Landmark of Itasca Rehabilitation and Nursing Cent

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to provide sufficient food to meet the daily nutritional requirements of residents and serve the facility planned/approved menu. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/18/26 at 11:58 AM when the facility failed to maintain two days' worth of food supplies on hand, failed to purchase food in quantities/quality to be able to serve all residents the planned, palatable menu, and failed to have sufficient food to serve double portions and dietary supplements to residents with recent significant weight loss. This applies to 14 of 14 residents (R11, R15, R16, R21, R22, R23, R24, R25, R27, R28, R30, R31, R32, and R33) reviewed for residents with significant weight loss and has the potential to apply to all 125 residents on oral diets at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer a food service operation in a manner to provide adequate quality/quantities of food to residents of the facility. This applies to all 125 residents receiving oral diets at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities as scheduled on the posted activities calendar. This applies to 4 of 4 residents (R1, R2, R3, R48) reviewed for activities in a sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse by employees. This applies to 2 of 3 residents (R3 and R4) reviewed for abuse in a sample of 10. R3's EMR (Electronic Medical Record) showed R3's diagnoses, including dementia, Alzheimer's disease, psychosis, mental disorder, schizophrenia, bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder. The writer made multiple attempts from 04/21/2026 to 04/24/2026 to speak with R3, but R3 refused to speak. R3's MDS (Minimum Data Set) dated 04/03/2026 showed that R3's cognition is intact and she is independent in her activities of daily living. R1's care plan dated 03/24/2026 showed R3 will remain safe, will be treated with respect and dignity, and reside in the facility free of mistreatment, including abuse/neglect. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement the facility's abuse prevention program policy that prohibits and prevents abuse, investigates allegations of abuse, protects residents during investigation, and reports abuse. This applies to 1 of 3 residents (R4) reviewed for abuse in a sample of 10. On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said that when she spoke to V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility. The next day, V1 (Administrator) spoke with her and did nothing about it. [...]

Inspectors wroteBased on the interview and record review, the facility failed to implement policies and procedures to investigate and report employee abuse to the State Agency and to protect a resident from further abuse by the alleged employee. This applies to 1 of 3 (R4) residents reviewed for abuse in a sample of 10. On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said when she questioned V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility. The next day, R4 said V1 (Administrator) spoke with her about the incident and did nothing about it. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that an allegation of an employee abusing residents was thoroughly investigated and that corrective action was taken. This applies to 1 of 3 residents (R3) reviewed for abuse in a sample of 10. R3's EMR (Electronic Medical Record) showed R3 has diagnoses that included dementia, Alzheimer's disease, psychosis, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. R3's MDS (Minimum Data Set) dated 04/03/2026 showed that R3's cognition is intact and that she is independent in her activities of daily living. R3's care plan dated 03/24/2026 showed R3 will remain safe, will be treated with respect and dignity, and reside in the facility free of mistreatment, including abuse/neglect. The writer made multiple attempts from 04/21/2026 to 04/24/2026 to speak with R3, but R3 refused to speak. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities to residents. This applies to 4 of 4 residents (R2, R3, R7, R10) who were reviewed for activities in a sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent from a resident or POA (Power of Attorney) prior to taking pictures of the resident. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to arrange and provide transportation for out of facility nephrology medical appointments for residents. This applies to 6 of 6 residents (R1, R8, R9, R10, R11, and R12) reviewed for appointments in a sample of 12.

Inspectors wroteBased on interview and record review the facility failed to treat residents with dignity and respect for 1 of 4 residents (R1) reviewed for resident's rights in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and assess a pressure wound prior to it becoming a Stage III wound for 1 of 5 residents (R2) reviewed for pressure ulcers in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and/or follow Enhanced Barrier Precautions (EBP) for 2 of 3 residents (R2 and R5) reviewed for infection control in the sample of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's mail was not opened prior to delivering it to the resident. This applies to 2 of 9 residents (R7 and R13) reviewed for resident rights in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received yogurt with breakfast per resident preference. This applies to 1 of 8 residents reviewed for dietary services in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who are dependent on the facility for ADLs (Activities of Daily Living) such as feeding, dressing, and incontinence care are provided the necessary assistance in a timely manner. This applies to 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed for ADLs in the sample of 12.

Inspectors wroteBased on observations interview and record review, the facility failed to provide portions as shown on the menu spreadsheet. This applies to all residents that receive foods prepared in the facility kitchen.

