Landmark Care and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of nursing staff to provide care and services for 13 of 13 residents (Residents 54, 35, 4, 3, 79, 89, 7, 53, 62, 90, 92, 6, and 23) reviewed for sufficient staffing as evidenced by failures related to Resident Rights, Quality of Care and Pressure Injuries. Additionally, resident interviews, staff interviews and reports from the resident council meeting provided evidence of insufficient staffing without resolution. This failed practice placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received wound care treatment and management in accordance with professional standards of practice regarding a surgical wound which was not consistently/adequately assessed, monitored, or had the ordered wound care dressing changes completed for 1 of 3 residents (Resident 3) reviewed for non-pressure related skin issues. These failures placed residents at an increased risk for unmet care needs, untreated skin impairments, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to investigate a staff altercation witnessed by 2 of 2 residents (Resident 1 and 2) reviewed for allegation of abuse. This failure placed residents at risk for unidentified emotional/psychological abuse and undermined their right to a safe environment free from the effects of staff misconduct.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light systems were functioning at all times in 1 of 6 observed resident rooms (room [ROOM NUMBER]) reviewed for call lights. This deficient practice placed residents at risk for avoidable accidents and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, assess, monitor, and revise care plan interventions for efficacy, and ensure care planned interventions were consistently followed to prevent avoidable repeated falls for 4 of 5 residents (Residents 21,19, 41, and 29) reviewed for falls. Resident 21 who had 14 falls between 04/13/2025 and 05/23/2025, experienced harm when they had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back) and required a back brace that supports and stabilizes the spine. Resident 19 fell while unsupervised and experienced harm when they sustained a laceration on their forehead, required transfer to the emergency room (ER) and sutures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development of pressure injuries and to implement wound treatment measures consistently to avoid worsening of pressure injuries for 1 of 3 residents, (Resident 46) reviewed for pressure injuries. Resident 46 experienced harm when they developed a pressure related fluid filled blister to the left heel and a pressure injury to their right lateral malleolus (the bony prominence on the outside of the ankle joint) that had both slough and eschar present in the wound. These failures also placed the resident at risk for pain, infection, and other medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 16 of 16 residents (Residents 2, 5, 10, 19, 21, 23, 25, 27, 29, 33, 34, 39, 41, 43, 46, and 64)reviewed for Resident Rights, Resident Mobility, Activities of Daily Living (ADLs) for dependent residents, Quality of Care, Pressure Injuries, and Accident Prevention. Additionally, reports in the facility grievance logbook, resident council meeting interviews, and staff interviews provided evidence of insufficient staffing without resolution. This failed practice placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect in a timely manner, for 3 of 5 sample residents (Residents 19, 21, and 29), reviewed for incidents of significant falls with injury. Failure to report an allegation of significant injuries due to unwitnessed falls to the State Survey Agency, as required. This deficient practice placed residents at risk of harm related to potential unrecognized abuse/neglect and disallowed the ability to recognize patterns of repeated incidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure thorough investigations were completed for 5 of 5 residents (Residents 33, 19, 41, 21, and 29) reviewed for falls, skin impairments, and injuries of unknown source. Failure to initiate incident reports and conduct thorough investigations to identify root cause(s) and all contributing factors placed the residents at risk for unidentified abuse or neglect, unidentified corrective actions, risk for injury, and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for1of 3 residents (Resident 25) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity, respect and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consents regarding the potential risks associated with the use of psychotropic medications (medications that alter thought processes) for 2 of 5 residents (Residents 33 and 64) reviewed for unnecessary medication. This failure placed the residents and/or the legal representatives at risk of not being fully informed about the medications prior to administration.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review, (PASARR) Level 1 were accurately completed upon or prior to admission and requirements for 1of 5 residents (Resident 41) reviewed for the PASARR process. This failure had the potential to place the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 5 residents (Residents 2, 25, and 10), reviewed for activities of daily living (ADLs), received adequate grooming, transferring assistance and nail care according to the residents' care plans. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure staff responsible for providing cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) had current CPR certification for 1 of 5 licensed nursing staff (Staff S) reviewed for CPR certification status. This failure had the potential risk of the facility having a lack of staff who were properly trained in CPR readily available to respond in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice for 2 of 3 residents (Residents 33 and 27), reviewed for quality of care. This failure placed the residents at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 3 of 6 sampled residents (Residents 19, 27, and 10) reviewed in a Restorative Nursing Program (RNP) for positioning, range of motion (ROM), and hand splinting, received consistent services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of consistently following documented care plans and providing services to identified residents. This failure of not following the restorative care plans on a consistent basis increased the residents at risk of being unable to maintain their current level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder (develops in some people who have experienced a shocking, scary, or dangerous event) for 1of 2 residents (Resident 64) reviewed for mood and behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) care plan in collaboration with contracted hospice services, that identified the provider responsible for performing each or any specific services/functions for 2 of 3 sampled residents (Residents 21 and 43) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were transferred to the Resident's Representative (RR) within 30 days of death, for 1 of 2 discharged residents (Resident 120) reviewed for conveyance of funds to the RR after death of Resident. This failure placed the RR at risk for loss of funds.