Lakeside Health and Wellness

Inspectors wroteBased on observation, interview and record review the facility failed to ensures a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary infections and to restore continence to the extent possible for 1 of 2 residents (Resident #10) reviewed for incontinent care. The facility failed to ensure Resident #10's catheter was secured to his leg and CNA T and LVN B properly cleaned the perineal/genital areas for Resident #10 during incontinent care for a catheter. This failure could place residents at risk for urinary tract infections and trauma. [...]

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 for 4of 6 residents (Residents #79, #28, #41 and #61) reviewed for accidents. 1. The facility failed to ensure 2 staff were utilized for bed mobility for Resident #79 on 01/19/26 and 01/20/26. 2. The facility failed to ensure Resident #28's disposable razor, shaving cream, and 3 bottles of liquid air freshener were not stored at the bedside. 3. The facility failed to ensure shaving cream was not stored in Residents #41and #61's bathroom. These failures could place residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 5 residents (Resident #1, Resident #10, and Resident #56) reviewed for pharmacy services. 1. The facility failed to ensure there was not a delay in administering Resident #1's Debrox (medication that softens and loosens ear wax to make it easier to remove), after it was ordered on 01/16/2026. 2. The facility failed to ensure Resident #56 received 2 puffs of Combivent (medication used to treat/prevent wheezing and shortness of breath) as ordered by the physician on 01/20/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for meal service. The facility failed to ensure [NAME] R followed the recipe for preparing ham for lunch on 01/19/26. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 16 of 23 residents (Residents #64, #8, #50, #9, and 12 anonymous) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide palatable food served at an appetizing temperature or taste for Residents #64, #8, #50, #9, and 12 anonymous residents, who complained the food served was cold and bland. The dietary staff failed to provide food that was palatable for the lunch meal observed on 01/20/26. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

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 for 1 of 1 ice machine reviewed for kitchen sanitation. The facility failed to ensure the ice machine, stored in the kitchen area, was free from black and brown substances at the bottom of the bucket on 01/19/26. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure complete and accurate documentation for 2 of 3 residents reviewed for medical records. (Resident #10, Resident #11.)The facility failed to ensure accurate and complete documentation was entered for Resident #10, Resident #11 related to wound care. This failure could place residents at risk for inaccuracy of clinical records and decreased continuity of resident care.1. Record review of Resident #10's face sheet, dated 01/20/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 5 of 6 residents (Resident #4, Resident #8, Resident #10, Resident #67, and Resident #79) reviewed for infection control. 1. The facility failed to ensure CNA E followed enhanced barrier precautions and performed proper glove while providing incontinent care to Resident #67 on 01/20/2026. 2. The facility failed to ensure CNA E did not handle linens with blood on them without gloves on 01/20/2026. 3. The facility failed to ensure CNA H performed hand hygiene while providing incontinent care for Resident #79 on 01/19/26. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protecting and promoting the rights of the resident for 1 of 5 residents (Resident #10) reviewed for resident rights. The facility failed to ensure CNA T spoke in a manner of dignity to Resident #10These failures could place residents at risk of embarrassment, isolation, and diminished quality of life. Findings Include: Record review of Resident #10 face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had a right to secure confidential and personal medical records and privacy during medical treatments for 2 of 24 residents (Residents #28, and #10) reviewed for resident rights. 1. The facility did not ensure RN G used a secure telephonic device to communicate with the facility NP. 2. The facility failed to ensure CNA T and LVN B provided privacy when providing incontinent care to Resident #10. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #10) reviewed for unnecessary psychotropic drugs. The facility failed to ensure Resident #10's GDR, dated 12-25, was completed after pharmacy recommended a dose reduction. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Record review of Resident #10 face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 5 residents (Resident #3 and Resident #68) reviewed for accuracy of MDS assessments. 1) The facility failed to ensure Resident #3's MDS accurately reflected the resident was PASRR positive for mental illness. 2) The facility failed to ensure Resident's #68's MDS accurately reflected PASRR positive for mental illness. These failures could place residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were coordinated with Preadmission Screening and Resident Review (PASRR) program under Medicated in subpart C to the maximum extent practicable to avoid duplicative testing and effort and coordination included incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 8 residents (Resident #41) reviewed for PASRR.The facility did not ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Resident #41 who had a diagnosis of mental illness upon admission. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received proper treatment devices to maintain vision and hearing abilities, and if necessary, assisted the residents in making appointments for 1 of 2 residents (Resident #61) reviewed for hearing devices. The facility did not ensure an appointment for an audiologist (healthcare professional specialized in hearing) for Resident #61 after she reported missing hearing aids. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences for 1 of 2 residents (Resident #41) reviewed for oxygen therapy. The facility failed to ensure Resident #41's oxygen concentrator filter was cleaned. This failure could place residents at risk for developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 24 residents (Resident #41) reviewed for (DRR) Drug Regimen Review. The facility failed to timely implement Resident #41's signed Pharmacist Recommendation to Physician on 05/08/2025, which agreed with the pharmacy recommendation to discontinue Mag-Oxide 400 mg QAM (supplement). This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 4 medication carts (200 hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure one vial of albuterol sulfate 2.5 mg/3ml (medication used for breathing treatments) and a tube of diclofenac topical gel 1% (medicated gel applied on the skin to decrease pain/inflammation) were stored properly, when they were left on top of the 200 hall Nurse Medication Cart unattended on 01/21/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs for 1 of 2 (Resident #61) residents reviewed for dental services. The facility did not ensure Resident #61 was provided with routine dental services related to dentures in a timely manner. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 4 residents reviewed for personal food safety. (Residents #3 and Resident #52)The facility failed to ensure Residents #3's and Residents #52's personal refrigerator temperature logs were properly checked and documented. This failure could place the residents at risk for food borne illnesses.