Inspectors wroteBased on observations interview and record review, the facility failed to serve meals at required meal temperatures and appearance/consistency for palatability. This applies to all residents that receive foods prepared in the facility kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a substantial evening snack when the mealtimes exceed 14 hours per resident. This applies to all residents that receive foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an effective pest control program and failed to respond to sightings of rodent excrement, and dead and live rodents. The facility failed to take measures to eradicate and contain rodents including patching holes in walls, informing pest control vendor of rodent sightings, provide effective room cleaning, and staff failed to notify the Administrator of any evidence of pest or rodent presence in accordance with facility policy. This has the potential to affect all 126 residents who reside in the facility as reported on the Facility Data Sheet, dated November 18, 2025, completed by V1 (Administrator).

Inspectors wroteBased on observation and record review, the facility failed to serve residents with non-disposable cutlery. This applies to 6 of 6 residents (R5, R37, R38, R39, R40, R41) reviewed for dietary services in the sample of 41.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide meal preference as shown on the meal tickets. This applies to 5 of 5 residents (R13, R21, R31, R32, R33) observed for dietary services in the sample of 41.

Inspectors wroteBased on observations interview and record review, the facility failed to serve diets as ordered. This applies to 8 of 8 residents (R1, R21, R22, R23, R24, R25, R26, R27) reviewed for dietary services in the sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from physical abuse. This failure applies to 2 of 5 residents (R4 and R5) reviewed for abuse in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with a history of elopement was appropriately assessed and/or monitored to prevent elopement, failed to identify and assess residents who actively seek exits or display elopement behaviors, failed to ensure all exit doors/windows were secured/monitored, failed to promptly/effectively respond to triggered door alarms and perform a resident head count, and failed to maintain a current list of residents at risk for elopement at the front door exit per facility policy and resident care plans. The Immediate Jeopardy began on 11/4/25 at approximately 10:20 PM when R1 removed window lock hardware, tied bed sheets together, and repelled out of a second-floor window of the facility with temperatures at approximately 55-56 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified full time Social Services Director. This applies to all 129 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary monitoring and supervision for a resident with a history of suicidal ideation and a history of obtaining knives. The facility also failed to have a system in place to accurately screen residents for suicide risk in a timely manner, and ensure residents with suicide risk were identified, and interventions were put in place. This failure resulted in R1 sustaining self-inflicted stab wounds and expiring at the facility from apparent suicide. This failure resulted in Immediate Jeopardy when the facility lacked interventions and processes to protect a resident with a history of suicidal ideation from keeping sharp knives in his room and sustaining self-inflicted stab wounds and expiring from apparent suicide. [...]

Inspectors wroteBased on interview and record review, the administration failed to provide oversight and leadership to ensure staff is qualified to work as a Social Service Director. The administration also failed to ensure self-harm/suicide risk screening assessments were completed accurately, timely, and individualized and measurable care plan interventions were put in place for residents identified at risk for suicide. This applies to all 130 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. This applies to all 130 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food portions as shown on the facility menu spreadsheet. This applies to 129 facility residents receiving oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy to serve food at a palatable temperature. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for dietary services in the sample 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to plan and serve resident menus and food portions per facility policy. This applies to all 128 facility residents receiving oral diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve palatable meals per facility policy. This applies to all 128 facility residents receiving oral diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve meals on time to residents per the facility meal schedule. This applies to all 128 facility residents receiving oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene after touching soiled dishes and failed to store foods to prevent cross contamination. The facility also failed to sanitize equipment prior to use and failed to utilize food service supplies to avoid potential chemical contamination of foods. This applies to all 128 facility residents receiving oral diets.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of physical abuse. This applies to 4 of 4 residents (R10, R15, R21, and R24) reviewed for abuse in a sample of 25.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide dementia care and behavioral interventions to a resident who had chronic dementia-related behaviors. This applies to 1 of 3 residents (R25) reviewed for behavior management in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared for residents were nutritive, palatable, and attractive. This applies to all 119 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician orders for dietary supplements to prevent further weight loss in a resident with significant weight loss. This failure resulted in R38 experiencing significant weight loss ( 7.87% weight loss in one month and10.72% weight loss in six months). This applies to 1 of 3 residents (R38) reviewed for nutrition in the sample of 25.

Inspectors wroteBased on interview, and record review, the facility failed to implement their abuse policy to conduct background checks on employees prior to working in the facility. This applies to all 125 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to plan and serve the facility menu per facility policy. This applies to all 123 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene and utilize chemical sanitizing solution in a three compartment sink per facility policy. This applies to all 123 residents residing in the facility and receiving oral diets.

Inspectors wroteBased on interview and record review, the administration failed to ensure healthcare worker background checks were being completed for newly hired staff. This applies to all 125 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to include the Medical Director in attendance at facility QAPI (Quality Assurance Performance Improvement) meetings per facility policy. This applies to all 125 residents residing in the facility.

Inspectors wrote2. R67's admission record showed R67 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, schizophrenia, hypertensive heart disease and conversion disorder with seizures or convulsions. R67's physician orders showed R67's scheduled medication for 9:00 AM included Probiotic Oral Capsule 250 MG (Saccharomyces boulardii) give 1 capsule by mouth one time a day, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) give 500 mg by mouth two times a day, Metoprolol Tartrate Oral Tablet 50 MG give 1 tablet by mouth two times a day, and diltiazem HCl Oral Tablet 60 MG give 1 tablet by mouth four times a day. On April 29, 2025, at 9:16 AM, V7 (LPN) was preparing R67's medications. V7 had long artificial nails, painted with white polish and did not perform hand hygiene prior to putting R67's medications into the cup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from the active medication cart and discarded. The facility also failed to label, and date opened eye drops to determine the expiration date. This applies to 7 of 7 residents (R72, R90, R48, R69, R37, R9, and R24) reviewed for medication labeling and storage in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications. This applies to 8 of 8 residents (R54, R116, R73, R9, R15, R97, R37 and R78) reviewed for controlled medications in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to perform monitoring on a resident after an incident. This applies to 1 of 1 resident (R37) reviewed for accidents in the sample of 25.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide positioning devices for hands that had contractures and limited range of motion. This applies to 2 of 2 residents (R18 and R20) reviewed for limited range of motion in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident for PTSD (Post-Traumatic Stress Disorder), identify their PTSD triggers, and develop interventions to aid in the management of the residents PTSD. This applies to 1 of 2 residents (R63) in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as prescribed. There were 27 opportunities with 4 errors resulting in a medication error rate of 14.81%. This applies to 2 of 6 residents (R9, R69) residents reviewed for medication administration in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident utilizing a mechanical lift as per facility policy. This failure resulted in R1 experiencing pain and discomfort related to numerous facial fractures, a left periorbital hematoma, nondisplaced fracture of C2, left frontal subdural hematoma along the left frontal convexity, and hemorrhage within the bilateral maxillary and bilateral sphenoid sinus caused by the fall. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain good personal hygiene for 5 of 5 residents (R1, R2, R3, R4 and R5) reviewed for ADLs (activities of daily living) in a sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a call light accessible to dependent residents. This applies to 3 of 3 residents (R1, R2 and R3) reviewed for accommodation of needs in a sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assisted to reposition in bed. This applies to 3 of 6 residents (R3, R4 and R5) reviewed for ADLs (activities of daily living) in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical records included complete documentation of a resident's death. This applies to 1 of 3 residents (R12) reviewed for medical records in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' privacy, as staff took photographs of residents, with a mobile device, without the resident's consent. This applies to 4 of 4 (R6, R9, R10, R11) residents reviewed for resident privacy. On September 10, 2024, at 4:20 PM, V33 (CNA) stated she had taken photos of residents in the facility on May 19, 2023, May 21, 2023, and June 1, 2023, on the dementia unit. V33 stated she had shared the photos with V46 (CNA). On September 11, 2023, at 1:22 PM, V38 (CNA) stated V46 showed the photographs V33 sent to her via cell phone, to both herself and V24 (CNA). On September 12, 2024, at 1:05 PM, V1 (Administrator) and V2 (Director of Nursing) reviewed photos that V1 stated she had received from V46 that were identified as having been taken by V33. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to immediately report suspicions of abuse in accordance with their policy. This applies to 4 of 4 (R6, R9, R10, R11) residents reviewed for allegations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered with licensed nurse supervision. This applies to 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to prevent a resident from being served food that was spoiled. This applies to 1 of 3 residents (R2) reviewed for spoiled food in a sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 2 of 4 residents (R1, R2) reviewed for activities of daily (ADL) care in a sample of 7. The Findings Include: 1. R1 is a [AGE] year-old male admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 is dependent on toileting hygiene. On 8/20/24 at 10:07 AM, R1 was in his bed and upon the surveyor's request V4 (Licensed Practical Nurse) checked on R1 for incontinence. R1 was observed with double diaper with the inner diaper soaked in urine with blackish discoloration. On 8/20/24 at 10:10 AM, V4 stated, R1's certified nursing assistant (CNA) is changing another resident and I will change R1. [...]

