Life Care Center of Richland

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed-hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of transfer to the hospital for 3 of 3 residents (Resident 1, 2, and 3) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility.

Inspectors wroteBased on interviews and record review the facility failed to provide notification to the residents' representative of a significant change in condition for 1 of 3 residents (Resident 1) reviewed for notification of changes. This failure placed the residents at risk of not having their representative involved in health care decision making for timely care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely notification of changes in a resident's condition for 1 of 5 residents (Resident 1) reviewed for falls. Specifically, a nursing assistant failed to promptly report a resident's fall, resulting in delayed assessment, monitoring, intervention, and required notifications. This failure placed the residents at risk for undetected or worsening injuries, delayed medical intervention, and serious complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistants were verified on the state Nurse Aide Registry prior to start of employment for 1 of 3 staff (Staff D) reviewed for staff qualification and background review. This failure placed the residents at risk for poor care, injury, and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan [(BCP) an initial, temporary plan of care, developed within 48 hours of admission to ensure immediate safety and continuity of care] that included the essential needs, physician orders, social services, and Preadmission Screening and Resident Review [(PASARR) - a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes] recommendations for 3 of 3 residents (Resident 1, 2, and 3) reviewed for baseline care plan. This failure placed the residents at risk for immediate health and safety concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed when nursing staff failed to accurately transcribe and follow physician orders for 1 of 3 residents (Resident 1) reviewed for medication administration. This failure placed the residents at risk for a delay in receiving medications, medication errors, and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered physical therapy (PT) was received in a timely manner for 2 of 3 residents (Residents 1 and 2) reviewed for specialized rehabilitation services. This failure placed the residents at risk for decline in function and/or not achieving the highest practicable level of physical, mental, and functional well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an incident involving a missing resident to the administrator, local law enforcement, and the State Agency (SA) for 1 of 2 residents (Resident 1) reviewed for missing residents. This failure disallowed the administrator to conduct a thorough investigation, local law enforcement to assist in the search for Resident 1, and lack of oversight from the SA.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge plan that included education for care and maintenance of an indwelling urinary catheter ([IUC] a flexible tube inserted into the bladder to drain the urine) and ensuring home health services were provided for 1 of 3 residents (Resident 3) reviewed for discharge planning. This failure placed the resident at risk of serious injury, rehospitalization, and lack of necessary care and services after discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and notification to administrative staff and local law enforcement for 1 of 3 residents (Resident 1) reviewed for elopement. This failed practice placed the residents at risk for serious injury and/or exposure to the elements.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (UTI, a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 2 residents (Resident 2), reviewed for urinary catheter care. This failure placed the residents at risk of developing serious medical complications, secondary to an infection in the bladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement (a resident leaving the facility unsupervised and undetected) for 1 of 2 residents (Resident 1) reviewed for avoidable accidents. This failure placed the residents at risk for exposure to extreme weather temperatures, serious injury, and/or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1) recognize a change in condition for 3 of 6 residents (Residents 39, 9 and 35) reviewed for quality of care, and 2) ensure residents received treatment and care in accordance with professional standards of practice and physician orders for 2 of 5 residents (Resident 8 and 71) reviewed for unnecessary medications. This failure placed residents at risk for a delay in treatment, unmet care needs, and negative health outcomes. Resident 39 experienced harm when the facility failed to recognize the immediacy of a change of condition and did not notify the physician with a resident who exhibited signs and symptoms of change in orientation, oxygen level, blood pressure and pulse which resulted in hospitalization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents requiring assistance with showers, oral care, and nail care, were provided timely assistance according to their needs and preference for 6 of 10 sampled residents (Residents 11, 35, 13, 82, 9, and 26) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of infection, decreased dignity, and a decreased quality of life. Findings Included . <Resident 11> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include Alzheimer disease (a brain disorder that slowly destroys a person’s memory and thinking skills). The 06/26/2025 comprehensive assessment showed Resident 11’s cognition was severely impaired and was dependent upon staff for bathing and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate staffing levels in order to provide care and services needed for 8 of 10 residents (Residents 11, 35, 13, 82, 9, 26, 8, and 18) reviewed