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that documented resident specific goals, physician orders, treatment plans and social services needs for 5 of 5 residents (Residents 1, 2, 3, 4 and 5) reviewed for baseline care plan. This failure place residents at risk of not receiving necessary care and services and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to privacy, security, and confidentiality when a staff member relayed confidential information to a visiting family member for 1 of 1 resident (Resident 2) reviewed for personal privacy/confidentiality of records. This failed practice placed residents at risk for the loss of confidentiality and privacy and the right to have their preferences honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care and services according to standards of practice when they failed to timely implement their grievance process for 3 of 3 residents (Residents 3, 4, and 5) reviewed for grievances. This failed practice placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report suspected allegations of abuse and/or neglect to the State Agency for 1 of 1 resident (Resident 1) reviewed for abuse/neglect. This failed practice placed the residents at risk for unidentified and ongoing abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation into an allegation of abuse and did not protect the resident from further potential abuse when the Alleged Perpetrator (AP) was not removed for 1 of 1 resident (Resident1) reviewed for abuse. This failed practice placed residents at risk for unidentified abuse, unmet emotional needs, and the continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to document in the medical record any discussions regarding Advanced Directives (AD), including incorporation into the care planning process, for 2 of 3 residents (Residents 1 and 2) reviewed for AD. This failure placed the residents at risk of losing their right to have their preferences/decisions followed regarding end-of-life care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) and to implement wound treatments timely to avoid worsening of a PU/PI for 3 of 3 residents (Residents 20, 41, and 60), who had multiple co-morbidities with an increased risk for PU/PI, reviewed for PU/PI. Resident 20 experienced harm when they developed a Stage II PI (partial thickness skin loss with exposed top inner layers of skin) to their right buttock and an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their left buttock, and expressed significant pain and discomfort. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 14 of 14 residents (Residents 54, 10, 5, 28, 55, 25, 41, 20, 60, 59, 2, 3, 26, and 276) as evidenced by failures related to Resident Rights, Resident Mobility, Activities of Daily Living (ADLs), Quality of Care, Urinary Catheters, Pressure Injuries, Accident Prevention, Infection Control Practices, and Competent Staff. Additionally, reports in the facility grievance logbook, resident council meeting interviews, and staff interviews provided evidence of insufficient staff. These failures placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage [(NOMNC) a notice that indicates when your care is set to end from a skilled nursing facility] as required for 3 of 3 residents (Resident 280, 281, and 67) reviewed for beneficiary notification. Additionally, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] for 1 of 1 resident (Resident 67) reviewed for ABN requirements. These failures placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive resident-centered care plans consistent with the residents identified care needs for 2 of 6 residents (Resident's 4, and 60) reviewed for accuracy of care plans. This failure placed residents at risk for not receiving appropriate goods and services consistent with their identified care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 5 of 11 residents (Residents 5, 28, 54, 55, and 10) reviewed for activities of daily living (ADLs). The failure to receive adequate showering and grooming care according to the residents' care plan placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 4 residents (Resident's 7 and 26), reviewed for unnecessary medications, had adequate monitoring and assessment for the use of psychotropic medications (medications that alter brain activity of mental functioning and behavior). The facility did not ensure as needed psychotropic medications had stop dates as required or consistently perform assessments for abnormal voluntary movement (AIMS) testing with the use of antipsychotic medications [a class psychotropic medication that has a high risk for serious adverse side effects (ASE)]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions [(EBPs) an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities] were implemented for 7 of 7 Residents (2, 3, 20, 26, 41, 60, and 276) reviewed for infection control practices. The failure to identify, provide appropriate signage, and educate residents and staff on the need for EBPs placed all residents at risk for exposure, transmission of MDRO's, and serious medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident care equipment in a fully functional manner, for 3 of 3 mechanical lifts (Lift's 1, 2, and 3) reviewed for safety. This failure placed residents who were dependent for transfers at risk for injuries and potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for 3 of 3 residents (Residents 54, 10, and 5) reviewed for dignity. The failure to shower residents on a regular basis placed the residents at risk for distress, embarrassment, and an undignified existence.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to the resident and their representative of the facility's intention and justification for the discharge of 4 of 4 residents (Resident 50, 4, Unidentified Resident 1, and Unidentified Resident 2) reviewed for facility-initiated discharges. Additionally, the facility failed to send a legible copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes). This failed practice disallowed the resident and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 1 of 2 residents (Resident 50) reviewed for hospital transfers. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy and completion of a Preadmission Screening and Resident Review (PASARR) for 2 of 7 residents (Residents 10 and 36) reviewed for PASARR Level 1. This failed practice placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and provide to the resident and/or resident representative, a baseline care plan within 48 hours of admission that documented resident specific initial goals, physician orders, and treatment plans for 2 of 2 newly admitted residents (Residents 20 and 59) reviewed for baseline careplans. This failure placed the residents at risk of not receiving continuity of care and resident centered care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the ongoing review, coordination of care conferences, and revisions to care plans were implemented for 4 of 4 residents (Resident 28, 35, 54 and 55) reviewed for care planning. This failure placed the residents at risk for unmet care needs and decreased quality of life. Findings including . <Resident 28> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory), anxiety (a feeling of worry, nervousness, or unease), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The comprehensive assessment dated [DATE] showed Resident 28 required maximal assistance for activities of daily living (ADLs) and had moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide goods and services that met professional standards of care for 1 of 1 resident (Resident 41) reviewed for quality of care. Resident 41 had referrals for follow up with specialized physicians (a group of physicians who focus on specific illnesses or diseases) related to their complicated medical condition. The facility failed to follow through with the referrals which placed the resident at risk for a decline in their health status.

