Lily Springs Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the residents through the means other than a postal service for 12 of 12 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend, within 24 hours of delivery by the postal service. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to ensure scoops for dry storage food bins were stored separately. The facility failed to ensure expired food items were removed from dry storage and discarded. The facility failed to ensure a box of sugar was sealed in a manner that prevented contamination. The facility failed to ensure 6 bags of tortillas were free of contamination which resulted in permanent marker used to date bleeding through into the food. The facility failed to ensure the DC washed his hands and changed his gloves during food preparation after touching contaminated surfaces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 5 of (Resident #19, Resident #22, Resident #60, Resident #58 and Resident #07) of 7 residents reviewed for smoking. The facility failed to implement their smoking policy and conducted smoking evaluations as required per the policy for Residents #19, #22, #60, #58, and #07. The failure could place residents at risk of injury, burns and fire accidents from unsafe smoking practices.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #07) reviewed for care plans in that:The facility failed to ensure Resident #07's comprehensive care plan addressed smoking and the risks related to the smoking at the facility. This failure could place residents at the risk of burns and fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #13) of four residents reviewed for infection control. The facility failed to ensure staff practiced hand hygiene when performing perineal care (incontinence care) for Resident #13. The failure put residents at risk for infection, hospitalization, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books. The facility failed to ensure a binder placed in a bin at the entrance of the facility and titled Survey Binder contained the results of the most recent health recertification survey or all surveys, certifications and complaint/ incident investigations during the 3 preceding years and any plan of correction in effect with respect to the facility. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #1) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #1 to address herbehavior of banging on the wall of her room that occurred on 05/05/2026 and two other times, dates unknown. This failure could place residents at risk of not receiving care and services to meet individualized, behavioral, medical and nursing needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity for 2 of 8 residents reviewed for dignity. The facility failed to ensure Residents #1 and 2 were spoken to with dignity by LVN A on 01/07/2026 during their smoke break. This failure placed residents at risk of anger and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 7 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 call light was within reach on 11/12/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were provided care and services to carry out activities of daily living to maintain personal hygiene for 1 of 7 residents (Resident #2) reviewed for quality of life. The facility failed to provide showers to Resident #2 in compliance with her shower schedule. This deficient practice could place residents at risk of decline in overall health.

Inspectors wroteBased on interview and record review, the facility failed to maintain the residents' freedom retain and use personal possessions for one (Resident #1) of one resident reviewed for personal property. The facility failed to allow Resident #1 to have a powered wheelchair because she had display aggressive behaviors. This failure could place resident at risk of not being able to retain personal property, at risk of feeling disrespected, having reduced dignity and 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 each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of refusal of Nystatin Powder medication from 06/13/25 to 08/12/25. This failure placed residents at risk of not receiving goals and interventions for the residents' individual needs for person-centered care.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident # 24) reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Five staff (LVN D, LVN E, CNA, ADON, and ADM) reviewed for infection control. 1. The facility failed to ensure hand hygiene practices were used when passing resident lunch trays to residents in the dining room. These failures could place residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation interview and record review the facility failed to ensure residents had adequate supervision and assistance devices to prevent accidents for 1 (resident #51) of 10 residents reviewed for accidents and hazards. The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall and fracture to the right femur. This has led to anxiety around shower times, and a reduced quality of life. An IJ was identified on 05/02/2025 at 4:30 PM. The initial IJ template was provided to the facility on [DATE] at 4:38 PM. While the IJ was removed on 05/04/25 at 12:21 pm, the facility remained out of compliance at the scope of isolated and a severity of no actual harm due to the injury sustained by Resident #51. Findings Included: [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 5 of 5 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 5 confidential residents. The facility failed to provide activities to support the mental and physical wellbeing of the residents in the secured unit. These failures could place residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: Observation on 04/14/25 at 10:30 am in the hallways of the secured unit revealed 3 residents in the hallway walking in and out of open rooms. [...]