for activities of daily living (ADLs), restorative therapy, and specialized therapy services (therapy that improves performing daily tasks, mobility and function). This failed practice placed residents at risk for an undignified existence and unmet care and service's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and discard medications when medications were not in use and when medications have expired on 2 of 2 medication carts (Team 1 and 2 medication carts) and 1 of 2 medication rooms (Team 2), reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on observation, interview and record review the facility failed to inform the Resident Representative (RR) of changes in the resident's pain medication regimen for 1 of 2 residents (Resident 57) reviewed for an order change for pain medication. This failure disallowed the RR to make an informed decision concerning the resident's care needs. Findings Included .<Resident 57> Review of the medical record showed the resident was admitted on [DATE] with diagnoses of a right hip fracture, muscle weakness, seizures and dementia (cognitive impairment). The 07/01/2025 nursing assessment/ care plan showed Resident 57 was totally dependent on staff for all activities of daily living to include bed mobility and transfers to a wheelchair. Resident 57's pain medication orders included a narcotic pain reliever which was discontinued on 07/10/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication, leaving medications at bedside for 1 of 2 residents (Resident 82), reviewed for medication administration. This failure placed the residents at risk for medication errors and adverse medication interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly financial statements for resident trust accounts were provided in accordance with generally accepted standards of accounting practice for 1 of 3 residents (Resident 6), reviewed for trust accounts. Failure to provide resident /resident representative's quarterly financial statements for the months of January, March, November and October 2024, placed the resident at risk for loss of personal funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received their mail for 1 of 1 resident (Resident 8) reviewed for resident rights. This failed practice put the resident at risk of not being able to make independent choices regarding their mail preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed during resident council meetings (a meeting of the facility's residents to communicate concerns, request improvements and keep up to date of the facility's activities/events) and individually, underwent prompt resolution through to their conclusion nor were residents appropriately updated on the voiced grievance progress/conclusion for 2 of 5 residents (Resident 77 and 69) reviewed for the grievances process. This failure placed residents at risk for unresolved concerns and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents on psychotropic medications (drugs that affect brain activities associated with mental processes, emotions and behavior) had non-pharmacological interventions (alternative treatment of a resident's symptoms that are directed toward understanding, preventing and relieving a resident's distress or loss of abilities and do not involve the use of medications) consistently attempted and were being monitored for individualized behaviors prior to psychotropic administration to reflect adequate need of the medication for 2 of 5 residents (Residents 11 and 71) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a patient-centered discharge plan by the interdisciplinary team and document required discharge information for 1 of 4 residents (Resident 45) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, worsening of wounds, psychological distress, and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to follow up on written notices of bed holds (holding or reserving a resident's bed while the resident was absent from the facility) given at the time of hospital transfers, and/or failed to send a copy of the notice of transfers to the representative for 2 of 4 residents (Residents 26 and 1) reviewed for discharge process. This failure placed residents at risk of not being informed of their rights regarding a bed hold and the lack of advocacy. Findings Included . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS- a comprehensive assessment tool) accurately reflected the status for 2 of 10 sampled residents (Resident 10 and 35) reviewed for accuracy of assessments. This failure placed the resident at risk for unidentified care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative therapy services, including the use of an orthotic (a device designed to support, align, or correct function of movable parts of the body) were consistently implemented for 2 of 3 residents (Residents 8 and 35) reviewed for restorative therapy. This failure placed the residents at risk for loss of range of motion (ROM, the amount of movement that a joint can achieve in a specific direction), deconditioning (a decline in physical health from prolonged inactivity or illness), and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 97) reviewed for hydration were consistently monitored and received adequate hydration fluids as per physician orders. This failure placed residents at risk for dehydration, constipation, urinary tract infections (UTI), and other health complications including worsening cognitive impairment and behavioral changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered Occupational (OT, specialized therapy that improves performing daily tasks) or Physical therapy (PT, specialized therapy that improves mobility and function) was received for 2 of 4 residents (Residents 13 and 18) reviewed for therapy services. This failure placed the residents at risk for decline in function, decreased independence, and the worsening or development of contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).

