Lakeview Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing skin monitoring, physician notification, and timely treatment for one resident (Resident #1) who developed skin shearing (mechanical injury caused by the combination of friction and gravity, where the skin sticks to a surface, like bedding, causing deep tissue damage and blood vessel damage) and an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage could not be determined due to slough (dead tissue) or eschar (necrotic tissue)) pressure ulcer (localized damage to the skin that usually occur over a bony prominence as a result of pressure). In addition, facility staff failed to complete a skin assessment and provide wound care for one resident (Resident #2) who was admitted to the facility with a pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper foot/wound care was performed for one resident (Resident #3) who had a wound to the great toe and a blister to the second toe. The resident's great toe wound became infected. The facility also failed to ensure the resident's second toe blister was documented on the resident's skin assessments. The sample was 10. The census was 95. Review of the facility's foot care policy, dated 10/2022, showed: -Policy statement: Residents receive appropriate care and treatment in order to maintain mobility and foot health; -Policy implementation: Residents are provided with foot care and treatment in accordance with professional standards of practice. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment when staff failed to provide hot water for bathing and personal care for residents. This affected six out of nine sampled residents (Residents #3, #5, #6, #7, #8 and #9), five of six additional sampled resident rooms, and two of two shower rooms. The census was 92. Review of the facility's Water Temperatures Policy and Procedure, revised 12/2009, showed: -Policy Interpretation and Implementation; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of 98 degrees Fahrenheit (F) - 120 degrees F, or the minimum and maximum allowable temperature per state regulations; -Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log; [...]

Inspectors wrotejw Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by failing to obtain and administer a resident's medication for rheumatoid arthritis (RA, a chronic autoimmune disease that causes the body's immune system to attack its own tissue resulting in joint inflammation, pain and stiffness), who was on Medicare Part A (While a resident is on Medicare part A, the facility is required to cover the cost of room and board, nursing care, therapy, medical supplies and equipment, medications, transportation and social services at 100 % for the first 20 days, after that there is a co-pay) and failed to follow physician ordered wound treatments for a wound vac (A medical device that uses suction to help wounds heal), and failed to obtain orders for a wet to dry dressing (a type of wound dressing that [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure resident rooms (Resident #87, #25 and #64) were free from gnats (small, two winged fly that resembles a mosquito). This failure had the potential to affect all residents. The sample was five. The census was 77. Review of the facility's pest control policy dated May 2008, showed: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services are provided by the facility's vendor; -Windows are screened at all times; -Maintenance services assist when appropriate and necessary in providing pest control services. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice and per the resident's plan of care when staff failed to apply wraps to Resident #13's legs, per physician orders. The sample was size was five. The census was 77. Review of the facility's Wound Care policy revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Preparation: -Verify there is a physician's order for this procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: -Notify the supervisor if the resident refuses the wound care; [...]

Inspectors wroteTN: See edit below in red Based on observation, interview and record review, the facility failed to ensure two residents, who were incontinent of bladder, received the necessary services to maintain good personal hygiene when staff failed to check or clean one resident who was bed bound (Resident #25) and left one resident in his/her wheelchair surrounded by a large puddle of urine (Resident #64). In addition, staff failed to provide showers at least twice weekly for both residents. Review of the facility's Activities of Daily Living (ADL), Supporting policy, last revised in March 2018, showed: -Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident records were complete and accurately documented when staff documented treatments were provided when they were not (Residents #24, #87 and #13). The sample was 5. The census was 77. Review of the facility's Wound Care policy revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Preparation: -Verify there is a physician's order for this procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: -Notify the supervisor if the resident refuses the wound care; -Report other information in accordance with facility policy and professional standards of practice. 1. [...]

Inspectors wroteSee deficiency cited at event id #ISJ412 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 10/21/24. Based on observation, interview and record review, the facility failed to ensure call lights were in working order, including visible notification at the nurses station for four of 23 sampled residents (Residents #32, #46, #64, and #60). The census was 89. Review of the facility's Call System, Residents policy, revised September 2022, showed: -Policy Statement: Residents are provided with a means to call staff for assistance through communication systems that directly calls a staff member or a centralized work station; -Policy Interpretation and Implementation; -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; [...]