Inspectors wroteBased on observation, interviews, and review, the facility failed to have sufficient staff who provide direct services to residents to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 14/14 residents that reside in the secured unit. The facility failed to adequately staff the secured memory care unit (600 hallway) which resulted in a disproportionate number of incidents affecting the 600 hallway. This failure could place residents at risk for accidents with major injuries, boredom, depression, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #116 and Resident #55) reviewed for infection control. The facility failed to ensure CNAs were conducting hand hygiene when changing gloves when providing peri-care to Resident #116 The facility failed to ensure CNAs were following Enhanced Barrier Precautions by donning a gown with gloves when providing care to Resident #116 and Resident #55. The facility failed to ensure hand hygiene was being conducted with glove changes during Resident #116's wound care. These failures could place residents at risk of transmission of disease and infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodations to meet the needs and preferences for 1 of 6 residents reviewed for accommodations. The facility failed to ensure that Resident #47 had the call light device in reach while lying in bed. The facility failed to accommodate Resident #47 with a call light device that would meet their individual needs. This deficient practice could affect and diminish the resident's quality of life by potentially placing the resident at risk of injury, not receive timely care or receive nursing interventions to meet the resident's needs.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement abuse reporting policies for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to implement policies that required reporting of major injury after an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room from the shower and sustained a fracture to the right femur. This deficient practice could place residents at risk of continued abuse and neglect if abuse policy is not properly implemented.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately but not later than 24 hours after the allegation was made for one (Resident #51) of five residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident on 01/17/25 where Resident #51 fell out of the shower chair while transporting back to his room and sustained a fracture to the right femur. This deficient practice could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's RP when there was a need to alter treatment significantly for 1 of 5 (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when his medication Ativan (anxiety) was discontinued by the Doctor on 02/24/2025. This failure could place residents at risk of their responsible party not being involved in the communication of medication no longer being taken by the resident.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan which reflected Resident #1's Advanced Directive was full. Resident # 1 expired at the facility on [DATE] and there was no CPR performed . An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel and related physician orders and the residents advance directives for one of seven (Resident #1) residents reviewed for CPR . The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, which included CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 fell back in his bed while talking to Emergency Medical Services and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 4 of 7 residents (Residents #1, #2, #3, and #4) reviewed for medication administration. The facility failed to ensure Med Tech M had a current and active license. Med Tech M provided medications to Residents #1, #2, #3, and #4 while her Med Tech license was expired from [DATE] through [DATE]. This failure could place residents at risk for inadequate care and/or services.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for one of seven residents (Resident #1) reviewed for abuse and neglect . The facility failed to report to the State Survey Agency an incident when Resident #1's Advanced Directive was not followed, and CPR was not administered to Resident # 1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Residents #2) reviewed for medications and pharmacy services The facility failed to ensure Resident #2 received his hospital ordered medications when it was not documented whether Levofloxacin (a medication used for treating infections) and Metronidazole (a medication to treat various infections) were ordered when Resident # 2 discharged from the hospital to the facility on [DATE]. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures to ensure each resident was offered an influenza immunization October 1 through March 31 annually, unless the immunization was medically contraindicated or the resident had already been immunized during this time period and before offering the pneumococcal immunization, each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized for 2 of 7 residents (Resident #3 Resident #4) reviewed for immunizations . The facility failed to document the flu vaccine for Resident #3 and Resident #4 which resulted in double flu vaccinations. This failure could place residents at risk of not receiving necessary medical care and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for inventory of personal property. The facility to have a completed inventory of personal property lists for Residents #1, #2, and #3. This failure could place residents at risk of not having personal property replaced in the event of damage or loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one medication room reviewed for pharmacy services. The facility failed to ensure the medication room was kept locked or under direct supervision of authorized staff on 10/08/24. This failure could place residents at risk of having unauthorized staff having access to their medications, and accessing and ingesting medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize residents,.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop the comprehensive person-centered care plan for one resident (Resident #1) out of five residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan. This deficient practice places the resident at risk for not receiving the necessary and appropriate care.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biological's were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for one (Med Cart #1) of six medication carts reviewed for medication storage in that: The MA failed to lock and secure Med Cart #1. This failure could allow residents, visitors and unauthorized staff access to prescription and over-the-counter medications. Findings Included: Observation on 08/21/2024 at 9:04 am revealed, Med Cart #1, sitting in the hallway near nurses' station, was unsupervised and unlocked. Review of the cart's contents revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The MA assigned to the cart was not within eyesight. Another staff member shouted the MA's name down the hall and quickly locked the cart. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop the comprehensive person-centered care plan for one resident (Resident #1) out of five residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan. This deficient practice places the resident at risk for not receiving the necessary and appropriate care.

Inspectors wroteBased on interviews and record reviews the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for one resident (Resident #1) of three (3) residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was completed upon admission and revised or updated to reflect changes in Resident #1's care needs for falls, medications (antibiotics, anti-hypertensive, anti-depressant), Cognition. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for one of four residents (Residents #1) reviewed for resident rights. The facility failed ensure CNA A and CNA B identified themselves and explained or asked permission to perform a mechanical lift transfer and incontinent care for Resident #1 on 06/13/24. This failure led to Resident #1 exhibiting nonverbal signs of fear and/or pain including widened eyes, an open mouth, and facial grimacing during the procedure. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for of five residents three (Resident #2, Resident #3 and Resident #4) of five residents reviewed for ADLs. The facility failed to provide showers to Residents #2, #3 and #4 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of three residents (Resident #1) reviewed for mobility . The facility failed to apply a hand contracture cushion to Resident #1's contracted hand. This failure could place residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to be free of discrimination from the facility in exercising his or her rights and to be supported by the facility to exercise his or her rights for 1 of 15 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3 had a place to have private telephone conversations when she did not consent to her roommate having electronic monitoring that included audio monitoring. The facility failed to ensure Resident #3 gave permission before her property was searched by staff. These failures could place residents at risk of loss of privacy and loss of the ability to communicate privately which could result in a decline in their psychosocial well-being and quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (500 hall cart and 100 hall cart) of 4 medication carts, 1 (500 hall linen cart) of 3 linen carts, and 2 (Resident #5 and Resident #6) of 5 residents reviewed for medication storage. 1) The facility failed to ensure a medication cup, with 3 types of unidentified cream, was not left unattended on a linen cart . 2) The facility failed to ensure a bottle of medicated shampoo and two tubes of a wound care cream were stored in a secure place. 3) The facility failed to ensure a medication cup, with 3 types of unidentified cream, was not left unattended at Resident #5's bedside. 4) The facility failed to ensure eyedrops were not left at Resident # 6's bedside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal and oral hygiene for 1 of 5 (Resident #1) residents reviewed for ADL's. The facility failed to ensure Resident #1 received regular showers. These failures placed resident at risk of poor personal hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible in 2 of 6 resident hallways (Hall 1 and secured hall 6). The facility failed to keep the linen carts free of items that could be dangerous to residents. This failure could result in residents experiencing accidents, injuries, loss of dignity , and diminished quality of life.