Inspectors wroteBased on interview and record review, the facility failed to implement effective measures of their infection prevention and control antibiotic stewardship program (ASP) regarding monitoring of residents prescribed antibiotics to ensure appropriate antibiotic use for 1 of 2 residents (Resident 33) reviewed for antibiotic stewardship. This failure increased the risk for development of multidrug-resistant organisms (MDRO/a bacteria that are resistant to many antibiotics), and unmet care needs related to infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, accurately assess, and provide sufficient supervision to prevent elopement (a resident leaving the facility unsupervised and undetected) for 2 of 3 residents (Resident 1 and 2) reviewed for elopement. This failure placed the residents at risk for exposure to the elements, serious harm, and/or death.

Inspectors wroteBased on interviews and record review the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 4 of 4 NACs (Staff A, B, C, D) reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of those NACs and the quality of care provided to residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to supervise to ensure the physician's diet order for 1 of 3 residents (Resident 1) was followed as ordered. This failed practice placed Resident 1 at risk for medical complications due to a choking incident.

Inspectors wroteBased on interviews and record review, the facility failed to identify and take timely action when a change of condition after a fall occurred for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to right hip pain and a delay in medical treatment for a fractured right hip.

Inspectors wroteBased on interview and record review, the facility failed to consistently assess, perform dressing changes as ordered, and implement wound provider recommendations timely for application of a wound treatment device for 1 of 3 residents (Resident 2), reviewed for pressure injuries (PIs - injury to the skin and underlying tissue due to prolonged pressure). The facility failed to timely monitor, assess, implement wound provider recommendations, and perform dressing changes as ordered. This failed practice resulted in harm to Resident 2, when they experienced worsening/deterioration of the PI to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis).

Inspectors wroteBased on interviews and record review, the facility failed to report an incident of neglect regarding a fall with significant injury to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate an incident of neglect, due to a fracture from a fall, for 1 of 4 residents (Resident 1), reviewed for investigations. Despite the significant changes in Resident 1's condition resulting in a hip fracture, and lack of staff assessments and timely medical care, the investigation did not include any statements by Staff C, G, and H. There was no investigation regarding the lack of timely assessments regarding significant changes in the resident's condition, pain medication and lack of obtaining the necessary medical evaluation and treatment. This failed practice placed residents at risk for unrecognized neglect, lack of monitoring, corrective action, and/or a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) including incorporating ADs into the care planning process for 2 of 3 residents (Residents 22 and 35) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the identification of physical and verbal abuse, and the protection of residents from their Alleged Perpetrator/Alleged Perpetrators (AP/APs), after allegations of abuse were reported to the facility for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse/neglect. This failure placed the residents at risk for further abuse, fear, and unmet care and services.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse/neglect for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse and neglect. This failure placed the residents at risk for further and unrecognized abuse/neglect and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and thorough investigation had been completed, nor did they ensure the residents were protected from their alleged perpetrator (AP) by not removing the AP from having any further contact with those residents during the investigation phase of the reported allegations of abuse/neglect for 4 of 7 residents (Residents 22, 52, 45, and 54) reviewed for abuse and neglect. The failure to conduct a thorough investigation to rule out root cause, contributing factors, and identifying preventative measures of the abuse/neglect allegations placed the residents at risk for further unmet care needs and psychosocial harm. Review of a policy titled Abuse-Protection of Residents dated 06/17/2024, showed the facility would Prevent further potential abuse, neglect ., or mistreatment while the investigation is in process. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) discharge assessment upon discharge, within the required 14-day time period, for 5 of 5 residents (Residents 1, 15, 33, 49, and 51). This failed practice placed residents at risk for not having their needs met upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that had the minimum requirements documented for dietary orders, physician orders, and treatment plans for 3 of 4 residents (Residents 19, 35, and 50) reviewed for recent admissions. The failed practice placed the resident at risk of not receiving continuity of care and resident centered care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 5 residents (Residents 5, 6, 13, 14, and 22) reviewed for activities of daily living (ADLs), received adequate showers, grooming, and oral care according to the residents' care plans. This failure placed the residents at risk for unmet hygiene needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections with, 1) hand hygiene and glove change for 6 of 6 staff (Staff F, T, U, V, LL, and OO) reviewed during resident cares, and isolation precautions requiring hand washing, 2) improper use of Personal Protective Equipment (PPE) in infection isolation rooms (rooms that require the use of PPE), when sorting facility residents laundry, and with self-testing of infectious diseases for 6 of 6 staff (Staff F, T, N, HH, KK, and PP) reviewed for standard precautions with PPE, 3) cleaning and disinfecting of the facility's isolation precaution room (a process used to reduce the transmission of infectious bacteria and organisms in the healthcare setting) without an Environmental Protection [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer of funds, from a resident trust account, were completed within 30 days following their discharge for 1 of 4 residents (Resident 316) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on observation and interview the facility failed to maintain a quiet, comfortable and homelike environment for 1 of 1 resident (Resident 218) reviewed for homelike environment. This failure placed the residents at risk for fatigue, unwanted noise at night, and a non-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to implement 5 of 8 components (identify, protect, report, investigate, and coordinate with quality assurance performance improvement [QAPI] of their abuse/neglect policy/procedure for 4 of 7 residents (Residents 22, 53, 45, and 54) reviewed for allegations of abuse/neglect. Additionally, the facility failed to ensure the development of their abuse/neglect policy/procedure by not including Coordination with QAPI component. This failure placed the residents at risk for unrecognized abuse, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to provide a written notice to the resident and/or their representative of the discharge for 2 of 2 residents (Residents 14 and 51) reviewed for hospitalization. In addition, the facility failed to properly notify the Office of the State Long-Term Care (LTC) Ombudsman (a person who advocates for residents in nursing homes). This failure placed the residents at risk for unmet discharge needs.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of a hospital transfer for 3 of 3 residents (Residents 14, 19 and 51) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on interview and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were correct on admission and corrected/updated as needed for 3 of 5 residents (Resident 19, 30 and 46) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review the facility failed to assist ensure an effective, resident-centered discharge plan was in place for 1 of 1 resident (Resident 46), reviewed for discharge planning. The failure to initiate a discharge plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-worth, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received medications or supplements that were physician prescribed and monitored as ordered for 1 of 1 resident (Resident 21) reviewed for insulin. This failed practice had the potential to cause the resident to experience adverse side effects and ineffective medication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide outside vision services for 1 of 1 resident (Resident 52), reviewed for experienced changes to their vision. This failed practice put the resident at risk for unmet vision needs and the ability to maintain their independence.