Inspectors wroteSee the SOD cited at F602, Event ID# ISJ412 Based on observation, interview and record review, the facility failed to prevent the diversion (the unauthorized removal) of Schedule II controlled medications (medication with higher potential of dependency and abuse) for one resident (Resident #194). The census was 89. The Director of Nursing (DON) was notified on 12/13/24, of the past non-compliance which began and ended on 11/12/24. The facility began an investigation, interviewed staff and the pharmacy delivery person, performed medication carts review on each hall, notified the police, in-serviced staff on abuse and misappropriation of resident property (including drug diversion), and terminated Licensed Practical Nurse (LPN) A. Review of the facility's Identifying Exploitation, Theft and Misappropriation of Resident Property Policy, revised April 2021, showed: -Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately notify a resident's responsible party (RP) after the resident eloped from the facility (Resident #38). The facility also failed to notify two residents' RPs after a change in condition (Resident #196 and #89). In addition, the facility failed to notify the RP after a transfer to the emergency room (Resident #243). The sample size was 33. The census was 99. Review of the facility's change in a resident's condition or status policy, revised November 2015, showed: -Policy statement: The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.); [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations when one resident eloped from the facility and was found by police (Resident #38). In addition the facility failed to notify DHSS when allegations of abuse were made by two residents (Residents #52 and #48). The sample size was 33. The census was 99. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating Policy, dated revised September 2022, showed: - Reporting Allegations to the Administrator and Authorities: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of the residents. (Residents #38, #47, #344, #67, and #48). The sample was 33. The census was 99. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, showed: -Policy Statement: A comprehensive, person-centered plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; Policy Interpretation and Implementation: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure physician orders for tracheostomy and ventilation machines (a machine that provides positive pressure ventilation) were compete with all pertinent information to care for residents and failed to have orders for continuous oxygen monitoring for residents with a tracheostomy (Residents #13, #25, and #245). Additionally, the facility failed to have staff trained on how to set and monitor the functioning of ventilation machines and continuous oxygen monitoring devices. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration; -Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol; Assessment: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care needs. The facility did not have a system in place to ensure the required coverage was provided. As a result one resident, who experienced acute shortness of breath had to call 911 for intervention. (Resident #35). Another resident called 911 on one occasion because he/she could not get staff to answer his/her call light to help reposition a tube and on another occasion because he/she had a soiled brief and had waited 10 hours for staff to clean him/her. (Resident #46). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their licensed staff were competent in their knowledge of the facility policy and procedures for how to provide tracheostomy (tube surgically inserted into the trachea for the purpose of breathing) care and suctioning to residents. In addition, the facility failed to train their licensed nursing staff on the use of the facility's continuous oxygen monitoring system, piped in oxygen system, and the wall suctioning equipment. This had the potential to affect the 15 residents at the facility who had a tracheostomy and required frequent suctioning and oxygen saturation monitoring. The facility census was 99. Review of the facility's Suction Policy, revised [DATE], showed: Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs (drug or chemical that is regulated by the government in terms of its manufacture, possession, and use) with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 99. Review of the facility's Controlled Substances Policy, dated November 2022, showed: -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Review of the facility's Controlled Substance Shift Change Count-Check Sheet, dated 10/1/24 through 10/14/24, showed: -On the 100 hall: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store medications according to acceptable standards of practice, when staff failed to lock the medication carts on one hall, date medications when opened, failed to store an unopened insulin pen in the refrigerator, and date an opened vial of a purified protein derivative (PPD, used to diagnose tuberculosis (TB) infection). For three of three medication carts reviewed and one of two medication storage rooms reviewed. The facility identified six medication/treatment carts and three medication rooms. The census was 99. Review of the facility's Medication Labeling and Storage Policy, dated 2001, showed: -Policy statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not address complete staffing needs to include respiratory therapists, restorative therapy, social services, and dietary service staff. In addition, the facility assessment failed to address staff competencies to meet the needs of residents. The census was 99. Review of the facility's undated Facility Assessment, showed: -No names and/or titles of staff involved in completing assessment; -Average daily census: 90; -Special treatments and conditions: -Oxygen therapy: 14-20 on average; -Suctioning: 7-10 on average; -Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) care: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to perform hand hygiene between glove changes and failed to wear appropriate personnel protective equipment (PPE) for four residents (Residents #243, #82, #73 and #52) who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs, bacteria or fungi resistant to multiple antimicrobials (an agent that kills microorganisms or stops their growth)); that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS). [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and/or provide vaccinations as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines. Two of five sampled residents (Residents #89 and #245), did not receive vaccines for influenza (a vaccine that can protect against the flu) and pneumococcal (a vaccine that can protect against pneumonia). In addition, these two residents, and another resident (Resident #47) did not receive the COVID-19 (an infectious disease caused by the SARS-CoV-2 or corona virus) vaccines. Furthermore, these three sampled residents and another resident (Resident #68), four out of five residents, did not receive a completed purified protein derivative skin test (PPD skin test, a method for diagnosing latent tuberculosis (TB, a bacterial infection that can affect the lungs and other parts of the body)). The census was 99. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all call lights in the facility were in working order including audible notification at the nurse station on the 100 and 200 halls. The census was 99. Review of the facility's Answering the Call Light Policy, dated October 2010, showed: -Purpose: The purpose of this procedure is to respond to the resident's requests and needs; -Report all defective call lights to the nurse supervisor promptly. Observation on 10/10/24 at 6:13 A.M. showed Resident #20's call light was illuminated outside the resident's room with a red light light up on the wall inside the resident's room. There was no audible sound in the hall. During an interview on 10/10/24 at 5:05 A.M., Licensed Practical Nurse (LPN) P said call lights did not sound on the 100 and 200 halls, they just illuminated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dignity of one resident (Resident #9). Staff failed to intervene when the resident was sitting in the common area with his/her brief exposed. The sample was 33. The census was 99. Review of the facility's Dignity Policy, dated February 2021, showed: -Policy statement: Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self -worth and self-esteem. -Residents are treated with dignity and respect at all times. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/14/24, showed: -Severe cognitive impairment; -Upper and lower body dressing: Dependent, helper does all the effort. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations of individual needs and preferences by failing to ensure call lights were within reach for three sampled residents (Residents #51, #41 and #58). Staff also failed to ensure residents with limited mobility needs and preferences were met when staff did not honor one resident's preference to have his/her head turned (Resident #58). The sample was 33. The census was 99. Review of the facility's Answering the Call Light policy, revised 10/2010, showed: -Purpose: To respond to the resident's requests and needs; -General Guidelines: -Explain the call light to the new resident; -Demonstrate the use of the call light; -Ask the resident to return the demonstration so that you will be sure that the resident can operate the system (Note: [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate one allegation of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) (Resident #52). The sample size was 33. The census was 99. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating Policy, revised September 2022, showed: -Policy Statement: All reports of resident abuse, are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported; -Investigation Allegations: -All allegations are thoroughly investigated. The Administrator initiates investigations; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services in accordance with acceptable standards of practice when the facility failed to obtain one resident's labs per physician orders (Resident #27) and when staff failed to complete neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological status for the entire 72 hours for one resident (Resident #52). The sample was 33. The census was 99. Review of the facility's Lab and Diagnostic Test Results-Clinical Protocol Policy, dated November 2018, showed: -The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs; -The staff will process test requisitions and arrange for test; -The laboratory, diagnostic radiology provider, other testing source will report test results to the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing standards when the facility failed to enter one resident's (Resident #343) treatment order into the computer for nine days resulting in the wound treatment not being administered per physician orders. In addition, one resident was observed to not have an ordered treatment in place (Resident #89). The sample was 33. The census was 99. Review of the facility's Wound Care Policy, revised [DATE], showed: -Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Preparation: -Verify that there is a physician's order for this procedure; -Review the resident's care plan to assess for any special needs of the resident; -Documentation: The following information should be recorded in the resident's medical record; -The type of wound care given; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety and adequate monitoring for one resident (Resident #38), whom the facility identified as an elopement risk, and failed to prevent the resident from eloping from the facility. The facility failed to document the elopement in the resident's medical record and in the resident's plan of care. The sample size was 33. The census was 99. Review of the facility's Elopement policy, revised December 2007, showed; -Policy Statement: -Staff shall investigate and report all cases of missing residents; -Policy Interpretation and Implementation; -Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. -When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate administration of enteral (passing through the intestine) nutrition for a resident who was dependent on a gastrostomy tube (g-tube, a tube inserted through the abdomen that brings nutrition directly to the stomach) (Resident #245). The resident did not receive the continuous order of the tube feeding for approximately five hours. The facility identified 19 residents who received tube feedings. The census was 99. Review of the facility's Enteral Nutrition Policy, revised in November 2018, showed: -Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered; -The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) had documented assessments and monitoring related to dialysis and ongoing documented communication with the dialysis center. The facility identified 10 residents as receiving dialysis, of which one was sampled (Residents #89). The sample was 33. The census was 99. Review of the facility's Care of a Resident with End-Stage Renal Disease, Policy, dated September 2010, showed: -Policy Statement: residents with end-stage renal disease (ESRD, kidneys no longer work as they should to meet the body's needs) will be cared for according to currently recognized standards of care; -Policy interpretation and implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly drug regimen review (DRR) recommendations were followed timely. The requirements associated with the medication regimen review (MRR) apply to all residents, whether short or long stay. The facility failed to complete the timelines and responsibilities for the MRR by the consultant pharmacist when they failed to address MRR irregularities for two residents investigated for the MRR (Residents #48 and #14). The facility census was 99. Review of the facility's Pharmacy Services Role of the Consultant Pharmacist, dated 2001, showed: -The consultant pharmacist will provide specific activities related to medication regimen review including: -A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through with the pharmacist's recommendations regarding gradual dose reductions and documentation of behavior monitoring, side effects and related diagnoses for the use of the antipsychotic medications, for two residents (Resident #48 and #68). The sample was 33. The census was 99. Review of the facility's Pharmacy Services Role of the Consultant Pharmacist, dated 2001, showed: -The consultant pharmacist will provide specific activities related to medication regimen review including: -A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to administer medications per physician orders for three residents (Residents #246, #47 and #195). The sample was 33. The census was 99. Review of the facility's Administering Medications Policy, dated revision April 2019, showed: -Policy statement: medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders, including any required time frame; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for three residents (Residents #47, #27 and #344). The sample was 33. The census was 99. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician orders and complete tracheostomy (the presence of a surgical airway placed in the neck to help oxygen reach the lungs) treatment orders for one of four sampled residents (Resident #12) requiring tracheostomy care and maintenance. The census was 106. Review of the facility's Tracheostomy Care Policy, revised 10/2023, showed: -The following must be documented in the resident's record: -The procedure completed; -The condition of the stoma and surrounding skin; -The resident's tolerance of the procedure; -Any provider notification of unexpected or abnormal findings. Review of Resident #12's medical record, showed: [...]