Inspectors wroteon 5/14/2024, 0505/15/2024, Based on observation, interview, and record review, the facility failed to provide services to prevent a potential reduction in range of motion for 2 of 2 residents (Residents 55 and 25) reviewed for range of motion and/or use of splints. This failure placed the residents at risk for decreased mobility and loss of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate staff supervision during dining for 2 of 2 residents (Residents 20 and 59), and to provide a safe, functional environment for 5 of 5 shower rooms (South Hall shower room [ROOM NUMBER], shower room [ROOM NUMBER], North Hall shower room [ROOM NUMBER], shower room [ROOM NUMBER], and shower room [ROOM NUMBER]) reviewed for accidents. These failures placed the residents at risk of choking episodes, aspiration (when food or liquid enters the airways or lungs), access to toxic (a substance that can be poisonous or cause adverse health effects) chemicals, and dissatisfaction with their shower experiences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate justification for the placement of a urinary catheter (a flexible tube inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) for 1 of 1 resident (Resident 54) reviewed for placement of a urinary catheter. Additionally, the facility failed to ensure the appropriate care and use of a urinary catheter for 1 of 1 resident (Resident 3) by positioning the catheter drainage bag below the level of the bladder to prevent infection during a transfer with the mechanical lift. This failure placed the residents at risk for urinary tract infections (UTIs) and serious medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with accepted standards of practice for 1 of 1 resident (Resident 2) reviewed for respiratory care and treatment. This deficient practice placed the resident at an increased risk of respiratory and tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe.) status complications, including infection and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services were consistent with professional standards of practice for 1 of 1 resident (Resident 4) reviewed for dialysis services. The failure to monitor Resident 4's condition before and after dialysis treatments, complete a comprehensive care plan, adhere to a fluid restriction, provide ongoing communication, and collaboration with the dialysis facility, ensure a current written agreement was in effect between the facility and the dialysis facility, and ensure policies and procedures were developed and implemented placed the resident at risk for complications and adverse medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing, monitoring, or treating past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event] for 1 of 2 residents (Resident 10) reviewed for mood and behavior. This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets, which included documented demonstration, necessary to safely and efficiently perform care for residents' needs in the area of Peripherally Inserted Central Catheter [(PICC) - a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term administration of antibiotics, medications, nutrition, and blood draws] line for 2 of 2 nursing staff (Staff Q and R) reviewed for staff competencies. This failure placed residents at risk for adverse outcomes related to PICC lines and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure mental and psychosocial health needs were identified and met for 1 of 1 resident (Resident 10) reviewed for behavioral health. Failure to identify and utilize person-centered interventions placed the resident at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's physician order of heparin (a substance that slows the formation of blood clots) was not implemented as observed during the medication administration observation, resulting in a significant medication error for 1 of 3 residents (Resident 276) was free from significant medication errors. This failure placed the resident at risk for adverse complications from the significant medication error and an unmet care needs. Findings including . Review of the policy titled, Administering Medications, dated June 2023, showed that all medications would be passed according to physician orders and medication guidelines. The licensed nurse were to follow general guidelines for safe and accurate medication administration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide the vital services needed for wound healing and treatment of serious infection by consistently providing dressing changes and initiating antibiotics timely for 3 of 3 residents (Resident's 1, 2 and 8) reviewed for pressure injuries (wounds over a bone caused by pressure). Resident 1 experienced harm when the Stage 4 pressure injury (a wound with full tissue loss and exposed bone, tendon and muscle) that was acquired at the facility worsened, they experienced pain and the osteomelitis (a high risk infection in the bone that can lead to full body system wide infection) was not treated timely. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their resident representatives (RR) provided an informed consent (the process in which a health care staff educates a resident and/or their RR about the risks, benefits, and alternatives treatment of a given procedure, intervention, or medication therapy and obtains the resident consent), in advance of implementing psychotropic (a type of drug [like antidepressants, anti-anxiety, and antipsychotics] that affects brain activities associated with mental processes and behaviors) medications for 2 of 3 residents (Residents 3 and 4) reviewed for psychotropic medications. [...]