Inspectors wroteBased on observation, interviews, and record review the facility failed to complete skin assessments or obtain treatment orders to manage pressure ulcers to prevent the development and/or worsening of pressure ulcers for 1 of 1 (Resident 52) reviewed for pressure ulcers. This failure placed the resident at risk for developing and/or worsening of pressure ulcers and increased pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic (medications capable of affecting the mind, emotions, and behavior) medications for 1 of 5 residents (Resident 30) reviewed for unnecessary medications. The facility failed to ensure psychotropic medications had a gradual dose reduction (GDR, is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) to determine continued need and use of a medication, nor were person-centered behaviors being monitored to reflect adequate need of the medication. These failures placed the resident at an increased risk for receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were destroyed in 1 of 1 medication room (Team 1 med room) and 1 of 2 medication carts (Team 2 med cart). These failures placed residents at risk for receiving expired medications and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were labeled and dated, expired foods were removed, and proper temperatures were consistently monitored for 2 of 2 snack/nourishment refrigerators (Teams 1 and 2) reviewed for infection control. This failed practice placed residents at risk for food borne illness.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's representative (RR) of significant changes in condition resulting in hospitalization for 1 of 3 residents (Resident 1) reviewed for notification. The failure to notify the RR placed the resident at risk of not having them involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident's responsible party of significant changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the responsible party placed the resident at risk of not having them involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interview and record review the facility failed to provide a completed State Reporting Log (documentation used by facilities to report incidents of possible abuse, neglect, abandonment, mistreatment, injuries of unknown source, exploitation, major disasters/outbreaks, unexpected death/suicide, evacuation, or misappropriation of resident property in nursing homes) available to State Investigators upon their request. The failure to provide a completed State Reporting Log placed all residents at risk of unidentified abuse and neglect.

Inspectors wroteBased on interviews and record review the facility failed to ensure a resident was adequately assessed/monitored after an unwitnessed fall which resulted in a lack of timely diagnosis for 1 of 3 residents (Resident 1), reviewed for significant changes in condition. Failure to assess/monitor Resident 1 following a fall placed them at risk for delay in treatment.

Inspectors wroteBased on interviews and record review the facility failed to consistently monitor and develop planned interventions for edema (swelling caused by too much fluid in the tissues), monitor weight gain and effectiveness of diuretic therapy (medications that help reduce fluid buildup in the body) for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to a decline in their mobility and delay in receiving medical treatment.