Inspectors wroteSee Event ID 97R513. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 4/15/24. Based on observation, interview and record review, the facility failed to follow their policy by failing to develop comprehensive, person-centered care plans. Resident #40 had been identified for a three month significant weight loss, but his/her care plan had not been updated to include double portions at meals or adaptive devices (special eating equipment and utensils) at meals. Resident #41 had a care plan for malnutrition, but it did not include all of his/her adaptive devices or his/her preference to have finger foods. Resident #42 had a diagnosis of malnutrition, had been identified with a six month significant weight loss, but the care plan did not address the resident's nutritional needs. [...]

Inspectors wroteSee Event ID 97R513 Based on observation, interview and record review, the facility failed to ensure residents received adaptive equipment at meals as ordered, to assist with resident eating independence and increase food/fluid intake. Four residents with orders for adaptive eating equipment were sampled and problems were found with three (Residents #39, #40 and #41). The census was 94.

Inspectors wroteSee Event ID 97R513 Based on observation, interview and record review, the facility failed to ensure staff checked residents for incontinence at least every two to three hours. This resulted in residents left urine saturated for extended periods of time. Seven residents were sampled and problems were identified with two (Residents #37 and #5). The census was 94.

Inspectors wroteSee Event ID 97R513 Based on observation, interview and record review, the facility failed to ensure wound treatments were completed as ordered. Residents #31 and #28 had physician ordered wound treatments to be completed daily. On Saturday 5/4/24 and Sunday 5/5/24, neither resident had there wound treatments completed. Two residents with wounds were sampled and problems were found with both. The census was 94.

Inspectors wroteSee Event ID 97R513 Based on observation, interview and record review, the facility failed to ensure residents received their pressure ulcer (an injury to the skin and the tissue below the skin due to pressure on the skin) treatments as ordered, and failed to accurately document missed treatments. The facility also failed to update one resident's care plan regarding the presence of a pressure ulcer. Five residents with pressure ulcers were sampled and problems were found with two (Residents #29 and #30). The census was 94.

Inspectors wroteSee Event ID 97R513 Based on observation, interview and record review, the facility failed to follow their policy and failed to implement and/or promptly implement the Registered Dietician's (RD) dietary recommendations for residents that experienced severe three month weight loss (greater that 7.5%) and severe six month weight loss (greater than 10%), and failed to ensure residents' heights were readily available to the RD so resident's body mass index (BMI, used to determine if a person is underweight or overweight) and ideal body weights (IBW, the ideal weight for men/women based on height and weight) could be calculated. The facility also failed to develop care plan interventions for residents experiencing severe weight loss. In addition, the facility failed to ensure residents received adaptive utensils, plate guards, and cups as ordered during meals. [...]

