Lawson Manor & Rehab

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) from misappropriation of his/her property, when an employee took the resident's narcotic (highly addictive prescription medication) medication. The facility census was 41. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, showed:-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation;-The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:-Protect resident from misappropriation of property by anyone including, facility staff;-Develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of resident property. [...]

Inspectors wroteBased on interview and record review, the facility failed to report Resident #1's missing narcotic (a highly addictive medication) medication to the state survey agency within the required time frame. This deficient practice affected one of four sampled residents. The facility census was 41. Review of the facility's Abuse Investigation and Reporting policy, dated July 2017, showed:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -All alleged violations, including misappropriation of property will be reported by the facility Administrator, or designee, to the State licensing and certification agency; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a safe and effective medication system when staff did not follow facility policies and procedures in counting narcotic medications, a card of oxycodone medication (a highly addictive prescription medication used to treat severe pain), for one resident (Resident #1). Additionally, staff removed multiple doses of oxycodone from the facility's emergency medication kit at one time without the need for all of the doses to be removed from the emergency medication kit. The facility census was 41. Review of the facility policy titled, Controlled Substances, dated November 2022, showed:-The facility was supposed to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect Resident#1's right to be free from abuse when he/she was choked around the neck by another resident (Resident #2) causing redness to Resident #1's neck and Resident #1 feared Resident #2. Facility census was 48. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, showed:-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; [...]

Inspectors wroteBased on interview and record review, the facility failed protect one sampled resident's (Resident #1) right to be free from physical abuse when Resident #2 grabbed Resident #1 by his/her arms and pushed him/her backwards causing Resident #1 to fall and sustain a skin tear approximately 3 inches in length to the underside of the resident's left arm. The facility census was 44. On 7/30/25, the Administrator was notified of the past noncompliance which began on 7/23/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 7/28/25. Review of the facility's Abuse Policy, revised April 2021.,showed: -The residents have the right to be free from abuse. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner in the memory care unit, failed to maintain the dining room in a clean and sanitary manner, and failed to ensure the kitchen serving area was is good repair. This had the potential to affect all residents residing on the memory care unit. The facility census was 42. The facility did not provide the requested policy on cleaning and repair of the kitchen. 1. Observation of the dining room and food serving area of the memory care unit on 06/02/25 at 10:38 A.M. showed: -The inside of the microwave was covered with food debris; -The inside of the refrigerator has a brown sticky substance in the bottom of the refrigerator with red droplet marks running down the inside walls of the refrigerator; -A plate of covered food with no name and no date was in the refrigerator; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account when the facility did not provide residents with refunds from their personal funds from the facilities operating account in a timely manner for six residents (Resident #38, #148, #149, #150, #151 and #152). The facility census was 42. Review of the facility policy, Conveyance of Resident Funds, dated 3/2001, showed: -Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death; -The resident's personal funds and final accounting of funds are returned to the resident, the resident representative, or to the resident's estate, within 30 days from the date of the resident's discharge, death, or eviction from the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 42. Review of the facility policy, Surety Bond, dated 3/2021, showed: -Our facility had a current surety bond to assure the security of all residents' personal funds deposited with the facility; -All funds (including refundable deposits) entrusted to the facility for a resident are covered by the facility on behalf of its residents; -The purpose of a surety bond is to guarantee that the facility will pay for the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents' funds. Review of the facility maintained Resident Trust Bank Statements for the period 05/2024 through 04/2025, showed an average monthly balance of $56,867.19. [...]

Inspectors wrote2. Review of resident's Outside the Hospital Do Not Resuscitate Order (OHDNR) signed [DATE] showed the resident code status as DNR. Review of Resident #33's admission Assessment, dated [DATE], showed: -Resident had moderate cognitive impairment; -Diagnoses included stroke, diabetes, ashtma, depression, and anxiety. Review of physician's orders, dated [DATE], showed an active order for DNR (Do Not Resuscitate), as of [DATE]. Review of the resident's care plan, dated, [DATE], showed: -Resident was a full code -Resident's wishes would be followed through the next review date. -Check POS for current code status. During an interview on [DATE] at 11:29 A.M., the Administrator said all locations where the code status is listed should match. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, or develop a care plan that showed interventions for facility staff to utilize to protect the resident and prevent trauma from recurring for one resident who was identified as having a past tramatic event (Resident #19), out of 12 sampled residents. The facility census was 42. Review of facility policy, Trauma Informed Care, dated 2001, showed: -Purpose: To guide staff in providing care that is trauma-informed in accordance with professional standards of practice; -Trauma results from an event, series of events, or set of circumstances that is experienced by the individual as physically or emotionally harmful or life threatening that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being; [...]