Inspectors wroteBased on interviews and record review the facility failed to ensure staff responsible for providing cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) had current CPR certification for 4 of 16 licensed nursing staff (Staff A, B, C, D) reviewed for CPR certification status. This failure had the potential risk of the facility having a lack of staff who were properly trained in CPR readily available to respond in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe transfer utilizing the sit-to-stand lift (a mechanical lift used to assist residents that have difficulty standing up on their own) for 2 of 2 residents (Residents 1 and 2), reviewed for resident's that used a sit-to-stand transfer device. Resident 1 experienced a left arm fracture when they slipped out of the mechanical lift device during the transfer from their bed to the wheelchair when the waist support strap was not tightly secured. This failure placed other residents at risk for injury, falls, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used and resident testing for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) was performed in accordance with Centers for Disease Control and Prevention (CDC) guidelines by 2 of 5 staff (Staff A, G) observed for infection control practices. This failure placed residents and staff at risk for contracting COVID-19.

Inspectors wroteBased on interview and record review the facility failed to ensure pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) were offered to 3 of 5 residents (Resident 3, 4, 5) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease and a diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to provide the necessary care and services for 1 of 2 residents (Resident 1) with diabetic ulcers (open wound that can occur in residents with diabetes) a) to obtain treatment orders and perform timely, accurate, and thorough assessments; and b) failed to evaluate and monitor regarding a change of condition for 1 of 3 residents (Resident 1) reviewed for assessments. These failures placed Resident 1 at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary and organized manner in accordance with professional standards for food service safety. The kitchen was in a state of disrepair; surfaces lacked deep cleaning, and bulk foods were not labeled. This failure placed all residents, staff, and visitors that ate food from the kitchen at risk for food borne illnesses and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a system of records for accurate accounting, reconciliation, and destruction of controlled substance medications (a group of medications that have the potential for abuse and/or physical or psychological dependence) for 2 of 3 medication carts (Halls 100 and 200) and 2 of 3 controlled substance logbooks (Halls 100 and 200), reviewed for medication storage. Failure to accurately verify the inventory of controlled medications through change of shift reconciliation and assure appropriate destruction procedures were maintained, placed residents at risk of financial loss, inadequate pain management, and the potential for drug diversion (the abuse of prescription drugs used for purposes other than intended by the prescriber). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that reflected the physical needs and preferences for 1 of 1 resident (Resident 17) reviewed for choices. The facility failed to ensure that the resident's living environment was conducive to their physical limitations, which placed the resident at risk for an increased dependence on staff and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure written transfers/discharge notices were provided to residents and/or their representatives, and to the Office of the State Long Term Care Ombudsman for 2 of 2 residents (Residents 18 and 3), reviewed for facility initiated hospital transfers. These failures disallowed the residents and/or their representatives and the Long Term Care Ombudsman the opportunity to have the knowledge of where and why the resident was transferred, and/or how to appeal the transfer if desired.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or their representative of the facility's bed hold policy at the time of hospital transfer for 3 of 3 residents (Residents 18, 3, and 23) reviewed for hospitalization. This failure disallowed the residents and/or their representative's access to the information needed to safeguard their return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing services to 1 of 3 residents (Resident 31) reviewed for restorative nursing and range of motion (ROM). Restorative nursing services were not provided for eight weeks starting in April 2023. This failure placed the residents at risk for pain, muscle contractures (shortening or hardening of muscles and tendons and stiffening of joints), and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 5 residents (Residents 3 and 8) reviewed for accident hazards, received adequate supervision and appropriate use of assistive devices to prevent accidents. Resident 3 rolled out of bed onto the floor while receiving peri-care (cleansing of a resident's private areas) from Staff Q, Nursing Assistant (NA). Resident 8 reportedly was transferred with a Hoyer (mechanical lift) lift by one staff member instead of the required two staff members as directed by the facility policy and the resident's care plan. These failures placed the residents at risk for preventable accidents and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an assessment was performed before and after receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services for 2 of 2 residents (Residents 20 and 18), reviewed for dialysis. These failures placed the residents at risk for unnoticed change in medical condition, delay in treatment, and a diminished quality of life.