Inspectors wroteBased on interview and record review, the facility failed to successfully notify the resident's legal representative regarding a significant change in condition for R3 who was sent out to the hospital. This applies to 1 of 4 residents (R3) reviewed for significant change in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide privacy and confidentiality for a resident by posting her photo on social media without her permission. This applies to 1 of 3 residents (R1) reviewed for privacy and photography in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to use the proper equipment to transfer a resident resulting in a left femur fracture that required surgical repair. This applies to 1 of 2 (R7) residents reviewed for hospitalizations in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter cares for residents with indwelling urinary catheters, and failed to ensure a catheter collection bag was placed below the level of the bladder. This applies to 4 of 4 (R33, R39, R68, and R122) reviewed for catheters in a sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders for resident medications to be at the bedside. The facility also failed to complete self-administration of medication assessments for residents. This applies to 3 of 10 residents (R29, R45, R106) reviewed for medications in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure linens were handled in a manner to prevent transmission of micro-organisms and failed to cleanse and sanitize hands to prevent cross-contamination. This applies to 3 of 3 residents (R114, R97 and R122) reviewed for infection control in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from mental abuse and mistreatment by V6 (CNA-Certified Nursing Assistant). This applies to 1 of 3 residents (R1) reviewed for mental abuse in the sample of 4.

Inspectors wroteBased on observation and interview, the facility failed to ensure elevators were maintained in safe, operating condition. This applies to 1 of 3 residents (R1) reviewed for furnishings/equipment not maintained in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's right to receive mail for 1 of 3 residents (R2) reviewed for resident rights in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received an antibiotic ear medication in a timely manner for 1 of 3 residents (R1) reviewed for medications in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for a resident (R1) with a known history of physical aggression. This failure resulted in (R1) grabbing (R4) around the neck, throwing him to the ground, and R4 hitting his head on the floor. (R4) was transferred to a local hospital for evaluation of a head injury. This failure has the potential to affect all residents in the building as R1 is ambulatory throughout all units of facility and accesses the elevator independently.

Inspectors wroteBased on observation, interview and record review the facility failed to assess the risk for developing a pressure ulcer, failed to identify and assess a facility acquired pressure ulcer and failed to follow physician's orders for treatment. This applies to 3 of 3 residents (R3, R4, R5) reviewed for pressure ulcer in the sample of 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to have menus and serve portion servings to meet nutrient needs that are approved in advance by a licensed Dietitian. This applies to all 123 residents that receive oral diets prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care, hygiene, and grooming for residents who require staff assistance for activities of daily living (ADL) care. This applies to 4 of 7 residents (R71, R90, R47, R84) reviewed for ADL care in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform quarterly activity assessments and failed to provide residents with activities that promote their sense of well-being and meet their interests. This applies to 4 of 4 residents (R11, R20, R48, R87) reviewed for activities in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide perineal and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 6 residents (R20, R21, R82, R220) reviewed for incontinence and catheter care in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label medication of when it was opened to determine the expiration date. This applies to 5 of 6 residents (R12, R31, R86, R88, R221) reviewed during medication storage and labeling inspection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve yogurt for food preference as shown on diet cards. This applies to 4 of 4 residents (R26, R39, R46, R63) observed for dining in the sample of 26.

Inspectors wroteBased on observation, and interview, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provision of incontinence care. This applies to 5 of the 26 residents (R20, R21, R47, R82, R220) reviewed for infection control in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a POLST (Physician Ordered Life Sustaining Treatment) form signed by the physician before designating a resident as a DNR (Do Not Resuscitate) status. This applies to 1 of 2 residents (R109) reviewed for advanced directives in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident receives foot care and treatment for overgrown, thick and painful toenails. This applies to 1 of 1 resident (R84) reviewed for foot care in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and provide adaptive equipment and services to residents to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 9 residents (R80, R84) reviewed for mobility and range of motion in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for a resident identified as a high elopement risk. This applies to 1 of 3 residents (R370) reviewed for elopement in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify placement of gastrostomy tube (g-tube) prior to flushing the g-tube with water and administering medications through the g-tube. This applies to 2 of 2 residents (R25, R47) reviewed for gastrostomy tube (g-tube) in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident did not receive unnecessary psychotropic medications. This applies to 3 of 5 residents (R109, R370, and R72) reviewed for unnecessary psychotropic medications in the sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve diet consistency for residents that have swallowing problems. This applies to 2 of 2 residents (R22, R60) reviewed for dining in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide appropriate assistive eating device to maintain ability to eat independently for a resident identified with limited ROM (range of motion) of the upper extremities. This applies to 1 of 1 resident (R84) reviewed for assistive eating device in the sample of 26.