Lakewood Rehabilitation & Healthcare Center

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to ensure a resident or the resident's representative was fully informed of and participated in treatment decisions related to intravenous micronutrient and hydration therapy, including the failure to provide information necessary to make an informed decision and the failure to obtain consent prior to administration of treatment for one of 22 residents reviewed (Resident 103).

Inspectors wroteBased on review of employee personnel files, select facility policies, external contract agreements, and staff interviews, it was determined the facility failed to fully implement abuse prohibition procedures to ensure the facility did not employ or otherwise engage individuals who may have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law for one of six employees reviewed (Employee 9).

Inspectors wroteBased on a review of clinical records, information submitted by the facility, the facility's abuse prohibition policy, and staff interviews, it was determined the facility failed to accurately and completely report, document, and investigate an allegation of abuse to identify the alleged perpetrator and ensure resident protection measures were implemented in accordance with federal and state reporting requirements for one of 22 residents reviewed (Resident 81).

Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument (RAI) Manual, Minimum Data Set (MDS) assessments, and staff interview, it was determined the facility failed to ensure MDS assessments accurately reflected residents' clinical status for two of 22 residents reviewed (Residents 112 and 103).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered or evaluated the need for a prescribed medication according to physician-ordered parameters for two of 22 residents reviewed (Resident 4 & Resident 12).

Inspectors wroteBased on clinical record review, review of the facility's restorative nursing policy, staff interviews, and resident interview, it was determined the facility failed to implement and evaluate an individualized restorative nursing program with measurable resident-centered goals, resident participation in care planning, and ongoing reevaluation to modify the program as necessary for one of 22 sampled residents (Resident 13).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure a resident who entered the facility with an indwelling urinary catheter was assessed for catheter removal at the earliest possible time unless the resident's clinical condition demonstrated that continued catheterization was necessary for one of 22 residents reviewed (Resident 11).

Inspectors wroteBased on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident regarding significant weight loss for one of 22 residents reviewed (Resident 5).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two of 22 residents reviewed (Residents 1 and 30) who required care and monitoring of a Peripherally Inserted Central Catheter (PICC) line.

Inspectors wroteBased on observation, clinical record review, review of facility staffing schedules, and staff and resident interviews, the facility failed to provide sufficient nursing staff with the appropriate competencies to ensure timely and quality care and services for two of 22 residents reviewed (Residents 10 and 14).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure the pharmacist conducted medication regimen reviews at least monthly for one resident out of five reviewed (Resident 42).

Inspectors wroteBased on a review of select facility policy, clinical records, and a staff interview, it was determined the facility failed to offer pneumococcal immunization in accordance with facility policy and current Centers for Disease Control and Prevention (CDC) recommendations, unless medically contraindicated or the resident had already been fully immunized, for one of five residents reviewed (Resident 81).

Inspectors wroteBased on a review of clinical records, employee personnel records, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for two of 22 residents reviewed (Residents 1 and 30).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed medication to one of four sampled residents (Resident CR1).

Inspectors wroteBased on review of select facility policies, clinical records, facility-provided investigative documentation, observations, and staff interviews, it was determined the facility failed to ensure that one resident (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure placed one of eight residents sampled in Immediate Jeopardy to the health and safety of residents.

Inspectors wroteBased on a review of clinical records, information submitted by the facility, the facility's abuse prohibition policy and staff interviews, it was determined the facility failed to accurately and completely report and document an alleged incident of sexual abuse for 1 of 8 residents reviewed (Resident 1) to the State Survey Agency and the Area Agency on Aging.

Inspectors wroteBased on a review of clinical records, select facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in accordance with federal requirements. Specifically, the facility's administration failed to ensure that one of eight residents sampled (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure resulted in Immediate Jeopardy to resident health and safety.

Inspectors wroteBased on review of select facility policies, clinical record review, review of facility-provided documentation, and staff interviews, it was determined that the facility failed to protect and maintain personal privacy and dignity when staff recorded a resident receiving incontinence care without consent. This failure resulted in a violation of personal privacy protection for 1 of 5 sampled residents (Resident 1). This concern represents past non-compliance, as the facility identified, addressed, and corrected the issue before the survey.

Inspectors wroteBased on clinical record review, facility policy, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences and failed to ensure that residents were invited to participate in the care planning process for three of 20 residents reviewed (Residents 16, 51, and 85).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three of 20 sampled residents (Residents 49, 78, and 82).

Inspectors wroteBased on a review of select facility policy and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for five of 20 residents reviewed (Residents 22, 5, 196, 76, and 83).