Inspectors wroteBased on interviews and record review the facility failed to protect the resident's right to be free from verbal abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA D was observed standing over resident, loudly talking and telling Resident #1 you tripping in response to resident's statements on 03/01/2025. This failure could place residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life and abuse. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 4 residents (Resident #2) reviewed for misappropriation and exploitation, in that:The facility failed to ensure that Resident #2 was not subject to financial misappropriation or exploitation from CNA C. CNA C purchased personal items with the monies of Resident #2 in the amount of $230.83 during an outing to a local store without the permission of Resident #2. This failure had the potential to affect the residents in the facility by placing them at risk for decreased quality of life, feelings of loss and misappropriation of property. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 4 Residents (Resident #3) whose records were reviewed for care plan revision/timing, in that: The care plan of Residents #3 was not updated to reflect a pureed diet. This deficient practice could affect any resident and contribute to residents not receiving the care and services they need.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #4) of four residents reviewed for physician orders for treatments. The facility failed to follow physician orders and remove Resident #4's staples to back of head on 11/13/25, five days after insertion during an ER visit on 11/8/25 per physicians' orders. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 6 residents reviewed for respiratory care (Resident #6). The facility failed to ensure Resident #6's oxygen tubing and water were changed out and dated. The facility failed to ensure Resident #6 had an order for her oxygen. The facility failed to have an order in place to ensure Resident #6's oxygen tubing and water were changed and dated, and the filter cleaning was completed weekly on Sundays. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 3 residents (Resident 30) reviewed for urinary catheters. The facility failed to properly anchor Resident #30's foley catheter to prevent pulling and tension of the foley catheter tubing which resulted in a tear in his penis 3.5 cm in length and an ER visit on [DATE]. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #22, and Resident #15) reviewed for pharmacy services. The facility failed to ensure MA V accurately reconciled Resident #8's narcotic medication log when she administered Resident #8's morphine (controlled medication used for pain) tablet on 10/15/24. The facility failed to ensure MA V accurately reconciled Resident #22's narcotic medication log when she administered Resident 22's pregabalin (controlled medication used to treat pain caused by nerve damage) tablet on 10/15/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.75%, based on 12 errors out of 64 opportunities, which involved 2 of 7 residents (Resident #18 and Resident #57) reviewed for medication administration. The facility failed to ensure LVN W administered Resident #57's scheduled morning medications as prescribed on 10/15/24. The facility failed to ensure MA X administered Resident #18's multivitamin with minerals and Reglan as prescribed on 10/15/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 23 residents (Resident's #6, #14, and #39) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #6, Resident #14, and Resident #39, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

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 safety in the facility's only kitchen. 1. The facility failed to ensure hair restraints were worn appropriately by dietary staff. 2. The facility failed to ensure the dishwasher was in correct temperature range of 120 during wash cycle. 3. The facility failed to ensure chemical test strips were used for dishwasher. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 5 residents (Resident #43 and Resident #176) and 2 of 4 clean linen carts (Hall 300 and Hall 400 clean linen carts) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure the MDS Coordinator applied PPE prior to flushing Resident #176's PICC line on 10/16/2024 2. The facility failed to ensure CNA M changed her gloves and performed hand hygiene and did not touch the wipes container with dirty gloves while providing incontinent care to Resident #43 on 10/14/2024. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 23 residents reviewed for advanced directives. (Residents #66 and #225) 1. The facility failed to ensure Resident #66's OOH-DNR was completed accurately. 2. The facility did not ensure Resident #225 had a physician order for her preferred code status. 3. The facility did not ensure Resident #225's code status was readily available to facility staff. These failures placed the residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #22) of 23 residents reviewed for privacy and confidentiality. The facility failed to ensure MA R closed Resident #22's EMR before entering the supply room and leaving the medication cart unattended. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.