Inspectors wroteBased on observation, inter, and record review, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pressure ulcers. The facility failed to: 1) - Provide treatment and services to heal Resident #2's PUs on the gluteus, sacrum, and left heel and the wounds became larger. - Provide treatment and services to prevent infection to Resident #2's sacral PU and it became infected. An IJ situation was identified on 03/18/24. L The IJ template was provided to the facility on [DATE] at 2:40 PM. [...]

Inspectors wroteBased on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 3 of 19 residents reviewed for Resident rights (Resident #167, Resident #10, and Resident #19). Facility failed to provide dignity and respect for Resident #19 by providing privacy while transporting resident down the hall. Facility failed to provide dignity and respect for Resident #10 by providing privacy while incontinent care. Facility failed to respect Resident #167's rights;resident did not receive a bath before leaving facility to attend dialysis. The facility's failure could place residents at risk of not being treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and clean bed and bath linens that are in good condition for 10 of 23 (Resident #3, Resident #20, Resident #22, Resident #25, Resident #26, Resident #30, Resident #50, Resident #62, Resident #116 and Resident #167) residents reviewed for a safe, clean, comfortable, and homelike environment. The facility failed to regularly change the sheets of Residents #20, #22, #30, 50, #116 and #167. The facility failed to put a bottom sheet on Resident #25's bed. The facility failed to keep the floors of the facility clean. The facility failed to keep Resident #62's urinals clean and empty. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal and oral hygiene for 4 (Resident #20, Resident #167, Resident #35, and Resident #116) of 19 residents reviewed for ADLs. 1. The facility failed to ensure Resident #20 received a shower regularly or changed her sheets. 2. The facility failed to ensure Resident #167 received a shower regularly. 3. The facility failed to ensure Resident #34 received a shower regularly. 4. The facility failed to ensure Resident #116 received a shower regularly. These failures could place residents at risk of poor hygiene and grooming and thereby decrease their quality of life. Findings Included: 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of one facility reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 4 (Resident #10, Resident #5, Resident #1, and Resident #35) of 19 Residents in that: 1. CNA M did not perform hand hygiene before, after, or during incontinent care of Resident #10. 2. CNA N did not perform hand hygiene before, during, or after incontinent care of Resident # 5. 3. MA Q did not perform hand hygiene before or after administering ear drops to Resident #1. 4. MDS LVN did not perform hand hygiene before or after administering insulin injection to Resident #35. 5. Medication room did not have paper towels available to perform hand hygiene. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #55) of 19 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #55 was admitted to hospice. This failure could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #49 and Resident #59) of 28 residents reviewed for accuracy of assessments. 1. Resident #49's MDS indicated she was rarely/never understood and able to answer a question about pain despite not being an active participant in the MDS process. 2. Resident #59 was discharged from the facility on 09/29/23 but did not have a discharge MDS in her EHR. This failure could place residents at risk of being inaccurately assessed and therefore not receiving necessary care. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #49 and Resident #55) of 19 residents reviewed for care plans. 1. Resident #49's care plan did not address pain or the pain medications she was prescribed. 2. Resident #55's care plan listed him as full code when he was DNR. These failures could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for one (Resident #22) of 19 residents reviewed for PRN orders for psychotropic drugs. Resident #22 had two active PRN orders for the same anti-anxiety medication (Lorazapam) with order start dates of 12/12/23. Neither order had an end date. [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles 1. 20 loose pills were found in the Hall 100 medication cart. 2. 1 loose pill was found in the Hall 400 medication cart. These failures could result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteResident #116 FTag Initiation Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area, for 2 (Resident #116 and Resident #41) of 19 residents reviewed for call system functioning. 1. The facility failed to ensure Resident #116's call light button was functioning and within reach. 2. The facility failed to ensure Resident #41's call light was within reach. This failure could place residents at risk of being unable to call for assistance from staff.