Inspectors wroteRefer to Event ID NI0V12. Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46.

Inspectors wroteRefer to Event ID NI0V12. Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46.

Inspectors wroteRefer to Event ID NI0V12. Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46. The facility did not provide an NA certification policy. Review of the NA employee list showed: -NA A employed since 6/24/24; -NA B employed since 4/26/24; -NA C employed since 7/15/24; -NA D employed since 7/16/24; -NA E employed since 6/7/24; -NA F employed since 2/12/24. During an interview on 12/4/24 at 11:29 A.M., NA A said: -He/She was not enrolled in any Certified Nurse Aide class; -He/She had worked in facility since July 2024, and worked in facility last year from July 2023-November 2023. During an interview on 12/4/24 at 12:48 P.M., NA B said: -He/She was not enrolled in CNA class after working for the facility for six months; [...]

Inspectors wroteBased on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46. Review of facility policy, employee screening for tuberculosis, revised March 2021, showed: -All employees are screened for latent tuberculosis infection and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. -Newly hired employee is screened for LTBI and active TB disease after an employment offer had been made but prior to employee's duty assignment. Observation on 12/4/24 at 1:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's visitation rights were not restricted when Resident #6 had a visitor that was asked to leave and not permitted to visit the resident. This affected one of six sampled residents (Resident #6). The facility census was 47. Review of facility policy, Resident Rights, undated, showed: -Resident has right to receive visitors of their choosing at time of their choosing and interact and participate with members of community and activities inside and outside facility, subject to resident's right to deny visitation, and in a manner that did not impose on rights of another resident. -Facility must provide immediate access, subject to resident's right to deny or withdraw consent at any time to any resident by: -Immediate family and other relatives of resident; [...]

Inspectors wroteBased on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46. Review of facility policy, Abuse Investigation and Reporting, Revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be thoroughly investigated by facility management. -Individual conducting the investigation will as a minimum: [...]

Inspectors wroteBased on observations and interviews, the facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 40. The facility provided an undocumented time frame for when the facility had a DON working which showed: - A DON worked from 1/23/23 - 3/5/23; - A DON worked from 3/6/23 - 6/20/23; - A DON worked from 6/21/23 - 9/15/23; - A DON worked from 9/16/23 - 1/16/24; - A DON worked from 2/9/24 - 3/9/24. Observations from 3/12/24 through 3/15/24 and on 3/18/24, at various times showed the facility had charge nurses (CN) available, but did not have a DON. During an interview on 3/15/24 at 9:01 A.M., the Assistant Director of Nursing (ADON) said: - He/she did not know who the DON was; - He/she was the ADON but did not think they had a DON. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, temperature check food before it was served to residents, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 40 residents. 1. Review of facility policy, sanitation of dining and food service areas: -Dining service staff will uphold sanitation of the dining areas according to a thorough written schedule. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way, that any reasonable person would expect, when they failed to provide privacy by leaving window blinds open during a resident's morning care exposing the resident (Resident #8), Failed to respect privacy of a resident, when the facility posted personal information about a resident's daily care routine on wall above his/her bed for anyone to view, (Resident #20), and additionally failed to provide treat residents in a dignified manner when staff stood while feeding resident during meals (Resident #37) and when staff administered inhalers in the dining room, which affected one of 12 sampled residents, (Resident #17). The facility census was 40. Review of facility policy, dignity, revised February 2021, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide acceptable accommodation of needs for two (Resident #23 and #192) of 12 residents sampled when they did not provide Resident #23 access to toileting options in his/her room and when Resident #192's leg was secured to the leg rest of his/her wheel chair with a gait belt to keep it immobilized when the foot pedal was not long enough. The facility census was 40. Review of facility policy, accommodation of needs, dated March 2021, showed: -Facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. -Resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to promote self-determination for four of 12 sampled residents when the facility failed to allow two sampled residents to be toileted per their request (Resident #18 & Resident #8), failed to allow resident to stay in bed per his/her request (Resident #8), failed to honor residents preferences for AM showers (Resident #11), and failed to offer meal choices. (Resident #192). This impacted four of 12 sampled residents (Resident #8, #11, #18, and #192). The facility census was 40. Review of the facility policy, Resident Rights, revised February 2021, showed: -Resident's have the right to self-determination -Be supported by the facility in exercising his or her rights; -Right to privacy and confidentiality. Facility did not provide requested policy regarding self determination. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a system that assures a full and complete separate accounting, according to generallly accepted accounting principles when the facility allowed the petty cash balances to have a negative balance for two months. The facility census was 40. Facility did not provide a policy regarding resident funds accounts. Review of the facility petty cash log showed: -May 2023 a negative cash balance of $-92.93 -June 2023 a negative cash balance of $-73.73 Review of the facility Resident Trust Fund (RTF) bank reconciliation report showed: -May 2023 month ending: Note at bottom of page showed petty cash starting balance was off by $100.00. Business Office Manager will take this from facility Petty Cash to refund the RTF account. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond amount covering the Resident Trust Fund (RTF) account. The facility census was 40. Review of the DHSS database, which tracks the most up to date information regarding approved bonds for RTF accounts for all facilities that hold resident monies, on 3/13/24 at 1:07 P.M showed an approved bond amount of $65,000. Review of the Resident Funds Bond Worksheet, a form used by DHSS to determine the facility's bond should be and if they have the appropriate approved amount for their bond, showed: -The average balance for the previous twelve months in the facility's RTF bank account of $51,292.59 -After multiplying this amount by 1.5, the approved bond amount should be $76,500. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that two sampled resident's (Resident #10 and #37) advance directive (a legal document which allows resident to plan and make their own end-of life wishes known in the event they are unable to communicate) were clear and placed in the resident's medical record when the facility failed to show that one resident (Resident #10's) physician's orders did not show his/her code status and when one resident (Resident #37) did not have a letter of enacted incapacitation when the resident's durable power of attorney (DPOA) had a signed an Out of Hospital Do Not Resuscitate Order (OHDNR). The facility census was 40. Facility did not provide a requested policy regarding advance directives. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for all residents when they did not repair gouges in walls and missing paint in resident rooms (Resident #29 and #20), repair broken lights at resident's beds (Resident #11 and #20), fix and repair peeling ceiling paint in kitchen, when they did not repair a clogged sink in the memory care unit, clean vents in the ceiling of the memory care unit, clean base boards, repair large holes in parking lots, and maintain repairs in resident rooms. The facility census was 40. Facility did not provide an environmental policy. 1. Review of Resident #11's quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed: [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were aware of how to file a grievance or complaint. This affected any resident who wanted to file a grievance. The facility census was 40. The facility did not provide a policy related to grievances. 1. Review of the resident's council meeting minutes showed: - 11/14/23 - the minutes did not indicate if the residents knew how to file a grievance; - 12/14/23 - the minutes did not indicate if the residents knew how to file a grievance; - 1/4/24 - the minutes did not indicate if the residents knew how to file a grievance. During a group meeting on 3/14/24 at 2:56 P.M., five out of five residents who were alert and oriented said they did not know how to file a grievance or who the grievance officer was. During an interview on 3/14/24 at 1:55 P.M., the Activity Director said: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer of discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; [...]

Inspectors wroteBased on interviews and record review, the facility failed to inform residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for three of 12 sampled residents, (Resident #1, Resident #10 and Resident #192) and failed to have the resident or family/legal representative sign the bed hold which affected Resident #1. The facility census was 40. The facility did not provide a policy regarding bed holds. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/24 showed: - Cognitive skills intact; - Independent with eating, oral hygiene, transfers, personal hygiene, toilet use and dressing; - Occasionally incontinent of urine; - Continent of bowel; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care to include measurable objectives and appropriate timeframe's for two of 12 sampled residents (Resident #33 and Resident #36). The facility census was 40. The facility did not provide the requested comprehensive care plan policy. 1. Review of Resident #33's Quarterly MDS dated , 1/7/24, showed: -Severe cognitive impairment; -The resident has delusions (false beliefs or judgments about reality); -Limited assistance with ADLs; -Diagnosis included, Dementia, diabetes mellitus (a metabolic disease, involving elevated blood sugar levels), and heart failure. Review of the resident's POS, dated March 2024, showed: - Activities - per care plan - Start date: 4/26/23 - Novolog( rapid-acting insulin), 5 units three times before meals for diabetes mellitus. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff utilized an Inter Disciplinary Care Team to developed and updated a care plan consistent with resident's specific conditions and needs which affected two of 12 sampled residents, (Resident #10 and #1) when they did not update care with interventions regarding unexpected weight loss for (Resident #10) and when they did not include residents (Resident #1) in his/her care planning. The facility census was 40. Review of Resident #10's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/19/24, showed: --He/She had a Brief Interview Mental Status (BIMS) score of 15, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff followed professional standards of care when staff failed to administer medications with food, which affected three of 12 sampled residents, (Resident #7, Resident #15 and Resident #33). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24 showed: - Cognitive skills intact; - Independent with eating, personal hygiene, toilet use, dressing and transfers; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with Activity of Daily Living (ADL) received the necessary assistance with grooming, bathing and incontinent care when the facilty staff failed to ensure three residents (Resident #36, Resident #142, and Resident #20) received regular showers, failed to provide complete incontinence care for one resident (Resident #37), and when staff failed to provide oral care to two resident (Resident #8 and #20). The facility census was 40. Review of the facility's Activities of Daily Living (ADL) policy revised March 2018, showed: -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good grooming, oral care and personal hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected four residents (Residents #2, #30, #36 and #142) out of 12 sampled residents. The facility census was 40. Review of the facility's Activities Programs, revised June 2018, showed: -Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well being of each resident; -The activities is provided to support the well-being of resident's and to encourage independence community interaction; -Activities are based on the comprehensive resident-centered assessment and the preferences of each resident; [...]

Inspectors wroteBased observation, interviews, and record review, the facility staff failed to provide repositioning and incontinent care according to professional standards of practice for three residents (Resident #3, #18, and #37) who were dependent upon staff for mobility and assistance with cares. This affected three of twelve sampled residents. The facility census was 40. Facility did not provide the requested policy regarding positioning. 1. Review of Resident #3's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/25/24, showed: -He/She had a Brief Interview Mental Status (BIMS) score of 7, a brief cognitive screening tool used to measure and track resident's cognitive decline or improvement in long-term care, showed resident was severely cognitively impaired. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 40. Review of the facility's policy for nurse aide qualifications and training program, revised August, 2022 showed, in part: - Nurse aides must undergo a state-approved training program; - The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state. 1. Review of the NA employee list showed: - NA D employed since 9/5/23; - NA F employed since 7/26/23. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent (5%). Facility staff made seven medication errors out of 25 opportunities for error, resulting in a medication error rate of 28%. This affected four of 12 sampled residents, (Resident #6, Resident #9, Resident #15 and Resident #17). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders); [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff did not leave medications unattended in the resident's rooms and in the dining room, which affected three of 12 sampled residents, (Resident #7, Resident #9 and Resident #11). The facility census was 40. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame; - Medications are administered within one hour of their prescribed tie, unless otherwise specified (for example, before and after meal orders); [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to five of twelve sampled residents (Resident #192, #36, #7, #9, and #11) The facility had a census of 40. Review of facility policy, serving temperature for hot and cold foods, dated 2016, showed: -Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. These are minimum serving/holding temperatures and may vary based on state regulations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection prevention and control practices to help prevent the development and the transmission of communicable diseases as well as infections, when staff failed to administer medication in a safe manner, when staff used their bare fingers to administer medications to one resident (Resident #15), and when staff failed to wash or sanitize their hands and change gloves between dirty and clean tasks. Additionally, staff failed to follow infection prevention measures when staff placed soiled linens directly on the floor when providing incontinent care for one resident (Resident #37) and when facility staff failed to follow their Employee Screening for Tuberculosis policy for three of 10 sampled new hires. The facility census was 40. [...]

Inspectors wroteBased on interviews the facility staff failed to ensure residents had timely access to their personal funds after business hours and on the weekend. This affected one of 12 sampled resident's. Resident #11, was not able to access personal funds after hours. The facility census was 40. The facility did not provide policy on funds access. Review of facility policy, Resident Rights, revised February 2021, showed: -Access personal records pertaining to him or herself. -Manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes). 1. Review of Resident #11's Quarterly MDS, a federally mandated assessment tool completed by facility staff, dated 2/15/24, showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one of 12 sampled residents (Resident #192). The facility census was 40. Review of facility policy, administering pain medications, showed: -Pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care pan, and the resident's choice related to pain management. -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. -Pain management is a multidisciplinary care process that includes the following: -assessing the potential for pain; -Recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of the pain; [...]

Inspectors wroteBased on interview and record review, the facility failed to properly document a discharge to home for one of three discharged residents, (Resident #40). The facility census was 40. The facility did not provide a policy for discharge planning. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE] showed: - Long and short term memory problems; - Physical behavior directed at others occurred one to three days; - Verbal behavior directed at others occurred one to three days; - Substantial to maximal assistance with eating and transfers; - Dependent on the assistance of staff for oral hygiene, toilet use, showers, dressing and personal hygiene; - Always incontinent of bowel and bladder; - Diagnoses included dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety and depression. [...]

Inspectors wroteBased on interview and closed record review, the facility staff failed to complete a comprehensive discharge summary for one of three discharged residents, Resident #40. The facility census was 40. The facility did not provide a policy for discharge summaries. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), dated [DATE] showed: - Long and short term memory problems; - Physical behavior directed at others occurred one to three days; - Verbal behavior directed at others occurred one to three days; - Substantial to maximal assistance with eating and transfers; - Dependent on the assistance of staff for oral hygiene, toilet use, showers, dressing and personal hygiene; - Always incontinent of bowel and bladder; - Diagnoses included dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), who displayed behaviors of self-harm including a recent attempt to commit suicide on [DATE], and failed to verbally communicate with the resident's physician regarding the residents behaviors of attempted self harm and of the resident's death, at the time the death occurred. The facility additionally failed to provide appropriate interventions and monitoring when they relied on the resident's roommate to alert staff when he/she determined the the resident needed assistance. The facility census was 45. A review of the facility's Accidents and Incident Policy with a revision date of [DATE], showed: - All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate incontinence care for two residents who required assistance.(Resident #4 and #5) of seven sampled residents. The facility census was 46. The facility provided policy, Dementia Care, dated November 2018 showed in part: -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. 1. Review of Resident #4's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/24/23 showed: -Brief Interview of Mental Status (BIMS) of 99; indicated significant cognitive loss. -No behaviors -Partial to moderate assistance by staff for Activities of Daily Living (ADL's: [...]

Inspectors wroteBased on interview, and record review the facility failed to train staff to adequately care for one resident (Resident #7) with behavioral health care needs. The facility census was 46. Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022 showed in part: -Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work rules or occupational functions successfully. Staff must meet the skills and techniques necessary to care for resident needs including (but not limited to) Behavioral health, Psychosocial care, Dementia care, Person centered care, and Communication. Review of the facility policy Dementia-Clinical Protocol dated November 2018 showed in part: -Nursing assistants will receive training in the care of residents with dementia and related behaviors. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly investigate falls and put interventions in place for Resident #3 who had multiple falls. The facility census was 45. A review of the facility's Accidents and Incident Policy with a revision date of July 2017, showed: - All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator; -The nurse supervisor/charge nurse and/or the department or supervisor shall promptly initiate and document investigation of the accident or incident; -The following data shall be include on the report: o The date and time of the incident; o The nature of the injury; o The circumstances surrounding the incident; o The time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were certified within four months and failed to ensure nurse aides were in a state-approved training program. Facility census was 43. Review of facility policy, Nurse Aide Qualifications and Training Requirements, dated May 2019 showed: -Nurse aides must undergo a state-approved training program. -Facility will not employ any individual as a nurse aide for more than four months unless that individual is competent and has completed a training program or a program approved by the state. -Facility will not employ any individual as a nurse aide for less than four months unless the individual is participating in a state-approved training program. Review of the NA employee list showed: -NA A employed since 10/2022. -NA B employed since 10/2022. -NA C employed since 10/2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective, comprehensive, data-driven QAPI program that focused on outcomes of care and quality of life when the facility failed to provide documentation and evidence of its ongoing Quality assurance and performance improvement (QAPI) program. Facility census was 43. Review of the facility QAPI plan showed: -Meet monthly. During the entrance conference interview on 12/5/22 at 9:37 A.M., the Interim Administrator said: -He/she started in November 2022. -He/she could not find any QAPI documentation for 2022 and only one meeting for 2021. -QAPI is monthly. During a follow up interview on 12/08/22 at 11:56 A.M. the Interim Administrator was not able to provide any documentation from 2021.

Inspectors wroteBased on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and did not review it annually. The facility also failed to ensure facility staff were informed on the facility's Water Management Plan. The facility was 43. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) and other opportunistic waterborne pathogens (e.g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect when staff stood while assisting two sampled residents with eating (Residents #1 and #10) and failed to provide assistance with grooming for seven residents (Residents #3, #7, #9, #20, #23, # 30 and #41). The facility census was 43 residents. Review of facility policy, dated 2001 and revised February 2021, showed: - Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth an self-esteem; - When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.); e. provided with a dignified dining experience. 1. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure four of four sampled residents (Residents #1, #2, #26, and #28) who were dependent on staff for activities of daily living, consistently had access to a call light or other means of summoning staff when needed. The facility census was 43. Review of facility policy, Call System, Resident, dated September 2022, showed: - Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor - If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected eleven residents. The facility's census was 43. Review of facility policy titled 'conveyance of Resident Funds' showed: -Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death, as applicable -The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate) jurisdiction per state law), as applicable, within thirty days from the date of the resident's discharge or eviction from the facility, or death. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the resident and/or resident representative of transfers and the reason for transfer in writing. This affected three of three sampled residents (Resident #6, #14, and #34). Facility census was 43. Review of facility policy, Transfer or Discharge Notice, dated March 2021, showed: -The resident and representative are notified in writing of the following information: specific reason for transfer or discharge, effective date of the transfer or discharge, and the location to which the resident is being transferred or discharged . 1. Review of Resident #6's 5 day Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/24/22, showed: -No Brief Interview for Mental Status (BIMS) score. This indicates the resident is never/rarely understood. -Diagnosis include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident centered care plans when the facility did not have a care plan that addressed seizures or anticoagulants for Resident #18, did not implement the repositioning care plan for Resident #34 and failed to implement the oxygen, falls, and contractures care plan for Resident #1. Facility census was 43. Review of facility policy, Care Plans, Comprehensive Person-Centered, dated March 2022 showed: -A care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The interdisciplinary team (IDT), in conjunction with the resident and family, develops and implements a comprehensive, person-centered care plan for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure staff provided assistance to dependent residents with grooming and showers by failing to provide at least two showers a week to six residents (Resident #1, #30, #26, #7, #20, and #3). The facility also failed to provide shaving for one dependent resident (Resident #41). The facility census was 43. Review of the facility's policy on Supporting Activities of Daily Living (ADL) Policy, March 2018, showed: -Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene. -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities, facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected two sampled residents (Residents #12 and #41). The facility census was 43. Review of facility policy, Activity Programs, dated June 2018, showed: -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure staff prepared foods in a form designed to meet each resident's individual needs when they did not ensure the pureed foods were of smooth consistency. This had the potential to affect all six residents on the pureed diet. The facility census was 43. Review of the International Dysphagia (Some people with dysphagia have problems swallowing certain foods or liquids, while others can't swallow at all.) Diet Standardization Initiative (IDDSI), dated 2022, showed: - The IDDSI Pureed level 4 (formerly known as Dysphagia Pureed) is designed for individuals who have moderate to severe dysphagia with poor oral phase abilities and decreased ability to protect their airway. - The diet follows the regular diet planned with foods pureed which are of a smooth, homogenous and cohesive consistency. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed ensure staff stored, prepared, distributed and served food to residents in accordance to professional standards for food service safety when they failed to label and date foods after opening, failed to ensure stored dishes were clean and free from dust and food particles, and failed to maintain kitchen tiles and ceiling in good repair and in a sanitary condition to prevent food contamination. This affects all residents who received food from the facility's kitchen. The facility census was 43. Review of an undated Daily Aide Checklist showed: - Properly date and label all items. Review of an undated Daily [NAME] Checklist showed: - All items in fridge properly labeled and dated; - All dishes clean and put where they belong. Must be dry. Observation on 12/5/22 at 9:25 A.M., showed: [...]

Inspectors wroteDuring an interview and record review, the facility failed to maintain a surety bond that was equal or greater [NAME] one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive moths from December 2021 through November 2022. This has the potential to affect all residents who had money in the trust account. The census was 43. Review of the facility Surety Bond Policy dated March 2021 showed: -Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident's written plan of care included both the most recent hospice (end of life care) plan of care and a description of the services furnished by the long term care (LTC) facility and the services furnished by Hospice for one sampled resident (Resident #1). The facility census was 43. Review of facility hospice program policy showed: -When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current staff -All hospice services are provided under contractual arrangement. [...]