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 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to ensure RN N did not verbally abuse Resident #233 on 09/21/2024. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #233) reviewed for abuse. The facility failed to implement their policy on reporting abuse when CNA H did not immediately report RN N's verbal abuse towards Resident #233 on 09/21/2024. The facility failed to follow its policy when RN N did not complete abuse training. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 23 residents (Resident #233) reviewed for abuse reporting. The facility failed to ensure CNA H immediately reported RN N's verbal abuse towards Resident #233 on 09/21/2024 to the abuse coordinator or designee. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement the baseline care plan that included the minimum healthcare information necessary to properly care for a resident including, but not limited to - initial goals based on admission orders and physician orders for 1 of 4 (Resident #225) residents reviewed for baseline care plans. The facility did not ensure Resident #225's preferred code status was addressed on the baseline care plan. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #224) The facility failed to ensure Resident #224 was assisted with facial hair removal. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for the facility's only resident with an enteral device (Resident #57). The facility failed to ensure LVN W checked Resident #57's gastrostomy placement (placement of the tube used for nutrition and medication administration) as ordered by the physician on 10/15/24. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 3 residents (Residents #43 and Resident #56) reviewed for respiratory care. 1. The facility failed to ensure Resident #56's oxygen concentrator was set at 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to ensure Resident #43's oxygen concentrator was clean. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for pharmacy services. (Resident #57) The facility failed to ensure LVN W did not prepare to and attempt to administer Resident #57's metoprolol (blood pressure medication) his blood pressure was low on 10/15/24. The facility failed to ensure LVN W prepared and attempt to administer Resident #57's Eliquis (anticoagulant medication) on 10/15/24. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wrote2. During an observation and interview on 10/16/24 at 4:28 PM, the MDS Coordinator entered Resident #176's room to flush her PICC line. The MDS Coordinator completed the procedure and went to the treatment cart to obtain disinfectant wipes to clean Resident #176's bedside table. The MDS Coordinator did not lock the treatment cart when she went back inside Resident #176's room to disinfect Resident #176's bedside table and wash her hands. The MDS Coordinator said it was her responsibility to lock the carts when leaving them unattended because residents could get in and get medications. Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 6 medication carts (treatment cart, 300-400 hall medication cart, and 100-200 nurses' cart) reviewed for pharmacy services. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 of 6 (RN N) employees reviewed for staff training. The facility failed to ensure RN N received abuse training. This failure could place residents at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. 1. The facility failed to ensure Resident # 1, was free from physical abuse on 04/03/2024, when CNA A used excessive rubbing force across Resident #1's chest while providing a shower which resulted in a 5 cm superficial laceration (cut or tear in the skin) across her chest at the level of the 2-3rd rib with surrounding ecchymosis (bruising), tenderness, and closed fractures of the 2nd and 3rd rib. 2. The facility failed to protect Resident #1 by not ensuring CNA A did not continue to provide care to Resident #1 after the shower room incident on 04/03/2024. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/03/2024 and ended on 04/04/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to implement their abuse polices by not ensuring CNA A did not continue to provide care to Resident #1 after CNA physically abused Resident #1 in the shower room on 04/03/2024. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 3 of 6 residents reviewed for pharmacy services. (Resident #2, Resident #3, Resident #4) 1. The facility failed to ensure Resident #2 was administered her Nifedipine (medication to treat high blood pressure and chest pain) on 4/12/24 when it was available in the facility's emergency kit. 2. The facility failed to ensure MA D administered Resident #3 only her ordered medication and did not administer Trazodone (anti-depressant medication) and Ativan (anti-anxiety medication) without orders on 6/25/24. 3. The facility failed to ensure MA C administered Resident #4 her amlodipine (medication to high blood pressure and chest pain) on 7/18/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 staff (CNA A and CNA B) observed for infection control. 1. The facility failed to ensure CNA A did not wipe Resident #1's vaginal area with a wipe visibly soiled by feces during incontinent care on 7/17/24. 2. The facility failed to ensure CNA B performed hand hygiene between glove changes, before exiting resident room, and prior to re-entering a resident room. 3. The facility failed to ensure CNA A and CNA B emptied the trash in Resident #1's room which had dirty gloves visibly soiled with feces following incontinent care and prior to exiting the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility lacked supervision to prevent accident hazards and failed to ensure that an environment was free from accident hazards for 3 of 6 residents reviewed for accident hazards. (Resident #249, Resident #42, and Resident #41). 1. The facility failed to ensure safety measures were in place to prevent Resident #249 and Resident #42 from obtaining an injury from hot coffee. 2. The facility failed to implement measures to prevent other coffee spills with burns. 3. The facility failed to monitor the temperatures of hot liquids served to residents. 4. The facility failed to identify residents at risk for coffee burns. 5. The facility failed to ensure Resident #249 and Resident #41 had new fall interventions implemented with each subsequent fall. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as set forth at 483.120(c) for 14 of 15 residents (Resident #33, Resident #28, Resident #6, Resident #8, Resident #100, Resident #17, Resident #45, Resident #149, Resident #15, Resident #2, Resident #41, Resident #27, Resident #12, and Resident #99) for residents observed for specialized rehabilitative services. The facility failed to provide Resident #33 with physician ordered physical therapy from the admission date of [DATE]. The facility failed to provide Resident #99 with physician ordered physical therapy from the admission date of [DATE]. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being for 48 of 48 residents reviewed. The administrator failed to follow the abuse and neglect policy. The administrator failed to collaborate with the regional director of the rehab company to ensure therapy services were provided as ordered. The administrator failed to monitor the director of rehab services to ensure the proper staff were available to provide physical therapy as ordered by the physician. The IP failed to ensure interventions were put in place to prevent an increase in UTIs. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. [...]