Inspectors wroteBased clinical record review and interview with staff, it was determined the facility failed to provide the right to communication with and access to persons and services outside the facility for one resident out of 20 sampled (Resident 51). Findings Include: A clinical record review revealed Resident 51 was admitted to the facility on [DATE], with diagnosis to include a hereditary ataxia (a group of genetic disorders characterized by progressive problems with coordination and balance (ataxia) that are inherited from one generation to the next. These conditions affect the nervous system, particularly the parts of the brain responsible for motor control, such as the cerebellum, spinal cord, and peripheral nerves) and muscle weakness. [...]

Inspectors wroteBased on clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to provide prescriptions for physician-ordered medications at the time of discharge to ensure a safe and orderly transition to home for one resident out of four closed records reviewed (Resident 146).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 20 sampled (Resident 19).

Inspectors wroteBased on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to follow the comprehensive care plan by not ensuring the consistent application of preventative measures for fall safety for one of 20 residents sampled (Resident 50).

Inspectors wroteBased on a review of clinical records, facility documentation and select facility policies and procedures and staff interview, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication transcription and medication administration resulting in a medication error for one of 22 residents reviewed. (Resident 3)

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure one resident dependent on staff for assistance with activities of daily living (ADLs) consistently received showers as planned to maintain personal hygiene for one of 20 sampled residents (Resident 85).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident out of 20 residents sampled (Resident 8).

Inspectors wroteBased on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 20 sampled (Resident 16).

Inspectors wroteBased on review of select facility policy, clinical records, and staff interview, it was determined the facility failed to ensure pneumococcal and influenza immunizations were offered and/or provided, unless medically contraindicated or previously administered, for one of five residents reviewed (Resident 6).

Inspectors wroteBased on a review of select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into allegations of potential resident-to-resident abuse for one resident out of 12 sampled (Resident 2) perpetrated by another resident (Resident CR1).

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide pharmaceutical services for acquiring medication to meet the needs of two of the five residents sampled (Residents 1 and 2) and failed to implement procedures to promote accurate accounting of narcotic medications for one of the five residents sampled (Resident 1).

Inspectors wroteBased on observations, review of clinical records, facility policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure adequate staff supervision and effective safety measures for a resident who expressed exit seeking behaviors and was identified as a wandering risk. The failure resulted in the elopement for one resident (Resident 1) out of 6 residents reviewed that were at risk for elopment. Following this elopement the facility further failed to promptly identify the resident's absence as well as identify supervisory and safety needs to prevent unsupervised exits from the facility, which placed residents in immediate jeopardy of unsupervised exits from the facility and the potential for serious bodily injury or death.

Inspectors wroteBased on a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to monitor one resident's whereabouts (Resident 1) and prevent an elopement for one out of 6 sampled residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation, the facility failed to provide quality care by not timely responding to Resident 1's change in condition, including the failure to implement appropriate interventions or timely transfer the resident to a higher level of care for one of 5 residents reviewed. (Resident 1).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined the facility failed to ensure provision of a written notice for a facility-initiated transfer to the hospital. Specifically, the facility failed to provide a written notice regarding the reason for the transfer to the resident and the resident's representative in a language and manner easily understood, for one resident out of 6 residents sampled (Resident 2).

Inspectors wroteBased on a review of clinical records, the facility's bed-hold policy, and staff and family interviews, it was determined the facility failed to provide written notice of the specifics of the facility's bed-hold policy, including the duration and reserve bed payment policy, to a resident's representative upon the resident's transfer to the hospital for one of six sampled residents (Resident 2).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure timely completion of prescribed laboratory services for one resident out of six sampled (Resident 1). This failure resulted in a delay in the monitoring and management of the resident's elevated potassium levels as ordered by the prescribing practitioner.

Inspectors wroteBased on a review of clinical records, select facility incident/accident reports, and staff interview it was determined the facility failed to timely implement effective safety interventions, including necessary staff supervision, at the level and frequency required, for a resident with known unsafe behaviors to prevent falls, including a fall with hip fracture for one resident out of the 24 sampled (Resident 91) and multiple falls for one out of the 24 sampled reviewed (Resident 33).

Inspectors wroteBased on a review of clinical records, observations, select facility policy, and staff, resident, and resident family interviews, it was determined the facility failed to implement pain management interventions and failed to recognize when the resident suffered pain without relief for one resident out of 24 sampled (Resident 260).

Inspectors wroteBased on observation, review of the facility's infection control tracking logs, facility policy, and staff interviews it was determined the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during ice storage for one of two resident pantries (East Nursing), medication administration and multi resident use blood glucose monitors for one of 3 residents sampled (Resident 77).

Inspectors wroteBased on observations, a review of facility provided documents, and resident and staff interview, it was determined the facility failed to maintain an effective pest control program, including observations made on two of the two nursing units (East and West) and experiences reported by two residents out of 24 sampled. (Residents 77 and 90).