Inspectors wroteBased on interview and record review the facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program that identified or corrected deficiencies related to the facility's skin program that did not meet professional standards for pressure injury care for 3 of 3 residents (Resident's 1, 2 and 8) reviewed for pressure injuries. This failure resulted in an emergent situation and placed other residents at risk to receive poor quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure goods and services were provided to avoid a decline in condition for 1 of 1 resident (Resident 1), reviewed for neglect. The facility did not follow through with a physician referral in a timely manner for a diagnostic test magnetic resonance imaging (MRI, an imaging examination to determine an extent of an injury) and a referral to a neurologist (a physician that specializes in the function and treatment of the neurological system). Resident 1 experienced harm when they had a decline in some of their fine motor skills, had increased pain, and anxiety. These failures placed other residents at risk for unmet care services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was adequately assessed/monitored after an unwitnessed fall which resulted in a lack of timely diagnosis/treatment for a major injury and the resident experiencing unnecessary pain for four days, before they were hospitalized for their right hip pain, for 1 of 3 residents (Resident 2), reviewed for falls. Resident 2 was harmed when they experienced unrelieved pain and distress after the fall on 02/08/2024, required hospitalization on 02/12/2024, and was diagnosed with a right femur (thigh bone) fracture. These failures placed all residents at an increased risk for delay in care, poor health outcomes, and a worsening of their medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure they did not employ staff with negative disqualifying crimes for 1 of 5 staff sampled, (Staff E) with a negative disqualifying finding on a background check for work with vulnerable adults. This failure placed residents at risk for possible abuse.

Inspectors wroteBased on interview and record review the facility failed to timely identify and initiate medical treatment for a pressure ulcer (PU, localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer and may be painful) present on admission for 1 of 3 residents (Resident 2) reviewed for pressure ulcers. This failure placed the resident at risk for worsening of the wound, increased discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the conveyance of the trust funds and a final accounting of the trust funds for two of two residents (12 and 15) reviewed for final accounting of the trust funds, were returned within thirty days of discharge. This failure placed the residents and /or their representatives at increased risk for financial loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate neglect for one of two residents (38) reviewed for abuse and/or neglect. This failure prevented the facility from identifying the extent and nature of the occurrence and placed the resident at risk for unidentified neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-Admissions Screening and Resident Review (PASARR) assessment was accurately completed upon or prior to admission to the facility or updated during a change in condition for three of six residents (8,16, and 21) reviewed for PASARR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health (MH) and/or developmentally disability (DD) care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain effective communication, hearing, and vision methods to carry out the activities of daily living for one of three residents (8), reviewed for communication and sensory. This failed practice put the resident at risk for unmet care needs, decreased independence, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two residents (55 and 17) reviewed for accidents, were free from hot liquid spills. The residents were served hot beverages without placing lids on the cups which resulted in spills and put them at risk for burns. Additionally, Resident 55 did not have their skin assessed after the incident which placed them at further risk for unidentified injury and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for one of two residents (8) reviewed for trauma-informed care. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure staff followed Washington State law for the disposition (the process of destroying unused medications) of Controlled Substance/Schedule Drugs (categories of drugs regulated by the U.S. government and classified based on their potential for abuse, potential to cause dependence and their accepted medical use) for two of three medication carts (North Cart 2 and South Cart 1) reviewed for destruction of controlled medications, by not having the controlled medications destroyed by two of the following individuals: A licensed pharmacist, the director of nursing or a registered nurse designee, and a registered nurse employee of the facility. Findings Included . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate was less than 5 percent (%). During the medication administration observation task. Staff L, Medication Assistant Certified-Endorsed (MAC-E) made two medication errors, an error rate of 6.45%. This failure placed residents at risk for not receiving medications according to the physician orders and a diminished quality of life.

Inspectors wroteBased on observation, interview and, record review the facility failed to serve meals that were at an appetizing temperature and palatable for 3 of 7 residents (4, 25, and 10) reviewed for meal satisfaction. Failure to serve food at the proper temperature, placed all residents at risk for decreased nutritional intake and food borne illness.