Inspectors wroteBased on observation, interview, 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 hospitalization related to infections for 1 of 13 residents reviewed (Resident #16) for urinary tract infection (an infection in any part of the urinary system) and 4 of 6 residents reviewed for (Resident #250, Resident #17, Resident#35 and Resident #9) infection control practices. *The facility had 13 urinary tract infections for the month of [DATE]. 7 of 13 residents had Escherichia coli (E. coli- bacteria in urine) in their urine culture and Resident #16 was admitted to the hospital with sepsis(a serious condition that happens when the body's immune system has an extreme response to an infection) for UTI's. [...]

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 safety in 1 of 1 kitchens reviewed for food safety requirements. The facility failed to ensure 3 skillets were free from encrusted carbon buildup on the outside and half of the inside of the cooking surface. The facility failed to prepare over easy fried eggs with pasteurized eggs. The facility failed to ensure [NAME] P wore her hairnet when entering the kitchen during meal service. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #249) of 6 residents reviewed for reporting allegations of abuse. The facility failed to report Resident #249's allegation of abuse to HHS. This failure could place the residents at risk for further potential abuse due to unreported allegations of abuse, and neglect.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team for 1 of 15 residents (Resident #40) reviewed for care planning. The facility failed to ensure Resident #40 had a person-centered care plan for activities. This failure could place residents at risk for social isolation, depression, and a decreased psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 1 residents reviewed for laboratory services. (Resident #41). The facility failed to implement timely treatments for Resident #41's urinary tract infections. This failure could place residents at risk for urinary tract infections as well as any other urinary/incontinence issues.

Inspectors wroteBased on observation, interview, and record review , the facility failed to provide food that was palatable for 1 of 15 resident (Resident #18) reviewed for palatable food and 1 of 1 test trays. The facility failed to provide palatable food served at an appetizing taste to Resident #18 who complained of the food not tasting good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #23) reviewed for preference. The facility failed to honor Resident #23's preferences for a vegan diet. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to obtain the most recent plan of care specific to each resident for 3 of 3 residents (Resident #'s 4, 38, and 249) reviewed for hospice services. The facility failed to obtain Resident #38's, Resident # 4's and Resident #249's most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 7 of 21 employees (RN F, RN G, Speech Therapist, Occupational Therapist, CNA H, CNA K, and CNA L) reviewed for required trainings. The facility failed to ensure RN F, RN G, CNA H, CNA K and CNA L received restraint and HIV training upon hire. The facility failed to ensure the Speech Therapist received HIV training annually. The facility failed to ensure the Occupational Therapist received restraint and HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV.