Life Care Center of Mount Vernon

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate incidents for 1 of 1 sampled resident (Resident 1) reviewed for injury during handling resulting in bruising, and failed to investigate 2 of 2 sampled residents (Resident 1 and 2) reviewed for resident to resident altercations. This failure prevented the facility from identifying the potential causes of the occurrence and contributing factors, placed residents at risk for unidentified abuse or neglect, risk for injury, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents right to be free from physical abuse for 2 of 2 sampled residents (Residents 3 and 4) reviewed for resident-to-resident altercations. Resident 3 caused potential harm for Resident 4 when they kicked them for not responding to a question. This failure placed residents at risk for potential physical or mental abuse, feeling safe, experiencing fear, intimidation, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate and ensure home health services were established prior to discharge for 2 of 3 sample residents (Residents 1 and 2) reviewed for discharge planning. This failure resulted in delays of necessary clinical services, placed residents at risk for unmet care needs, psychological distress and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate intervention, update and consistently implement the care plan to prevent accidents/falls for 1 of 2 residents (Resident 1) reviewed for accidents. The facility failure to provide adequate supervision and implement appropriate interventions placed residents at risk for further falls, injury, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish an appropriate plan of care, consistently provide the required assessments monitoring, and care interventions following a total knee replacement surgery for 3 of 4 residents (Residents 1, 2, and 3) reviewed for post-surgical care and hospitalization. Resident 1 experienced harm when they verbalized increased pain to the right foot that was unassessed for six days, developed a blood clot to their right foot that caused lack of blood flow to the foot that required transfer to the hospital where a surgical intervention was performed to remove the clot and the potential for right foot amputation (removal of limb). This failure placed all post-surgical residents at risk for unmet care needs, injury, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments were completed to evaluate the need for pressure offloading preventative measures post-surgery, assess and monitor skin integrity, and to consistently implement interventions to prevent development of an avoidable pressure ulcer/pressure injury (PU/PI - injury to skin and underlying tissue resulting from prolonged pressure) for 1 of 1 sampled resident (Resident 1), reviewed for pressure ulcers. Resident 1 experienced harm when they developed an unstageable PI [a full thickness wound where the depth of damage cannot be determined because the base is covered by slough (yellow, tan, or grayish tissue) or eschar (brown or black leathery tissue)] to their right heel, an unstageable PI to their right bottom foot, and a Deep tissue pressure injury (DTPI) to the right foot on the lateral side. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the needed assessments and monitoring for 1 of 1 resident (Resident 1) reviewed for post-surgical care and hospitalization, who experienced increased pain to their right foot for six days, licensed nurses did not assess the residents skin to their right foot for 11 days after surgery. Resident 1 experienced a blood clot that restricted the blood flow to their right foot, required surgical intervention and developed several pressure injuries to their right foot due to the lack of assessment and monitoring. This failure resulted in neglect to Resident 1, who experienced unmet care needs, and avoidable skin issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to respond to call lights for 5 of 7 sampled residents (Residents 8, 9, 10, 13, and 4) and 1 of 2 family members (CC1- Resident 2's family member) reviewed for sufficient nurse staffing. This failure placed residents at risk for frustration, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible and systematically organized for 3 of 6 sampled residents (Residents 4, 12 and 9) reviewed. This failure included inaccurate readmission and nursing assessment/documentation, and a hospice referral follow- up. These failures placed residents at risk for unmet needs, and inaccurate medical records.

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to assess/monitor the position of a catheter tubing (a flexible tube inserted into the bladder to remove urine and attached to a drainage bag) during catheter care and bed mobility/positioning to prevent the occurrence of an avoidable pressure ulcer (PU) and provide ordered treatment for the PU for 1 of 3 residents (Resident 3) reviewed for PU's. Resident 3 experienced harm when they developed an avoidable Stage III PU (full-thickness skin loss of skin, which is when fat is visible in the ulcer and granulation tissue which is new connective tissues and microscopic blood vessels, and rolled wound edges are often present. Slough, nonviable tissue, and/or eschar, dead or devitalized tissue, may be visible. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely initiate a grievance for 1 of 1 residents (Resident #2) reviewed for grievances. This failure placed residents at risk for delayed resolution affecting their quality of life. Findings Included. Review of the facility policy titled, Grievance Program (concern and Comment) revised 01/07/2025 showed residents had the right to voice grievances and the facility must ensure the prompt resolution of all grievances and there would be a recordkeeping system. The executive director or designee oversaw the compliance of the grievance process. Resident 2 admitted to the facility on [DATE] with diagnoses to include kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids in the body) and dependence on renal dialysis (filtration of the blood to remove waste). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to conduct a thorough investigation of an injury of unknown source for 1 of 3 residents (Resident 3) to rule out abuse and neglect. This failed practice placed residents at risk for potential unrecognized abuse or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide a thorough assessment to timely recognize a significant change in condition, take action to notify the medical provider as ordered, and to ensure required staff were certified in Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident (Resident 1) reviewed for an unexpected death in the facility. Resident 1 experienced harm when they had a significant weight gain over a 24-hour period, swelling in their left arm, slurring of their speech, difficulty breathing and change in their mentation throughout the day of [DATE], until they were found unresponsive without a pulse when assessment and treatment were delayed for several hours that constituted an immediate jeopardy. An Immediate Jeopardy (IJ) was identified, and the facility was notified of the noncompliance on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to conduct a thorough assessment, communicate a change in condition timely to the physician and notify other nursing staff to respond correctly to a medical emergency for 1 of 1 resident (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when they had a change in condition, several caregivers were aware of the change from the resident's baseline, which worsened when nursing staff failed to take timely action; the resident became unresponsive, required cardiopulmonary resuscitation (CPR), and an unexpected death occurred. These failures placed all residents at risk of unmet care needs and potential neglect. Findings Included . [...]

Inspectors wroteBased on interview and record review, the facility failed to identify and report to the State Hotline an unexpected death for 1 of 1 resident (Resident 1), reviewed for unexpected death in the facility. The failure to report an unexpected death prevented the facility from identifying the occurrence of abuse or neglect and placed other residents at risk for harm and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dignified and homelike experience and promote the rights of 1 of 1 resident reviewed for dignity (266), 2 of 3 (Residents 12 and 44) reviewed for urinary catheter use, 1 of 1 (Residents 4 and 11) dining observations and concerns voiced in resident council meeting (Residents 8, 11, 18, 24, 54, 214 and 265) residents reviewed for dignity when staff failed to interact with residents in a dignified manner, and failed to cover urinary bags, These failures placed residents at risk for feelings of emotional distress, frustration, humiliation, embarrassment, diminished self-worth and or quality of life, and a potential decline in nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the health records for 20 residents (Residents 7, 33, 35, 40, 44, 45, 46, 48, 51, 56, 57, 58, 59, 60, 114, 115, 119, 120, 121 and 165) on 1of 3 units reviewed for privacy and confidentiality. This failure placed residents at risk for violation of a resident's right to privacy and/or confidentiality, unwanted dissemination of personal health information, emotional distress and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was maintained in a clean, comfortable, homelike and safe environment, for 2 of 3 halls including resident rooms (315, 102, 106, and 114). Failure to ensure the facility was free from dust, kept clean, and had laundered privacy curtains placed residents at risk for decreased quality of life, compromised dignity and potential infection control issues.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns for 3 of 3 resident council's (January, February and March 2025), who verbalized complaints during a Resident Council (RC) meeting. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed to conduct thorough investigations for 3 of 3 allegations of abuse and/or neglect for (Residents 117, 164, and 216), 3 of 4 falls (Residents 46, 115, and 218), and 1 of 1 medication error (Resident 24) whose investigations were reviewed for thorough investigations. The failure to conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred. These failures placed residents at risk for repeated incidents and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's care plan was reviewed, updated, and implemented for 1 of 4 residents (Resident 218) for falls and failed to ensure residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns for 2 of 2 residents (Residents 24 and 54) reviewed for accidents. These failures placed all residents at risk for lack of consistent interventions, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in resident (Residents 14, 46, 5, 116, and 216) and resident council group interviews. The facility had insufficient staff to ensure residents received Restorative Nursing Program (RNP) services as evidenced by Restorative Nursing staff removed from restorative nursing duties to cover direct care duties impacting 2 of 4 residents (Residents 4, and 25) reviewed for limited ROM and restorative nursing services. These failures placed residents at risk for a delay in repositioning and toileting assistance, a decrease in resident safety and health needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 of 8 residents (Residents 5, 8, 11, 24 and 54) reviewed for medically related social services. Failure to assure resident safety, ensure residents were informed of their care, treatment and services available to them, and continuously monitor, thoroughly assess, and advocate for resident's rights placed residents at risk for harm, diminished quality of life and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the facility kitchen. This failure placed residents at risk for cross-contamination and foodborne illnesses. Review of document titled 'Sanitation and food safety' with a revision date of 09/08/2022 documented under Procedure that: Staff will wash their hands. * After handling raw or unwashed foods * After handling dirty dishes, soiled equipment or utensils * During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. * Before donning gloves to initiate a task that involves working with food. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physical environment accommodated resident needs for 2 of 2 residents (Residents 4, and 15) reviewed for accommodations of needs. This failure placed residents at risk for falls and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendation of the Level II Preadmission Screen and Resident Review (PASARR) evaluation were incorporated into the plan of care upon receiving recommendations for 1 of 6 sampled residents (Resident 24) reviewed for coordination of PASARR and assessments. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 6 residents (Residents 15, 46, and 114) reviewed for pre-admission screening and resident review (PASRR), received the required screening for necessary services. This failure placed the residents at risk for unidentified mental health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise care plans for 2 of 6 residents (Residents 30 and 114) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1 of 1 resident (Resident 4) access to a communication device. This failure placed the resident at risk for unmet care needs by decreasing the resident's ability to participate in daily living activities. Findings Included . <Resident 4> Resident 4 is a long-term resident of the facility. Resident 4's diagnosis includes traumatic brain injury (TBI, an injury to the brain caused by an external force), voice and resonance disorder (functional speech deficits). During a joint interview on 04/03/2025, at 4:04 PM, Collateral Contact 2 (CC2) and Collateral Contact 3 (CC3) stated that the facility is no longer using Resident 4's Tobii communication device. They stated that they were told staff had not been trained on the device, which had resulted in staff members not knowing how to operate it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 3 of 4 residents (Residents 4, 15, and 25) reviewed for activities. This failure placed residents at risk of becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure of 2 of 6 residents (Residents 4 and 114) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. These failures placed residents at an increased risk of adverse health events, discomfort and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to prevent pressure ulcers for 2 of 3 residents (Residents 15 and 46) reviewed for pressure ulcers. The facility failed to implement a turning/repositioning program for residents with decreased mobility and decreased functional ability resulting in the development of stage II pressure ulcers. Resident 46 did not receive thorough and ongoing skin assessments that included observing for change in risk factors, pressure points, and evaluating effectiveness of interventions. These failures placed Resident 15 and 46 and other residents at risk for the development of a pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and services were provided to increase, maintain and/or prevent a decline in Range of Motion (ROM) mobility for of 2 of 4 residents (Resident 4, and 25) reviewed for limited ROM and restorative nursing services. The facility's failure to ensure assessment and implementation of restorative nursing services placed residents at risk for functional decline and increased dependence on staff for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate hydration for 2 of 2 residents (Residents 15 and 266) reviewed for hydration. These failures placed residents at risk for inadequate intake and dehydration and for a decreased quality of life. Findings Included . <RESIDENT 266> Resident 266 was admitted to the facility on [DATE]. Resident 266 was severely cognitively impaired and had a diagnosis of dementia (a syndrome that typically leads to deterioration in cognitive functioning). A review of the document named 'Nutrition: Assessment/Nutritional Data Collection' dated 04/07/2025 documented that Resident 266's daily fluid needs are 1386-1438 milliliters. During observations on 04/03/2025 at 1:59 PM and 3:22 PM, Resident 266 was resting in bed with no fluids at the bedside. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure pain management was provided in accordance with the resident's physician's orders for one of three residents (Resident 164) reviewed for pain management. Failure to ensure prompt delivery and administer medications per the provider orders resulted in Resident 164's dissatisfaction with their care contributing to discharge against medical advice from the facility and placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure mental and psychosocial health needs were identified and met for 2 of 2 residents (Residents 30 and 114) reviewed for behavioral-emotional health. Failure to identify mental health needs and utilize person-centered interventions developed by an interdisciplinary team placed residents with behavioral needs, at risk for unidentified behavior triggers, unmet behavioral needs, refusal of care, self-neglect, lack of behavioral services and support, loss of dignity, loss of autonomy and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner for 2 of 5 residents (Residents 14, and 30) reviewed for unnecessary medications. Failure to act timely on the pharmacist's recommendations placed all residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 41 and 46) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for the use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors, updating care plans and complete consents. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse side effects, and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to consistently offer and/or provide a nutritional snack when ordered or requested for 4 of 6 resident's (5, 11, 54, and 265) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 3 units. The facility failed to ensure the staff used appropriate hand hygiene practices during personal care, and disposal of soiled garbage in accordance with infection control standards of practice. This failure placed all residents and staff at risk of potential infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were completed accurately for 3 of 3 residents (Residents 1, 2, and 3) reviewed for accurate electronic medical record documentation related to the route of medication administration of residents who were to have nothing by mouth (NPO). These failures placed residents at risk to receive inaccurate routes of medications, harm, and diminished quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure resident rights were being followed for 2 of 3 (Resident 1 and 2) residents when a scheduled appointment was canceled for Resident 1 without their knowledge, and the facility did not answer phone calls and Resident 2's guardian was unable to speak with staff or Resident 2. These failures placed residents at risk for unmet care needs, delays in communication or care, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a thorough investigation was completed for 1 of 3 residents (Resident 3) reviewed for investigations. This failure placed residents at risk for new or continued abuse, possible harm, and a decreased quality of life.

