Legendary Health Care Center

Inspectors wroteBased on observation and interview, facility administration failed to implement an effective system for ordering sufficient supplies necessary to meet residents' needs. The facility census was 37. The facility did not have a policy regarding sufficient supplies. 1. Review of Resident #3's Care Plan, dated 6/23/25 and revised on 9/25/25, showed the following:-He/She was able to perform his/her activities of daily living (ADLs) with staff's assistance;-He/She had frequent urinary incontinence; -He/She waited too long to get to the bathroom and voided down his/her legs and on the floor;-He/She wore size five-X incontinence briefs. Observation on 1/6/26 at 12:19 P.M., showed the following: -There were no gloves in the resident's room;-One incontinence brief two sizes too small for the resident was by the resident's bed;-The resident wore pants but did not wear an incontinence brief. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of care for one resident (Resident #2), in a review of six sampled residents, when staff failed to follow physician's orders related to administering Xarelto (blood thinner used to treat and prevent blood clots). The facility census was 37. Review of the undated and untitled facility policy for medication administration showed the following:-The facility shall ensure medications will be administered according to physician's orders;-The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: -Medication administered not in accordance with the prescriber's orders. Examples include, but not limited to: -Incorrect dose, route of administration, dosage form, time of administration; -Medication omission; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a complete assessment to identify a history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for two residents (Residents #30 and #14), in a review of 14 sampled residents. Resident #30 had a diagnosis of post traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) related to sexual abuse as a child. The facility failed to identify the resident's triggers, which included feeling unsafe during mechanical lift transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper hand hygiene techniques when preparing and serving food to residents, and failed to ensure food items in the freezers were stored in good condition without freezer burn. The facility census was 31. 1. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, last revised November 2022, showed the following: -Employees must wash their hands: Before coming in contact with any food surfaces, after handling soiled equipment or utensils, and after engaging in other activities that contaminate the hands.; -Gloves are considered single-use items and must be discarded after completing the task for which they are used; -The use of disposable gloves does not substitute for proper handwashing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current infection control standards for three residents (Residents #28, #20 and #19), in a review of 14 sampled residents, when staff failed to follow facility policy related to handwashing and glove usage when providing personal care to the residents. The facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards, and failed to complete a facility water assessment to identify potential sources of Legionella growth. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to assure eight discharged residents' (Residents #103, #107, #105, #101, #108, #106, #102, and #104) personal funds were not maintained in the facility's operating account when the facility did not reimburse the residents and/or their responsible parties after the residents were discharged from the facility. The facility census was 31. Review of the facility policy, [NAME], revised March 2021, showed upon resident discharge from facility, any credit balance remaining will be issued within 30 days of discharge. Review of the facility admission Agreement Exhibit B, Resident's Rights, revised 7/14/17, showed the following: -In general, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account that is separate from any of the facility's operating accounts; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure information on how to file a grievance/complaint was available to the residents, failed to ensure timely and consistent follow up with resident groups who filed a grievance/complaint, and failed to ensure a system was in place to allow for residents or their families to make an anonymous grievance/complaint. The facility census was 31. Review of the facility policy, Filing Grievances/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for three residents (Resident #2, #14 and #30), in a review of 14 residents. The facility census was 31. Review of email correspondence on 05/29/25 at 9:19 A.M., the Director of Operations said they do not have a Care Plan policy, they follow the guidance in the Resident Assessment Instrument (RAI) Manual. Review of the RAI Manual, dated 10/01/24, showed the following: -As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool; -It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff dated insulin (a medication used to treat diabetes) pens for three residents (Resident #15, #19 and #20) when opened to ensure the insulin was used within 28 days of opening. The facility census was 31. Review of the facility policy, Medication Labeling and Storage, revised February 2023, showed the following: -Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial; -Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date; - If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used to transfer residents and wheelchairs were maintained in good repair and in safe operating condition. The facility census was 31. Review of the facility policy, Safe Lifting and Moving of Residents, revised [DATE], showed the following: -Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote charges shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged; -Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order; -All equipment design and use will meet or exceed guidelines and regulations concerning resident safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff training needs as identified in the facility assessment and the annual in-servicing calendar were met, and 12 hours of training were completed per year to include dementia management and resident abuse prevention training per year for five certified nurse assistants (CNA)'s (CNA C, CNA R, CNA G, CNA Q and CNA H), in a sample of five CNA's who have been employed over a year. The facility census was 31. Review of the Facility Assessment, dated 05/12/25, showed the following -Staff competencies and annual training requirements per regulatory authority and/or facility policy included: -Abuse, neglect, exploitation and misappropriation; -Job responsibilities and lines of authority; -Advance directives; -Emergency preparedness; -Behavioral health facility policies and procedures; -Communication; -Change in condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided one resident (Resident #9's), in a review of 14 sampled residents, with an appropriately sized wheelchair that did not impede his/her ability to self-propel in his/her wheelchair. The facility census was 31. Review of the facility's policy, Accommodation of Needs, dated March 2021, showed the following: -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -Needs are evaluated upon admission and reviewed on an ongoing basis; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure gradual dose reductions (GDR's) were attempted, or document clinical contraindications for all psychotropic medications for one resident, (Resident #4 ), in a review of five residents sampled for unnecessary medications. The facility census was 31. Review of the facility policy, Tapering Medications and Gradual Drug Dose Reduction, revised June 2022, showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; -All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one resident (Resident #9), in a review of 14 sampled residents, when staff failed to follow physician's orders. The facility census was 31. 1. Review of Resident #9's undated Face Sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had private insurance and Medicaid was pending. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/17/25, showed the following: -admission diagnosis of fracture and other multiple traumas; -Orthopedic surgery to repair fractures of the pelvis, hip, leg, knee or ankle; -Cognition was intact; -Independent with transfers; -Upper and lower extremity impairment on one side; -Independent with a wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide (NA B), completed a nurse aide training program within four months of employment with the facility. The facility census was 31. 1. During an interview on 05/13/25 at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of the facility staff title listing, dated 05/12/25, showed the facility hired NA B on 09/20/24. 3. Review of NA B's employee file showed a hire date of 09/20/24 as a nurse aide. His/Her employee file did not include documentation he/she had completed his/her certification for a nurse assistant. 4. Review of NA B's nurse aide registry check showed no documentation to show NA B had a Certified Nurse Assistant (CNA) certification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one staff, Nurse Assistant (NA) J, in a review of five NA employee files, had completed a new training and competency evaluation program or a new competency evaluation program on hire. NA J, a former Certified Nurse Assistant (CNA), who did not continue working as a CNA for 24 consecutive months, had let his/her CNA certification expire. NA J had not completed the required retraining and had not been accepted to challenge the CNA exam or have any other approval to work as a CNA. The facility census was 31. 1. During an interview on [DATE] at 4:34 P.M., the Director of Nursing (DON) said the facility did not have a policy on nurse aide training. She expected staff to follow regulatory guidance. 2. Review of NA J's nurse aide registry check showed his/her CNA certification expired [DATE]. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were aware of posted resident rights, and failed to ensure resident rights were reviewed with residents during their stay. The facility census was 31. Review of the facility policy, Resident Rights, revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; -These rights include the residents right to: -Exercise his/her rights as a resident of the facility and as a resident or citizen of the United States; -Be supported by the facility in exercising his/her rights; -Exercise his/her rights without interference, coercion, discrimination or reprisal from the facility; -Be informed about his/her rights and responsibilities; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the contact information for the State Long-Term Care Ombudsman Program and the State Survey Agency were posted in a location that was accessible to all residents and could be read by residents in the facility without assistance. The facility census was 31. Review of the facility policy, Resident Rights, revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Communicate with outside agencies (local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents. The facility census was 31. Review of the undated facility policy, Resident Rights, showed the resident has the right to examine survey results. Review of the Examination of Survey Results, dated April 2007, showed the following: -A copy of the most recent standard survey, including any subsequent extended surveys, follow up revisits, reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) and a complete Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS-10055) to two residents (Residents #13 and #20), in a review of three sampled residents, or the resident's representatives, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 31. During an interview on 05/28/25 at 1:39 P.M., the Business Office Manager (BOM) said the facility did not have a policy for SNFABN CMS-10055 and the NOMNC CMS-10123 forms. Staff just followed the regulation. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly assess one resident (Resident #1) and notify the physician after the resident sustained an unwitnessed fall that resulted in increased pain, dizziness, vomiting, and a fractured hip, in a review of 10 sampled residents. After the fall, staff transferred the resident from the floor to the toilet, to a wheelchair, and then to his/her bed. During the transfer, staff said the resident yelled and screamed out in pain. The resident complained of his/her head hurting and feeling dizzy. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B did not perform neurological checks (assessing level of consciousness, visual fields, pupil constriction and dilation, upper and lower limb strength or limitation, speech and vital signs) with the resident after the unwitnessed fall. [...]

Inspectors wroteRefer to Event ID 0T6H13 Based on interview and record review the facility failed to ensure safe transfer techniques and prevent falls for two residents (Resident #1 and #3) in a review of six residents when staff failed to prevent Resident #1, who the facility identified as a fall risk and who was dependent on staff for all transfers and care needs, from rolling out of bed while staff provided care and failed to prevent the resident from falling to the floor when the mechanical lift (a device used to lift a resident from one surface to another with the use a sling) tipped over during a transfer. [...]

Inspectors wroteRefer to Event ID 0T6H12. Based on observation, interview, and record review, the facility failed to follow a physician ordered diet when staff provided the resident with orange juice and failed to provide nectar thickened liquids for one resident (Resident #33) in a review of seven sampled residents. The facility census was 36. Review of the facility policy, Therapeutic Diets, revised October 2017, showed a therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example, altered consistency diet. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to store food products to maintain quality and free from potential contaminants. Staff failed to maintain appropriate holding temperatures of cold food items. Staff failed to store and handle utensils and kitchenware in a sanitary manner. Staff failed to ensure proper hand hygiene and sanitization practices were employed. Staff failed to ensure food storage and preparation equipment and surfaces were clean and maintained. Staff failed to ensure the facility's ice machine drain contained an air gap. The facility census was 37. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff changed gloves and washed hands as indicated during the provision of care for one resident (Resident #12), in a review of 14 sampled residents, and failed to ensure proper infection control was utilized for respiratory care supplies for one resident (Resident #16). The facility also failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 37. Review of the facility's Handwashing/Hand Hygiene policy, dated August 2019, showed the following: -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two additional residents (Resident #17 and #19) who both had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking. Four additional residents (Resident #5, #6, #10 and #30) voiced concerns of staff awakening them between 4:00 A.M. and 6:00 A.M. when getting other residents up or getting them up when it was convenient for staff. The facility census was 37. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 37. Review of the facility's Mail and Electronic Communication policy, dated May 2017, showed mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries). 1. During a group interview on 8/9/23 at 10:05 A.M., Resident #30 and Resident #2 said residents do not receive mail on Saturdays. During an interview on 8/11/23 at 9:45 A.M., Transportation/Activities O said the following: -During the week, Activities Staff P brings mail into the facility from the mailbox; -He/She distributed the residents' mail around the building to residents' rooms; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and comfortable environment for residents when the facility failed to ensure resident's rooms and living spaces were clean and in good repair. The facility census was 37. Review of the facility's Maintenance Service policy, dated December 2009, showed the following: -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to: -Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; -Maintaining the building in good repair and free from hazards; -Providing routinely scheduled maintenance to all areas. 1. Observations on 8/8/23 between 10:23 A.M. and 4:15 P.M. showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 37. Review of the facility policy, Director of Nursing Services, dated August 2006, showed an RN is on staff eight hours each day between the hours of 6:00 A.M. to 8:00 P.M. 1. Review of the January 2023 Nurse Schedule, dated 01/01/23 through 01/31/23, showed no RN coverage on 01/20/23. Review of the February 2023 Nurse Schedule, dated 02/01/23 through 02/28/23, showed no RN coverage on 02/05/23, 02/12/23, 02/25/23 and 02/26/23. Review of the March 2023 Nurse Schedule, dated 03/01/23 through 03/31/23, showed no RN coverage on 03/02/23, 03/07/23, 03/08/23 and 03/09/23. Review of the May 2023 Nurse Schedule, dated 05/01/23 through 05/31/23, showed no RN coverage on 05/13/23, 05/14/23 and 05/27/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days for two residents (Resident #34 and Resident #3), in a review of 14 sampled residents. The facility also failed to ensure one resident's (Resident #18) physician provided a rationale when he disagreed with the pharmacist's recommendation for a gradual dose reduction (GDR). The facility census was 37. Review of the facility's Antipsychotic Medication Use, dated December 2016, showed the following: -Residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; -The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to remove and destroy outdated resident medications and failed to remove and destroy expired stock medications (over-the-counter medications used for more than one resident) from medication carts and medication rooms. The facility failed to destroy or return one discharged resident's medications and facility failed to document an open date on medication that the manufacturer suggested be destroyed 30 days after opening. The facility census was 37. Review of the facility policy, Labeling of Medication Containers, dated 4/2019, showed all medication will be destroyed according to the expiration date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the facility's diet spreadsheet menu. The facility census was 37. Review of the facility policy, Therapeutic Diets, dated 2001, showed the following: -Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences, the attending physician may delegate this task to a registered or licensed dietitian as permitted by state law; -Diet order should match the terminology used by the food and nutrition services department; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 37. Review of the facility policy, Guidelines for Staff Preparing Food Fundamentals to Prevent Food Borne Illness, dated 2011, showed the following: -Cold, under 41 degrees Fahrenheit (F), stops bacteria from growing; -Heat, over 135 degrees F, halts most bacteria; -Cold foods should be kept chilled, hot foods should be kept hot. Review showed the facility did not have a policy related to food holding temperatures or temperatures to be achieved at time of service to residents. Review of email correspondence, dated 08/10/23, from the facility's Registered Dietitian, showed point of service temperature for hot food was 120 degrees F and the holding temperature for cold food was 41 degrees F. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one resident (Resident #139) in a review of 14 sampled residents, with dignity and respect. Staff failed to assist the resident to use either a commode or toilet and directed the resident to urinate in his/her brief. facility census was 37. Review of the facility's Dignity policy, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -When assisting with care, residents are supported in exercising their rights, including allowing the resident to choose when to conduct activities of daily living; -Staff are expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance. 1. Review of Resident #139's baseline care plan, dated 08/1/23, showed the following: -Can communicate easily with staff; -Toilet use: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when one resident (Residents #18), in a review of 14 sampled residents, and one additional resident (Resident #13), were transferred to the hospital. The facility census was 37. During an interview on 08/11/23 at 2:45 P.M., the Director of Nursing (DON) said she was unable to find a Discharge/Transfer Policy. Review of the Bed Hold/Agreement Policy, revised December 2006, showed it did not address discharge transfer information. 1. Review of Resident #18's face sheet showed his/her family member was his/her responsible party. Review of the resident's progress notes, dated 03/26/23 at 7:42 A.M., showed the resident continues with inappropriate sexual behaviors. Review of the resident's progress notes dated 03/26/23 at 12:17 P.M., showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #139), in a review of 14 sampled residents, received care based on professional standards of practice. The resident had a diagnosis of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should) and received diuretic medication (medications that help reduce fluid buildup in the body). Staff catheterized (the placement of a tube in the bladder to drain urine) the resident for a urine specimen and received a residual amount of 1000 milliliters (ml) (in adults, 100 ml of residual urine is considered to be an abnormal level) . Facility staff emailed the physician's nurse but, did not attempt to contact the physician again regarding the large residual amount. The resident repeatedly complained of needing to urinate. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff safelytransferredd one resident (Resident #8), in a review of 14 sampled residents, who was unable to fully bear weight. The facility failed to ensure chemicals, stored in the dementia unit, were secured in a locked storage area. The facility census was 37. Review of the facility policy SafeLiftingg and Movement of Residents revised July 2017 showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately address one resident's (Resident #139's), in a review of 14 sampled residents, expressions and complaints of pain during cares. Staff failed to notify the resident's physician when the resident's pain was unrelieved by as needed (PRN) pain medication. The facility census was 37. Review of the facility policy, Pain Assessment and Management, dated 3/2020 showed the following: -The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician ordered diet when staff provided the resident with orange juice and failed to provide nectar thickened liquids for one resident (Resident #33) in a review of seven sampled residents. The facility census was 36. Review of the facility policy, Therapeutic Diets, revised October 2017, showed a therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example, altered consistency diet. 1. Review of Resident #33's undated face sheet showed the resident's diagnoses included dementia, end stage renal disease, oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat) and chronic kidney disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) to ensure protection of all personal funds the facility held for13 residents in the resident funds account. The facility census was 37. Review of the facility policy, Surety Bond, revised March 2021, showed the following: -The facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility; -A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, accounts for, safeguards, and manages; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality by not obtaining a apical pulse prior to Digoxin (used to improve the strength and efficiency of the heart or to control the rate and rhythm of the heartbeat) administration and failed to obtain a physician ordered blood test for one resident (Resident #21) in a review of 13 sampled residents. The facility census was 26. 1. Review of facility policy Administering Medications, updated December 2012, showed the following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 2. Review of facility policy Anticoagulation- Clinical Protocol, updated November 2018, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), by failing to implement their policy or to complete a risk assessment to determine susceptible locations for the growth of such organisms. The facility census was 26. 1. Review of the facility's Legionella Water Management Program Policy, dated 2017, showed the following: -The purpose of the water management program was to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; [...]