and complete weekly skin assessments for two of four (Resident R4, and Resident R199).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment and monitoring for pressure ulcers for two of three sampled residents (Residents R1 and R199). The facility Pressure injury prevention and treatment policy dated 1/2/24, and last reviewed 1/12/25, indicated that residents will be assessed for pressure injury risk on admission. Monitoring will be at least weekly, and an evaluation of the pressure ulcer/pressure injury will be documented. All assessments will include location/stage, size, pain, wound bed and appearance. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, resident interview, review of clinical records and staff interview, it was determined that the facility failed to assess residents for smoking safety for one of two residents (Resident R52).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview, it was determined the facility failed ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident receiving hemodialysis (Resident R45).

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for one of nine residents reviewed (Residents R86) and failed to ensure a physician completed the initial visit for one of nine residents (Resident R201).

Inspectors wroteBased on review of facility policy, controlled drug shift count record, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs for one of three closed record residents reviewed (Closed Record (CR) Resident R96).

Inspectors wroteBased on facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of four residents (Residents R4 and R78) and failed to identify a diagnosed specific condition for treatment for one of four residents receiving psychotropic medications (Resident R78).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent for two of five residents (Resident R24, and R47).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R46).

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 the required committee members for one of four quarters (January 2024 through March 2024).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for bed mobility for three of four residents (Resident R2, R3, and R4).

Inspectors wroteBased on review of facility policy, clinical record, and staff interviews, it was determined that the facility failed to provide adequate assistance for bed mobility for one of four residents (Resident R1), which resulted in the resident falling out of bed and sustaining a 1.5 centimeter laceration to the upper cheekbone.

Inspectors wroteBased on review of facility policy, resident interviews, resident representative concern, and facility documents, it was determined that the facility failed to provide a clean and homelike environment on two of three nursing units (Unit 1 and Unit 2).

Inspectors wroteBased on review of facility policy, resident grievances for 90 days, and resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for four of seven grievances reviewed.

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required timeframe one of four residents (Resident R1).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of four residents (Resident R1).

Inspectors wroteBased on a review of facility policy, facility documents, a resident interview, resident representative concern, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for two meals. (Lunch 8/18/24, and Breakfast 10/1/24)

Inspectors wroteBased on review of facility policies and documentation, observations, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak. The facility failed to perform contact tracing and testing per PA DOH guidelines and cohorted (an infection prevention and control strategy of grouping residents together who are identified with the same organism to confine their care to one area and prevent contact and spread to other residents) residents who were positive for COVID-19 with residents who were not tested and did not have symptoms of COVID-19. [...]

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 effectively manage the facility to prevent the development and transmission of a communicable infection.

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R2).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of three residents (Resident R37).

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 three residents (Resident R38).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, facility tour, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 11 residents (Resident R38).

Inspectors wroteBased on review of 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 influenza vaccination for one of five residents (Resident R36).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview it was determined that the facility failed to notify families of residents with positive COVID-19 (a contagious disease caused by a virus) test results in a timely manner for two of five COVID-19 positive residents (Residents R3, and R37.)

Inspectors wroteBased on review of 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 vaccination for one of five residents (Resident R36).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of verbal abuse for four of four residents (Residents R2, R3, R4, and R5).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of verbal abuse for four of four residents (Residents R2, R3, R4, and R5).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations of resident areas and nursing units, resident council interview and staff interviews it was determined that the facility failed to make certain anonymous grievance forms were readily accessible for residents use throughout the facility for three out of three nursing units (100 unit, 200 unit, the Memory Impaired Unit).

Inspectors wroteBased on review of clinical records, facility policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for three out of 12 months.

Inspectors wroteBased on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on review of facility policy, observations, resident council interview, and staff interview, it was determine that the facility failed to provide an active director for the Activities department for three out of 12 months (November 2023, December 2023, and January 2023).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to label/date opened medications on three of three medication carts (Medication Cart A, Medication Cart B, and the Memory Impaired Unit (MIU) Medication Cart). The facility failed to make certain that out-of-date medications were disposed of on one of three medication carts (Medication Cart B). The facility failed to secure controlled substances stored in the refrigerator utilizing double locks in one of two medication rooms (Unit 2A/2B Medication Room).

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 one of four quarterly meeting (October 2023 through December 2023). Findings Include: The facility Quality Assurance and performance improvement program policy dated 3/17/23, and last reviewed on 1/2/24, indicated that the facility will maintain a QAPI committee consisting of the administrator, Director of nursing, Medical director, infection preventionist. The committee will meet on a regular basis, at least quarterly, to coordinate and evluate activities. [...]

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R238) and the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for five of 12 months (May 2023, June 2023, August 2023, September 2023, and October 2023).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for five of twelve months (May 2023, June 2023, August 2023, September 2023, and October 2023).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) for one of three sampled resident records (Closed Resident Record CR7)

Inspectors wroteBased on review of facility policy, observations, resident council interview, and staff interview, it was determine that the facility failed to provide scheduled activities on one of three nursing units (Memory impaired unit-MIU).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for one of three residents (Resident R13).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for one of three residents with a urinary catheter (Resident R71).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weights were monitored, and that weight loss was identified and addressed in a timely manner for two of five residents (Resident R21, and R38).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who were receiving enteral feedings (nutrition through a tube) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R71).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of one residents receiving dialysis (Resident R39).

Inspectors wroteBased on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to protect one of five residents (Resident R1) from neglect who was left unassessed after identification of a change in condition.

Inspectors wroteBased on review of facility policy, documents, and clinical records and staff interviews, it was determined that the facility failed to make certain that residents were free from physical abuse, and verbal abuse for four of 74 residents (Resident R1, R2, R3, and R4). This has been identified as past noncompliance.

Inspectors wroteBased on review of facility policy, facility documents, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate allegations of physical and verbal abuse for three of 74 residents (Resident R1, R2, and R3). This has been identified as past noncompliance.