Inspectors wroteBased on observations and staff interviews, it was determined the facility failed to maintain residents right to privacy and confidentiality during a physician visit for 7 residents and failed to ensure personal privacy for one resident (Resident 78) by placing health care instructions in a place compromising the resident's privacy.

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to develop a comprehensive person-centered plan of care to meet the individualized needs of one resident out 24 sampled (Resident 72).

Inspectors wroteBased on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to conduct a timely bladder assessment and develop and implement an individualized plan to meet the resident's toileting needs, including timely staff assistance with toileting and incontinence management and justification for the continued use of an indwelling catheter for two residents out of 24 sampled residents (Resident 91 and 32).

Inspectors wroteBased on clinical record and select facility policy review, and staff interview it was revealed the facility failed to monitor weight as planned to ensure acceptable parameters of nutritional status are maintained to the extent possible for two of 24 residents sampled (Residents 27 and 78) and failed to ensure a physician ordered fluid restriction was maintained for one of 24 sampled residents (Resident 25).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff, resident and resident family interviews, it was determined the facility failed to ensure the physician provided services that met the resident's immediate care and needs for two out of 24 residents reviewed (Residents 77 and 260).

Inspectors wroteBased on observation, a review of clinical records, and resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents for two of two nursing units including care, service, and supervision provided to Residents 41, 39, and 77.

Inspectors wroteBased on observation, and staff interviews it was determined that the facility failed to store drugs and pharmacy supplies in a safe manner in one medication storage room out of two medication storage rooms and failed to remove medications awaiting final disposition in a timely manner and failed to document the accounting and disposition of residents' medications in the clinical record upon discharge of two of two sampled residents (Residents 108 and 107) and failed to ensure accurate narcotic accountability for one of 6 residents sampled (Resident 84).

Inspectors wroteBased on clinical record review, observation and staff interview, it was determined the facility failed to ensure a medication error rate of less than 5% for one of 4 residents (Residents 6 ) observed.

Inspectors wroteBased on review of clinical records and staff interview it was determined the facility failed to assure that two residents out of 24 sampled were free of a significant medication error (Resident 5 and 77).

Inspectors wroteBased on select facility policy, facility provided documentation, clinical records and staff interview, it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed demonstrate effective and thorough adverse event monitoring and response and use of the monitoring data to prevent similar adverse events in the facility in response to residents with repeated falls for 2 of 24 sampled residents (Resident 91 and 33) and implement any applicable performance improvement activities.

Inspectors wroteBased on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to 3 of five residents reviewed (Residents 31, 27 and 91).

Inspectors wroteBased on staff interviews and a review of employee personnel records it was determined the facility failed to provide abuse prevention training to two employees out of two reviewed. (Employee 7 and 15 ).

Inspectors wroteBased on observations, review of clinical records, and resident and staff interview, it was determined the facility failed to provide reasonable accommodation of the needs of a resident with sensitive skin for one of 24 residents reviewed (Resident 94).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined the facility failed to timely consult with the resident's physician regarding the need to initiate a new treatment for one resident out of 24 sampled (Resident 72).

Inspectors wroteBased on observation, clinical record, and staff interview it was determined the facility failed to ensure the resident received enteral feedings as prescribed for one resident receiving an enteral feeding out of two residents sampled (Resident 31).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure the physician wrote a progress note with each visit for one of 24 sampled residents (Resident 27).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure that one resident of 24 sampled was seen timely by a physician for the initial comprehensive visit (Resident 91).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to ensure the resident's drug regimen was free of unnecessary antibiotic medication for one out of 24 residents sampled (Residents 77).

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and use by dates for multi-dose medications in one of two medication storage rooms observed (West medication storage room).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one resident with a Medicaid payor source out of 24 residents sampled (Resident 80).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to accurately post daily nurse staffing information by failing to reflect staff absences due to call-outs and illness.

Inspectors wroteBased on observation, a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that one resident (Resident A2) was free from verbal and mental abuse, which resulted emotional upset and mental anguish and failed to implement sufficient measures necessary to protect other residents from verbal and mental abuse perpetrated by one resident (Resident A1) out of 10 sampled residents.

Inspectors wroteBased on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report multiple instances of verbal and mental abuse perpetrated by one resident out of 10 sampled (Resident A1) to the State Survey Agency and local Area Agency on Aging.

Inspectors wroteBased on a review of clinical records and resident and staff interview, it was determined that the facility failed to provide person centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, Ace wraps (elastic bandage), and further failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for diabetes management for one resident (Resident B1) of out of 10 sampled.

Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life and assures that each resident is treated with dignity by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by two of four residents sampled (Residents B1 and B3).

Inspectors wroteBased on clinical record review and staff interview it was determined that the baseline care plan of one of 10. residents sampled (Resident B2) failed to fully address the resident's individual needs upon admission.

Inspectors wroteBased on observation, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for one of 10 residents sampled (Residents B1).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to timely obtain and provide necessary respiratory care supplies and equipment required by one one of 10 sampled residents (Resident A3).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide pharmacy services to assure timely acquiring of physician ordered medications for one of 10 residents sampled. (Resident A3).

Inspectors wroteBased on observation, clinical record review, and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in the facility.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to timely obtain prescribed laboratory services for one resident out of 10 sampled (Resident CR1).

Inspectors wroteBased on a review of clinical records and controlled drug records and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate accounting and administration of controlled medications for two of 10 residents sampled (Resident 40 and Resident 76).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for two of 10 residents sampled (Resident 40, and 76).

Inspectors wroteBased on a review clinical records, the facility's plan of correction from the surveys ending February 29, 2024, and February 1, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify and correct ongoing quality deficiencies related to fully developing and implementing operational policies and procedures designed to protect residents from unacceptable practices of facility initiated disenrollment of residents from their Medicare health plans, the implementation of pharmacy procedures to promote accurate controlled drug records and administration, the pharmacist's identification of irregularities in residents' drug regimens and respiratory care.

Inspectors wroteBased on a review of guidance issued by the Centers for Medicare and Medicaid Services, select facility policy, and staff interview, it was determined that the facility failed to fully develop and implement operational policies and procedures designed to protect residents from unacceptable practices of disenrolling residents from their Medicare health plans.

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate prompt and thorough assessment of a resident displaying signs and symptoms of a change in condition to ensure the resident received timely and necessary treatment for one resident out of 10 sampled (Resident CR1), which resulted in the facility's failure to timely identify signs of digoxin toxicity.

Inspectors wroteBased on observation, clinical record review and staff interview it was determined that the facility failed to consistently provide respiratory care in manner to promote safe and optimal functioning for two residents out of 10 sampled (Residents 7, and 29).

Inspectors wroteBased on a review of clinical records and resident and staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one resident out of ten sampled (Resident 76).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 10 sampled residents (Resident CR1).

Inspectors wroteBased on review of clinical records, facility provided documents, and staff interviews, it was determined that the facility failed to maintain complete clinical records, according to professional standards of nursing practice by failing to document assessment of changes in a residents condition for one of 10 residents sampled (Resident CR1).

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, and select incident reports and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse perpetrated by another resident, (Resident 13), which resulted in physical distress to the resident victim, (Resident 14) out of 18 residents sampled.

Inspectors wroteBased on a review of clinical records, select facility policy, and medication records, and resident and staff interviews it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 14 sampled (Resident CR1) and failed to implement pharmacy procedures for accounting for controlled drugs on one of four medication carts.

Inspectors wroteBased on review of select facility policies, clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently implement planned, and functional safety interventions based on individual resident needs to promote resident safety and prevent repeated falls for one of 18 sampled residents (Resident 4)

Inspectors wroteBased on a review of clinical records, CMS guidance and facility documentation, and staff and resident interviews, it was determined the facility failed to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable practices of disenrolling residents from the Medicare Health Plans to ensure all risks of disenrolling are fully explained, both verbally and in writing, and that residents are assessed as competent at the time to make informed health care decisions for one resident of five reviewed (Resident 11).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide the necessary behavioral health care and services to meet the behavioral health needs and promote the highest level of physical, mental and psychosocial well-being of one of 18 sampled residents (Resident 4).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 18 sampled residents (Resident 7).

Inspectors wroteBased on a review of select facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that one resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 11).

Inspectors wroteBased on a review of the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by Residents 2, 3, 4, 5, and 6.

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to ensure that residents dependent on staff for assistance with activities of daily living consistently received showers as planned to maintain good personal hygiene for two of 11 residents sampled (Resident 9 and 10).

Inspectors wroteBased on a review of nursing staffing hours and ratios, resident census, clinical records, and grievances lodged with the facility observations, resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents.

Inspectors wroteBased on observations and staff interviews, it was determined the facility failed to maintain sanitary conditions in the facility's central supply area.

Inspectors wroteBased on observation, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for two of 11 residents sampled (Residents 4 and 9 ).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to consistently provide respiratory care, supplemental oxygen, as ordered by the physician for one resident out of 11 sampled (Resident 1).

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records for two residents (Residents 11, and 140) and for acquiring resident medications to ensure physician-ordered medications were available in a timely manner for one resident out of 19 residents reviewed (Resident 13).