Inspectors wroteSee Event ID 97R512 Based on observation, interview and record review, the facility failed to develop a care plan that identified interventions to prevent falls after one resident's Fall Risk Assessment completed on [DATE], identified the resident to be a high risk to fall. In addition, on [DATE], the facility developed a care plan identifying the resident as having cognitive impairment and exhibited cognitive loss related to impaired decision making skills and impulsivity with a goal of avoiding complications that included falls and injuries. On [DATE], the resident was placed in his/her room in a wheelchair with no supervision. The resident leaned forward in the wheelchair reaching for a blanket on his/her bed causing the resident to fall out of the wheelchair onto the floor with the wheelchair resting against his/her back and his/her left leg was caught underneath the wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff consistently provided residents with two showers per week as scheduled. Of the 9 residents sampled, problems were identified with 8 (Residents #3, #2, #1, #7, #5, #9, #10 and #11). Seven of those 8 were interviewed, and they all said they preferred to have their showers as scheduled. One resident (Resident #2) was not interviewable, but his/her shower record showed he/she did not receive his/her showers as scheduled. The census was 90. Review of the Facility Assessment (an assessment used to determine what resources are necessary to care for residents competently), dated 9/20/23, and completed by the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON), Director of Rehabilitation, Maintenance Supervisor, Dietary Supervisor, and Medical Director, showed: -Average daily census: 90; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan that identified interventions to prevent falls after one resident's Fall Risk Assessment completed on [DATE], identified the resident to be a high risk to fall. In addition, on [DATE], the facility developed a care plan identifying the resident as having cognitive impairment and exhibited cognitive loss related to impaired decision making skills and impulsivity with a goal of avoiding complications that included falls and injuries. On [DATE], the resident was placed in his/her room in a wheelchair with no supervision. The resident leaned forward in the wheelchair reaching for a blanket on his/her bed causing the resident to fall out of the wheelchair onto the floor with the wheelchair resting against his/her back and his/her left leg was caught underneath the wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report one resident's (Resident #1) excoriated buttocks identified upon admission to the physician for a treatment order and failed to monitor the excoriation until 2/15/24, when a nurse identified two abrasions on the buttocks, the physician was notified, and a treatment order was started. On 2/16/24, a nurse documented the resident had what appeared to be a stage 2 pressure ulcer (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) on the buttocks and a new order for Santyl (an ointment used to aid in wound healing by removing dead skin tissue) and a consult with the wound care company was ordered by the Nurse Practitioner (NP). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently ensure a ratio of no more than 12 residents assigned per Certified Nursing Assistant (CNA) on the day shift per the Facility Assessment (used to determine what resources are needed to provide adequate care, including staffing) necessary to meet the needs of the residents including their activities of daily living (ADLS, dressing, bathing, transfers, eating, and toileting). Eight residents were sampled (Resident #3, #2, #1, #7, #5, #9, #10 and #11) and all 8 did not receive showers as scheduled, and one (Resident #3) with pressure ulcers (also known as bedsores are localized damage to the skin and/or underlying tissue) was unclean and turned and repositioned timely. The census was 90. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had comfortable water temperatures for bathing. Residents #14, #15, #16 and #17 complained the facility water temperatures for the sinks and showers in their rooms were too cold to comfortably take showers and/or bed baths. Review of the facility's water temperature logs from October 6, 2023 through February 26, 2024, showed water temperatures in multiple resident rooms as well as community shower rooms were below the acceptable threshold of 105 Fahrenheit (F) to 120 F. In addition, water temperatures in the sampled residents' rooms on 3/6/24, showed the water temperatures remained below the acceptable water temperature range. The census was 90. Review of the facility Water Temperatures, Safety policy, dated 2002 and revised on 2009, showed: -Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff checked residents for incontinence at least every two to three hours. This resulted in residents left urine saturated for extended periods of time. Seven residents were sampled and problems were identified with two (Residents #37 and #5). The census was 94. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/24, showed: -Vision: Impaired - sees fine detail, including regular print in newspapers/books; -Hearing: Adequate; -Speech Clarity: Unclear speech - slurred or mumbled words; -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound treatments were completed as ordered. Residents #31 and #28 had physician ordered wound treatments to be completed daily. On Saturday 5/4/24 and Sunday 5/5/24, neither resident had there wound treatments completed. Two residents with wounds were sampled and problems were found with both. The census was 94. Review of the facility Wound Care policy, undated, showed: -Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Documentation: The following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The name and title of the individual performing the wound care; -Any change in the resident's condition; -If the resident refused the treatment and the reason why; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and failed to implement and/or promptly implement the Registered Dietician's (RD) dietary recommendations for residents that experienced severe three month weight loss (greater that 7.5%) and severe six month weight loss (greater than 10%), and failed to ensure residents' heights were readily available to the RD so resident's body mass index (BMI, used to determine if a person is underweight or overweight) and ideal body weights (IBW, the ideal weight for men/women based on height and weight) could be calculated. The facility also failed to develop care plan interventions for residents experiencing severe weight loss. In addition, the facility failed to ensure residents received adaptive utensils, plate guards, and cups as ordered during meals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurses received training for one resident's non-invasive mechanical ventilator (a machine that provides respiratory support), and failed to ensure nurses were aware the facility had back-up ventilators to use. The resident said his/her ventilator had repeatedly alarmed during the course of two or three nights, and facility nurses did not know why it was alarming or how to fix it. He/She eventually turned the ventilator off because the alarms prevented him/her from sleeping. In addition, the facility failed to obtain orders for the use of the non-invasive mechanical ventilator. The facility identified one resident with a non-invasive mechanical ventilator. (Resident #14). The census was 90. Review of the ventilator manufacturer's instruction manual provided by the facility, showed: -Possible Alarm Causes and Actions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adaptive equipment at meals as ordered, to assist with resident eating independence and increase food/fluid intake. Four residents with orders for adaptive eating equipment were sampled and problems were found with three (Residents #39, #40 and #41). The census was 94. Review of the facility Assistance with Meals policy, undated, included: Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; Policy Interpretation and Implementation: Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups; 2. [...]

Inspectors wroteSee the citationwritten at Event ID CF2112. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 11/14/23. Based on observation, interview, and record review, the facility failed to ensure staff routinely placed heel protectors and/or Podus Boots (multi-purpose boots designed to relieve pressure on the heels) for one resident (Resident #2) who was admitted with no pressure ulcers on the heels, and required maximum assistance to turn and reposition. On 11/30/23, the resident's heels were boggy/red and warm to touch. Facility staff failed to assess the heels and notify the physician about those changes. [...]