Inspectors wrotemonitor, assess, and take timely action in accordance with professional standards of practice for 17 of 32 resident's (Residents 59, 47, 5, 55, 1, 14, 23, 27, 31, 34, 40, 50, 58, 62, 63, 69 and 70) reviewed for bowel care and management, 1 of 1 resident (Resident 49) for a hospice referral and 1 of 1 resident (Resident 121) for neurological checks. These failures resulted in harm to Resident 59 when they experienced discomfort, pain, and hospitalization for a bowel impaction (the result of constant constipation when poop was stuck inside of the rectum). These failures placed the residents at risk for constipation, discomfort, a worsening of their condition, and a delay in receiving hospice care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 2 of 5 sampled residents (Resident 29 and 5) reviewed for ROM and restorative nursing services. Resident 29 experienced harm when they developed a significant, potentially avoidable, left-hand contracture (a permanent tightening of the muscles tendons, skin that causes joint to shorten and become stiff which prevents normal movement a body part affected) and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings Included . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was clean, comfortable, and homelike for 3 of 3 halls with stained carpet and failed to provide maintenance for resident rooms with broken blinds. These failures placed residents at risk for diminished dignity, and diminished quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure 1 of 3 sampled residents (Resident 55) was free from physical abuse by a cognitively impaired resident (Resident 57) who had a known history of unwanted touching and sexual aggression towards other residents (Resident 13 and 52). Failure to consistently provide supervision, and prevent unwanted touching by Resident 57, placed residents at risk for abuse, feeling safe, injury, and a potential decrease quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of allegations of potential abuse or neglect for 3 of 3 sampled residents (Resident 69, 5 and 55) reviewed for allegations of abuse and/or neglect and injuries of unknown source. The failure of staff to identify, report, and initiate an investigation for allegations placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument (RAI - an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments, - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), to holistically analyze the plan of care for 3 of 6 sampled residents (Residents 5, 29 and 121) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 8 sample residents (Residents 47, 55, 32, 5, 29, and 121) whose CPs were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to complete required annual performance reviews for 3 of 3 sampled Nursing Assistant Certified (Staff W, X, and Z) reviewed for annual performance review after one year of employment. Failure to complete annual performance evaluations, and ensure these staff members were adequately trained, placed all residents at risk for unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability or Related Condition and a Serious Mental Illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) assessments were completed timely for all residents following significant change in status for 3 of 5 sampled residents (Resident 10, 51 and 57) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASSR services for Resident's 10, 51 and 57, and other residents at risk for a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to implement a baseline care plan for 1 of 2 sampled residents (Resident 121) reviewed for baseline care plans. The failure to develop an effective and person-centered baseline care plan for falls placed the resident at risk for health complications, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 7 sampled residents (Resident 47, 59 and 121) reviewed for comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain oral health for 1 and 3 sampled residents (Resident 29) and communication devices in functional order for 1 of 1 sampled resident (Resident 5) reviewed for activities of daily living. This failure placed residents at risk for a decrease ability to communicate, maintain oral health, have unmet care needs, and a diminished quality of life.

Inspectors wroteReview of the facility's policy, Fall Management, reviewed on 12/04/2023, showed the facility would assess residents upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and identify appropriate interventions to minimize the risk of injury related to falls. Resident 121 admitted to the facility on [DATE] with diagnosis to include a stroke, vascular dementia (a general term for problems with reasoning, planning, memory, and other thought processes cause by brain damage from impaired blood flow to the brain), unspecified protein calorie malnutrition (the body lacks enough protein and energy to function properly). Review of Resident 121's nursing progress, note dated 04/16/2024, showed they were at risk for falls related to urinary urgency, lack of strength, and poor safety awareness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor meal intake and resident weights, and failed to implement and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 2 sampled residents (Resident 59 and 121) reviewed for nutrition. These failures placed residents at risk for weight loss, inadequate nutrition, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, and administering of all drugs, to meet the needs of each resident for 1 of 1 resident (Resident 59). Failure to ensure timely receipt and administration of ordered medications placed Resident 59 and other residents at risk for anxiety, discomfort, and withdrawal symptoms of headache, fatigue, dizziness, and constipation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 5 sampled residents (Resident's 51, 29, and 10) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure consents were obtained, person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that residents received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was safe and secure storage of drugs and biologicals when 1 of 4 medication carts (400 hall) was left unlocked and unattended, and medication found on the facility floor in 2 of 2 residents (Resident 17 and 32) rooms. These failures placed residents at risk of taking medications that were not prescribed to them, side effects, possible harm, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 1 (29) residents reviewed for dental care. This failure placed Resident 29 and all other residents at risk for pain, unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide appetizing and palatable food to 9 of 12 residents (6, 8, 12, 14, 23, 25, 44, 59, and 60). This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident medical records were accurate and consistent for 3 of 17 sample residents (Residents 11, 29 and 51) whose resident records were reviewed. The facility failed to ensure other resident information was not a part of Resident 11 and Resident 51's medical records and records (PASRR-preadmission screening and Resident Review and dental hygienist note) were accessible for Resident 29 in their medical records. These failures placed residents at risk for unidentified and/or unmet care needs, missed opportunities for care planning, and inaccessible health care instructions if/when needed.

Inspectors wroteBased on record review, and interview, the facility failed to ensure 2 of 5 Certified Nursing Assistants (NACs) (Staff X and Z) reviewed for training, had the required 12 hours per year of in-services and required annual dementia training. This failure placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents' representative(s) was notified timely for 1 of 3 residents (Resident 1) reviewed for notification of change of condition. Failure to inform Resident 1's representative(s) when they had new symptoms of confusion, burning with urination, and increased blood sugars resulted in their being unable to advocate for the resident and be involved in decision-making for treatment. This failed practice placed all residents representatives from being fully informed in decision-making for treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 of 5 sampled residents (Residents 1, 2, and 3) reviewed for quality of care. The facility failed to monitor and document residents condition after a fall, assess pressure injury's (PI - a pressure ulcer) weekly, and to provide pain management. These failures placed residents at risk for delayed identification of injuries, delayed wound healing, inadequate pain management, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation interview, and record review the facility failed to provide timely pain management and follow pain management orders for 2 of 3 residents (Resident 8 and 4) reviewed for pain. This failed practice resulted in harm to Resident 8 when they were not provided pain medication per physician orders which resulted in unmanaged pain. This failed practice placed all residents at risk of the potential for poor pain management and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete for 5 of 8 residents (Resident's 2, 3, 5, 6, and 7) reviewed for documentation. Failure to complete skilled charting, alert charting, timely complete admission assessment, and neurological checks after falls, placed residents at risk of staff not being able to identify changes in condition and residents not receiving the appropriate care and services for individual medical conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents' Power of Attorney was notified timely for 1 of 3 residents (Resident 1) reviewed for notification of change of condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to report allegations of potential abuse for 2 of 3 residents (Resident 2 and 6) reviewed for potential abuse and neglect. This failure to report to the required state agency resulted in lack of timely investigations and placed all residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans for 2 of 5 resident's (Resident 2, and 6) reviewed for care planning. These failures placed the resident at risk for lack of appropriate care, consistent interventions, unmet care needs, adverse health effects, frustration, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly assess wounds on admission and weekly, maintain clear and accurate wound documentation, and develop an individualized care plan for pressure ulcer for 1 of 3 sampled residents (Resident 2) reviewed for pressure ulcers (PU's). This failure placed residents at risk for deterioration of their wounds and for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure they were free of significant medication errors for 3 of 5 residents (Resident's 2, 3, and 8), to include administration of correct dose of blood thinner medication (aspirin), tamsulosin (used in men to treat the symptoms of an enlarged prostate which include difficulty urinating, painful urination, and urinary frequency and urgency) for one resident, and oxycodone (narcotic pain medication). Additionally, the facility failed to administer medications on a resident's date of admission. These failures resulted placed residents at an increased risk of blood clots (aspirin), urinary complications (tamsulosin), and poor pain management.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns for 1 of 3 resident council's (March 2023), who verbalized complaints during a Resident Council (RC) meeting. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to residents repeatedly reporting the same care issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement comprehensive person-centered care plans for 3 of 6 residents (Resident's 24, 57, and 38) reviewed for care plans. The facility failed to ensure a resident (Resident 24) had appropriate interventions for their dental needs. The facility failed to ensure a resident (Resident 57) had appropriate interventions for effective communication for a legally blind resident, and failed to ensure (Resident 38 and 57) had appropriate respiratory plan of care. This failure to ensure the comprehensive care plan was implemented placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, observation, and record review the facility failed to update and revise the care plan for 3 of 9 residents (Resident 28, 50, and 414) reviewed for care planning. The facility failed to update goals, interventions, resident preferences, and assess the effectiveness of current interventions related to nutrition and skin concerns. This failure placed residents at risk of unmet care needs and decline in their nutritional status.

Inspectors wroteBased on record review and interview the facility failed to follow physician's orders for 1 of 1 sampled resident (Resident 21) reviewed for orthostatic blood pressures (a person's blood pressure taken while lying down and then taken again while standing and or sitting upright). This failure placed the resident at risk for medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess and revise interventions as needed to prevent unidentified weight loss for 4 of 10 residents (Resident 54, 50, 24, and 414) reviewed for nutritional status and weight loss. These failures placed Residents 54, 50 and 24, at risk who had unidentified weight loss and placed residents at an increased risk for unmet nutritional needs, physical decline, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide education on the risks and benefits of the influenza and pneumococcal vaccines for 2 of 5 sampled residents (Residents 47 and 54) reviewed for influenza and pneumococcal immunizations. These failures placed residents at risk for communicable diseases and of not being fully informed before making decisions about care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered COVID-19 vaccine and/or provided education about COVID-19 (an infectious disease by a virus causing respiratory illness) vaccination, including benefits, and potential side effects, document if the vaccine was accepted and/or refused in the medical record, and document as to why the vaccine was refused for 2 of 5 residents (Resident 47 and 54) reviewed for COVID-19 immunizations. This failure denied the residents and/or their representative of the right to make informed decisions.

Inspectors wroteBased on interview and record review the facility failed to ensure 5 of 5 Nursing Assistants Certified (Staff C, D, E, F, and G) received the required dementia training per year. This failure of not ensuring staff received the required dementia care training placed residents at risk for unmet care needs potential abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified existence was maintained for three of three sampled residents (Resident 31, 47, and 24) reviewed for resident rights. The facility failed to ensure the residents urinary catheter bag was kept covered to ensure privacy and dignity of the residents. This failure placed the resident at risk for a diminished self-worth and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to make a referral for the Pre-admission Screening and Resident Review (PASRR) II (screening assessment for possible serious mental health disorders or intellectual disabilities) for 1 of 5 sampled residents (Resident 21). This failure placed the resident at risk for unidentified mental health care needs, lack of mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain effective communication, and vision methods to carry out the activities of daily living for 1 of 3 residents (Resident 57) reviewed for communication and sensory. This failed practice put the resident at risk for unmet care needs, decreased independence, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 3 residents (Resident 57 and 38) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure when oxygen (O2) was ordered there was a dosage, route, or parameters for titration, and failed to ensure O2 tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 57) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Resident 28) had a proper diagnosis for use of a psychotropic (antidepressants, antianxiety, antipsychotics, medications that affect mental function, behavior, and experience) medication. This failure placed the resident at risk for receiving unneeded or improper medications, side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine, and emergency dental services were provided to 1 of 2 residents (Resident 24) reviewed for dental services. This failure placed the resident at risk of unmet dental needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in a refrigerator were labeled and dated when opened, and discard food products on or before the use by date in 1 of 1 refrigerator (activity room) observed. These failures placed the residents at risk for potentially developing a food borne illness (caused by ingestion of contaminated food or beverages).