Inspectors wroteSee the citation written at Event ID CF2112. Based on interview and record review, the facility failed to ensure staff provided residents with showers in accordance with their preferences and needs. Of the nine residents sampled, five (Residents #23, #25, #27, #28 and #29) said they preferred to have showers, but did not receive their two scheduled showers per week. One additional resident was selected as a closed record and problems were identified (Resident #14). The census was 80. Review of the facility Bath, Shower/Tub policy, undated, included the following: -Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Documentation: -The date and time the shower/tub bath was performed; -The name and title of the individual(s) who assisted the resident with the shower/tub bath; [...]

Inspectors wroteSeethe citation written at Event ID CF2112. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 11/14/23. Based on interview and record review, the facility failed to ensure treatment order changes were made timely and accurately on the Physician's Order Sheet (POS) and Treatment Administration Record (TAR), ensuring residents received wound treatments as ordered. In addition, the facility failed to ensure staff documented wound treatments as being completed on the TAR or provide an explanation as to why a treatment could not be completed on the TAR or in the progress notes. The facility identified five residents with wounds, four were sampled and problems were identified with two (Residents #17 and #10). The census was 80. Review of the facility Wound Care policy, undated, included the following: -Purpose: [...]

Inspectors wroteSee the citation written at Event ID CF2112. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 8/24/23. Based on interview and record review, the facility failed to ensure staff transferred one resident (Resident #1) using a Hoyer lift (a machine used to transfer a resident unable to bear weight), resulting in the resident falling from a sit-to-stand lift (a machine used to transfer a resident that is capable of standing and bearing weight) during two transfers. The facility investigated the falls, but failed to identify all the causes of the falls, and failed to ensure staff were inserviced based on those problems. Additionally, the facility failed to ensure staff were observed for competency in using mechanical lifts prior to being allowed to using them, per facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer prescribed antibiotics, as prescribed by the physician, for a wound infection, and the wounds further deteriorated; failed to notify the Primary Care Physician of the resident's increased bruising; failed to promptly identify hemorrhaging following the debridement (removal of dead or infected tissue) procedure completed on two wounds; and failed to monitor for signs and symptoms of bleeding after wound debridement on a resident receiving an anticoagulant medication. On [DATE], the facility wound nurse accompanied the Wound Nurse Practitioner, who assessed the resident as needing a debridement procedure. The debridement was completed while the resident was receiving scheduled Xarelto (an anticoagulant medication which decreases the ability for blood to clot). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to turn and reposition a resident with existing pressure ulcers, failed to enter new orders, and failed to provide a pressure relieving mattress for one resident (Resident #4). The facility also failed to follow orders and complete wound assessments for one resident (Resident #13) and failed to complete skin assessments and document wound treatments for one resident (Resident #17). The sample size was three. The census was 80. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party after a change of condition for one resident (Resident #2). The sample was three. The census was 80. Review of the facility's change in a resident's condition or status policy, undated, showed: -Policy statement: The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.); -A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving possible abuse or neglect were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency, for one resident who sustained an injury of unknown origin, a fractured rib (Resident #17). The sample was 3. The census was 80. Review of the facility's abuse, neglect, exploitation or misappropriation - reporting and investigating policy, undated, showed: - All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident of the facility's bed hold policy at the time of transfer to the hospital for one resident (Resident #18) and at the time of therapeutic leave for one resident (Resident #6). The sample was 3. The census was 80. Review of the facility's bed hold and returns policy, undated, showed: -All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: 1: well in advance of any transfer (e.g., in the admission packet); and 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care and services for residents receiving enteral feeding (tube feeding) by not following physician orders for two residents (Residents #4 and #15) and by not documenting accurately in the medication administration record (MAR) for one resident (Resident #4). The sample size was three. The census was 80. Review of the facility's enteral nutrition policy, undated, showed: -Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered; -The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: Evaluation of the resident's current clinical and nutritional status; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for one resident (Resident #4) when staff did not respond when the resident cried out for help and did not leave the call light within the resident's reach for future requests or needs. The census was 79. Review of the Residents' Rights information, provided to residents upon admission, showed: -Policy statement: Employees shall treat all residents with kindness, respect, and dignity; -Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to: -Self-determination; -A dignified existence; -To be treated with respect, kindness, and dignity; -Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure basic life support, including cardio-pulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure each resident's code status is obtained timely upon admission, ensure code status matched the resident's wishes, and ensure each resident's code status was accurately documented. Resident #41 had both a full code and a do not resuscitate (DNR) code status sheet signed and dated the same day, a physician order for DNR, and, during an interview, the resident said he/she wanted to be a full code. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances when the facility did not file the grievance and/or the resolution timely for two residents (Resident #123 and #48). The facility failed to make information on how to file a grievance available to the residents, notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, and the contact information of the Grievance Official with whom a grievance can be filed. In addition, the facility failed to establish a grievance policy that identified the Grievance Official and directed the facility to maintain documentation of the grievances filed for a minimum of three years. The sample was 20. The census was 73. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their abuse and neglect policy for employee screening. The facility failed to check new employees' criminal background prior to employment for six of eight employees, and failed to check for a federal indicator (identifies when a staff person who has ever held a certified nursing assistant (CNA) certificate, has ever been found to have abused, neglected, or misappropriated resident property) through the state nurse aide registry, for four of eight employee files reviewed. The census was 73. Review of the facility's Background Screening Investigations policy, dated March 2019, showed: -Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow acceptable standards of practice when a routine pain medication was given outside of administration parameters (Resident #123). In addition, staff failed to document wound treatments as completed for four residents (Residents #47, #58, #8 and #2). The sample was 20. The census was 73. Review of the facility's Administering Medications policy, dated April 2019, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescribed orders, including any required time frames; -Medications are administered within one hour of their prescribed time, unless otherwise specified; -Topical medications used in treatments are recorded in the treatment administration record (TAR). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Controlled Substance (a drug that may be abused or cause addiction) policy when staff failed to count controlled substances inventory at each shift change for three out of three sampled narcotic books. The sample was 20. The census was 73. Review of the facility's Controlled Substance policy, revised November 2022, showed: -Policy: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) services. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to date insulin flexpens (prefilled injectable insulin) when opened and/or failed to store insulin flexpens in the refrigerator until opened. Staff also failed to label one opened multi dose vial of insulin with the resident's name, on one of the four medication carts checked. The census was 73. Review of the Facility's Medication Labeling and Storage Policy, revised February 2023, showed: -Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers; -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location; -The medication label includes, at minimum: a residents name; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to take food temperatures to ensure food served at time of service measured at least 120 degrees Fahrenheit (F) for hot food. This deficient practice affected all residents who ate meals at the facility. The sample was 20. The census was 73. 1. Review of Resident #63's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/13/23, showed: -Cognitively intact; -Required set up with eating. During an interview on 6/7/23 at 10:12 A.M., the resident said the food was cold, especially the eggs. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Required set up for eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system for identifying communicable diseases for all staff by not following their policy for tuberculosis (TB) testing for six of eight employee files reviewed and failed to follow proper infection control practices for two of four residents investigated for indwelling urinary catheters (Residents #51 and #55). The census was 73. 1. Review of the facility's Tuberculosis, Employee Screening policy, dated March 2021, showed: -All employees are screened for latent TB and active TB disease, using the tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for TB disease after an employment offer has been made but prior to the employee's duty assignment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 33 opportunities observed, two errors occurred, resulting in a 6.06% error rate (Resident #124). The census was 73. Review of the facility's Administering Medications policy, dated April 2019, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescribed orders, including any required time frame. Review of Resident #124's electronic physician order sheet, showed: -An order dated 5/31/23, for amlodipine besylate (used to treat high blood pressure) 5 milligram (mg) one time a day; -An order dated 6/6/23, for prednisone (steroid) 20 mg two tablets one time a day for seven days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident trust was reconciled monthly for 12 of 12 months. This had the potential to affect all residents who had money in the trust account. The census was 77. Review of the resident trust account, showed the following -November 2018, the trust reconciliation statement, showed the total of resident balances equaled $14,432.85. The reconciliation did not show any pending deposits, pending debits, or how the available petty cash was figured into the reconciliation; -December 2018, the trust reconciliation statement, showed the total of resident balances equaled $9228.35. The reconciliation did not show any pending deposits, pending debits, or how the available petty cash was figured into the reconciliation; -January 2019, the trust reconciliation, showed the total of resident balances equaled $11,196.78. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained a bond that was equal to or greater than one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive months from November 2018 through October 2019. This has the potential to affect all residents who had money in the trust account. The census was 77. Record review on 11/21/19 of the residents' personal funds account for the last 12 consecutive months from November 2018 to October 2019, showed the following: -The facility could not provide reconciled bank statements for the last 12 months; -The facility's current approved bond amount equaled $20,000.00; -The average monthly balance for the residents' personal funds equaled $13,604.05, (which could only be determined by using the ending bank balance plus the petty cash); [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two sampled residents (Residents #52 and #55) who remained in the facility and one sampled resident (Resident #222) who went home, upon discharge from Medicare Part A services. The facility census was 77. 1. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order to self-administer medication, document urinary output, clarify the diagnosis for an anti-seizure medication, administer a nutritional supplement as ordered, discontinue an order to be up at meals only, administer an anti-anxiety medication as ordered and carry over an order for a hand splint, for seven of 18 sampled residents (Residents #18, #30, #13, #31, #47, #16 and #8). The census was 77. 1. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/19, showed the following: -No cognitive impairment; -Diagnoses included diabetes, hemiplegia (paralysis to one side of the body) and communication deficit. Review of the physician's order sheet (POS), showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper perineal care (peri-care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for two of three residents observed (Residents #16 and #25) and failed to provide appropriate oral care to one resident (Resident #16). The sample size was 18. The census was 77. 1. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/19, showed the following: -Severe cognitive impairment; -Extensive assistance required for all personal care; -Frequently incontinent of bowel and bladder; -Diagnosis of dementia. Observation on 11/19/19 at 5:33 A.M., showed Certified Nurse Aide (CNA) L entered the resident's room, donned gloves and wet disposable no rinse wipes with warm water. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, facility policy and the comprehensive person-centered care plan, by failing to assess and treat pain, wounds and eye irritation for three of 18 sampled residents (Residents #64, #11 and #39). The census was 77. 1. Review of Resident #64's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/5/19, showed the following: -Moderate cognitive impairment; -Extensive assistance required for personal hygiene; -Special treatments/programs: Hospice care; -Pain presence: YES; -Pain frequency: Frequent; -Pain intensity: Moderate; -As needed (PRN) pain medications: YES; -Non medication interventions: NO; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate and safe transfer techniques were used in the care of residents (Resident #31, #48, #43 and #1) during four of four transfers observed. The facility also failed to prevent resident access to razors, iodine and nail clippers in two common areas. Furthermore, staff failed to properly dispose of used razors when two razors remained on a resident's night stand for three days (Resident #47). This had the potential to affect all residents who were able to move freely around the facility. The census was 77. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Dependent on staff for transfers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly assess and monitor residents for the use of bed/side rails, obtain physician's orders for the use of the bed rails, attempt to use alternative measures prior to installing a bed/side rail and failed to address the use of bed/side rails on the care plan for 12 of 18 sampled residents (Residents #21, #47, #64, #58, #30, #27, #8, #13, #42, #39, #37 and #10). The census was 77. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Severe cognitive impairment; -Required extensive assistance from staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene; [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety by failing to cover plates and desserts when serving meals to residents in the main dining room. Facility staff also failed to cover food stored in the walk in cooler and failed to properly store dishes to prevent contamination. The census was 77. 1. Observation of the main dining room on 11/18/19 at 12:19 P.M. and 5:33 P.M., showed facility staff brought uncovered plates of food out of the kitchen, through the corridor connecting 100 Hall to 200, 300 and 400 halls. While staff were serving, other facility staff, visitors and vendors walked through the main dining room and corridor. Observation of the kitchen on 11/20/19 from 8:00 A.M. to 8:10 A.M., showed the cook plated breakfast food from the steam table and then handed the plates to staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow acceptable infection control practices to prevent the spread of infection during blood sugar testing (BST) by not cleansing the glucometer (device used to check blood sugar) with an approved disinfectant and by placing the glucometer on an unclean surface for three of three residents observed (Residents #55, #45 and #33). The facility also failed to follow the facility's guidelines regarding Tuberculin Skin Testing (TST, the standard method for screening for tuberculosis) by not documenting the administration of the purified protein derivative (PPD) to test for tuberculosis for three recently admitted residents (Residents #30, #25 and #38) and by not obtaining a yearly tuberculin assessment for two residents (Residents #64 and #42). The sample size was 18. The census was 77. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by not honoring food preferences and failing to provide adaptive plateware and utensils so residents could eat independently for two of 18 residents sampled (Residents #47 and #8). The census was 77. 1. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Required extensive assistance from staff for bed mobility, transfers, toileting, personal hygiene and eating; -Diagnoses included heart failure, end stage renal disease, Alzheimer's disease, stroke, hemiplegia (paralysis on one side of the body), anxiety and depression; -Upper and lower extremities with impairment on one side. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete an inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one resident (Residents #48) with siderails to reduce the risks of accidents. The facility census was 77. Review of Resident #47's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Required extensive assistance from staff for bed mobility, transfers, toileting, personal hygiene and eating; -Diagnoses included heart failure, end stage renal disease, Alzheimer's disease, aphasia (loss of ability to understand or express speech caused by brain damage), stroke, hemiplegia, anxiety and depression; -Upper and lower extremities with impairment on one side; -Bed rails not in use. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written transfer/discharge notice to the resident and/or resident's representative, when transferred to the hospital for various medical reasons for nine sampled residents (Residents #37, #58, #64, #13, #27, #42, #11, #57 and #50). The sample was 18. The census was 77. 1. Review of Resident #37's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following: -admission date of 8/7/15; -Discharge to the hospital 5/6/19; -readmission to the facility 5/18/19; -Discharge to the hospital 8/23/19; -readmission to the facility 8/26/19; -No documentation the resident and/or their representative received written notice of the resident's transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the facility's bed hold policy to residents or their legal representatives, at the time of the transfers, for nine sampled residents who were transferred to the hospital for medical reasons (Residents #37, #58, #64, #13, #27, #42, #11, #57 and #50). The sample was 18. The census was 77. 1. Review of Resident #37's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following: -admission date of 8/7/15; -Discharge to the hospital 5/6/19; -readmission to the facility 5/18/19; -Discharge to the hospital 8/23/19; -readmission to the facility 8/26/19; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of the transfers. [...]