Living Center, the

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative and/or physician of a change in condition or treatment for two residents (Residents #1 and #4). Resident #1 was treated with permethrin cream (a topical cream used to treat scabies and lice) on 07/04/26. Staff did not notify the resident's representative until 07/07/26 when the representative questioned the rash when he/she visited the resident at the facility. Resident #4, who had a history of verbal aggression, exhibited verbally aggressive behaviors directed towards another resident on 07/11/26. The facility did not notify the resident's representative or the physician of the resident's behaviors as directed in the resident's plan of care. The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #4), with a diagnosis of a traumatic brain injury (damage to the brain caused by an external physical force, such as a violent blow or bump or jolt to the head which disrupts normal brain function and ranges from mild to severe), in a review of 11 sampled residents, received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. Staff failed to implement individualized interventions based on the resident's behavioral symptoms and underlying causes and to communicate these interventions to staff in order to address the resident's verbally aggressive behaviors directed towards his/her previous roommate (Resident #5). The facility census was 65. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed acceptable infection control practices when facility staff completed a central venous catheter (a long, thin flexible tube put into a large vein in the neck, chest or groin) dressing change and failed to ensure it was in accordance with the facility policy for one resident (Resident #3). The facility also failed to ensure Enhanced Barrier Precautions (EBP) were in place including posted signage to remind staff of the PPE requirements prior to entering the resident's room per facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1), in a review of seven sampled residents. Staff failed to monitor Resident #1, who was taken outside by staff, at approximately 1:27 P.M. to 3:30 P.M. The resident sat in the courtyard under the gazebo and self-propelled him/herself in the courtyard with temperatures between 78 degrees Fahrenheit (F) and 86 degrees F. When discovered by staff at approximately 3:30 P.M., the resident had wheeled himself/herself out from under the gazebo, had his/her back wheel of the wheelchair off of the sidewalk, had taken his/her shoes and socks off and had a red face and his/her skin was hot to touch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two ice machines were free of a buildup of debris, failed to properly store an ice scoop in the serving kitchen, and failed to ensure the refreshment area ice machine was equipped with an adequate air gap. The facility also failed to safely store food items in two refrigerators in the serving kitchen. The facility census was 69. 1. Review of the facility policy, Infection Prevention and Control, Nutritional Services, dated May 2015, showed the following guidance for the Ice Machine in the Food Server Area: -Run the scoop through the dish machine and air dry daily. Store them in clean Ziploc bag; -Wipe the exterior of the machine with warm, sudsy water, rinse and sanitize weekly; -The vendor is responsible for cleaning ice machine quarterly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for one resident (Resident #34), of 20 sampled residents and four additional residents (Resident #13, #38, #48 and #54). The facility census was 69. 1. During an interview on 07/18/24 at 3:59 P.M., Registered Nurse (RN) A said the facility followed the Resident Assessment Instrument (RAI) manual to guide completion of all of the MDS assessments and the facility did not have a specific policy related to MDS completion. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2023, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation for continued use of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Resident #12, #34 and #56), and failed to complete a 14-day review for the PRN (as-needed) use of a benzodiazepine (a drug that produces sedation and hypnosis) for three residents (Resident #42, #57 and #63) in a review of 20 sampled residents. The facility census was 69. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 20 sampled residents, remained free from misappropriation of property when Certified Nurse Aide (CNA) F took the resident's cellular phone and made charges of approximately $200 to the resident's online shopping account without the resident's knowledge. The facility census was 69. On 7/3/24 at 4:08 P.M., the administrator was notified of the past noncompliance which occurred on 6/25/24. On 6/25/24, the administrator became aware of the violation of misappropriation of the resident's phone and charges made to the resident's online shopping account by CNA F. Upon discovery, the facility canceled the contract with CNA F through the contracting company, conducted an investigation, and notified appropriate parties. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately, but no later than two hours after the allegation was made, for one resident (Resident #2), in a review of five sampled residents. Resident #2 reported staff threw him/her into the sink while assisting the resident in the bathroom on 9/17/23. The facility failed to report the allegation of abuse to the state survey agency. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -The residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility prohibited mistreatment, neglect or abuse of the residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from potential abuse after one resident (Resident #2), in a review of five sampled residents, reported Certified Nurse Assistant (CNA) A and CNA B threw him/her into the sink while assisting the resident in the bathroom. The facility allowed the staff to continue to work the remainder of their shift on 9/17/23 and the following night shift. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish, or deprivation by and individual, including a caretaker of goods or services that were necessary to attain or maintain physical, mental and psychological well-being; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify and communicate to staff effective interventions to prevent falls for one resident (Resident #2), who was admitted with left sided weakness from stroke, in a review of six sampled residents. The resident rolled out of bed on the left side when trying to obtain items that were out of reach. The facility staff also failed to use appropriate transfer techniques for the resident, who staff assessed as high risk for falls, when they failed to transfer the resident using a gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning) as directed in the resident's plan of care. The facility census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care and services to maintain the highest practical well-being for one resident (Resident #1) with a diagnosis of dementia, in a review of five sampled residents. The facility identified the resident did not like and became upset when staff of the opposite sex provided his/her care. The facility failed to ensure the direct care staff who provided care for the resident on 9/17/23 were of the same sex as the resident, and failed to follow the resident's care plan to approach the resident at another time when the resident was combative or refused care. During incontinence care on 9/17/23, the resident became upset, combative, swatting his/her arms, and resisted care. Staff continued to provide care for the resident, and the resident sustained a skin tear. The facility census was 67. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to routinely assess pain, administer pain medications timely after pain was identified, notify the physician of unresolved pain, administer pain medications in anticipation of activities that cause pain, and re-evaluate if medications administered were effective for one resident (Resident #1) who was distressed, and rated his/her pain a eight on a zero to ten scale with ten being the worst pain possible. The resident said he/she was hurting too bad to get out of bed for lunch. The resident had possible fractures that had been identified and had not been treated, and pressure ulcers to his/her heels and coccyx. The facility census was 67. Review of the facility's policy on Pain Assessment and Management, revised on March 2015, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure proper handwashing techniques during meal service. The facility census was 76. Observation on 02/06/23 during the noon meal service showed the following: -At 12:03 P.M., Dietary Aide A wore gloves and touched trays, plates, meal tickets, and ice cream cups, and without removing his/her gloves touched the potatoes on a resident's plate with his/her gloved hand; -At 12:10 P.M., Dietary Aide A touched plates and the microwave, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; -At 12:17 P.M., Dietary Aide A touched plates, trays, and utensils, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for three residents (Residents #9, #17 and #53), in a review of 19 sampled residents, when their call lights were not accessible for use. The facility census was 76. The facility did not have a policy on call light accessibility. 1. Review of Resident #9's face sheet showed the resident's diagnoses included dementia and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as a stroke). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/22, showed the following: -Moderately impaired cognition; -Total dependence on two staff for transfers. Review of the resident's care plan, revised on 1/23/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and professional standards of care for two residents (Residents #5 and #38), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy Physician/Provider Orders, revised 5/2018, showed all physician orders should be executed in a timely manner. Review of the facility policy, Administering Medications through a Metered Dose Inhaler, reviewed 10/2010, showed allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 1. Review of Resident #38's face sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD; a group of lung disease that block air flow and make it difficult to breathe). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good personal hygiene for eight residents (Residents #9, #17, #22, #26, #27, #37, #51, and #53), who required assistance to perform their activities of daily living (ADLs), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy, Care of Fingernails/Toenails, revised 10/2010, showed the following: -The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection; -General Guidelines: 1. Nail care includes daily cleaning and regular trimming; 2. Proper nail care can aid in the prevention of skin problems around the nail bed; 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident safety for three residents (Residents #5, #14 and #53) in a review of 19 sampled residents. Staff failed to use a gait belt while assisting two residents (Resident #5 and #14), and lifted the residents under both arms and pulled up on the back of the residents' pants during the transfer. Staff also failed to ensure two residents (Residents #14 and #53) had foot pedals on their wheelchairs prior to staff propelling the residents in the facility. The facility census was 76. Review of the facility policy How to Transfer an Individual Using a Gait Belt dated 2010 showed the following: The purpose was to provide safety and protection from possible injury during transfer and ambulation; 3. Apply the gait belt while the individual is in a comfortable sitting position. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent and educate residents and their responsible parties on the risk of bedrail use and failed to document attempted alternatives prior to installing the bed rails for seven residents (Resident #57, #27, #25, #22, #17, #4 and #7) and failed to assess one resident (Resident #7) in a review of 19 sampled residents, for bed rails and risk of entrapment. The facility census was 76. Review of the facility policy, Siderails and Beds - Safety, updated 5/22/22, showed the following: -Beds, bed frames, siderails and mattresses shall be routinely inspected by the engineering department for possible areas of entrapment; -Resident's individualized needs for siderail use shall be determined by a multidisciplinary team, and shall include, but not limited to, an assessment of: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility census was 76. Review of the noon meal menu for 02/06/23 showed meal items included chicken fried chicken, carrots and green beans. Observation on 02/06/23 of the noon meal showed the following: -At 12:03 P.M., staff served first the first resident meal tray from the steam table in the serving area; -At 12:37 P.M., staff served the last resident meal tray; -At 12:40 P.M., the test tray was received. The temperature of the chicken fried chicken was 98 degrees Fahrenheit, the grilled chicken was 100 degrees Fahrenheit, the carrots were 105 degrees Fahrenheit, and the green beans were 108 degrees Fahrenheit. The food was cool to taste. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands before or after applying gloves or when in direct resident contact, failed to change gloves during personal care and wound care, and failed to ensure proper handling of soiled linens, clothing and incontinence care items when indicated by professional standards of practice for six residents (Resident #5, #9, #14, #53, #57 and #420), in a review of 19 residents. The facility census was 76. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for seven residents (Resident #4, #7, #17, #22, #25, #27, and #57), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy, Siderails and Beds - Safety, updated 5/22/22, showed the following: -Beds, bed frames, siderails and mattresses shall be routinely inspected by the engineering department for possible areas of entrapment; -Inspection includes assessment of the following zones: 1. Within the rail; 2. Between the top of the compressed mattress and the bottom of the rails, between the rail supports; 3. Between the rail and the mattress; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #9), in a review of 19 sampled residents, received oxygen therapy consistent with professional standards of practice. The facility census was 76. During interview on 2/24/22, at 11:10 A.M., the Director of Nursing said the facility did not have an oxygen administration and monitoring of oxygen therapy policy. 1. Review of Resident #9's face sheet showed the following: -admission to the facility on 1/26/22; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain holding temperatures of pureed food items at 140 degrees Fahrenheit (F) and failed to maintain an ice machine air gap between the drain and the floor in the skilled facility. The facility census was 57. 1. During an interview on 7/22/19 at 11:04 A.M. Dietary Staff P said there were four residents in the long term care facility that were on a pureed diet. Pureed items came already molded/frozen and were cooked in the oven prior to serving. Observation on 7/22/19 at 11:33 A.M. showed Dietary Staff P temped the pureed food items for the nursing home residents and showed the following temperatures: -Pureed chicken and vegetable bake measured 169 degrees F; -Pureed corn measured 179 degrees F; -Pureed broccoli measured 179 degrees F; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided services that met professional standards of quality for medication administration for two residents (Resident #14 and #31) in a review of 15 sampled residents and when staff provided treatments without a physician's order for one sampled resident (Resident #25) and one additional resident (Resident #103). The facility census was 57. 1. Review of the facility policy, titled, Administering Medications, revised 01/01, showed the following: -Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders; -Except for single unit dose packets and IV's, only the individual preparing the resident's medication may administer it; -Medications may not be prepared in advance and must be administered within one (I) hour of their prescribed time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications with an error rate of less than 5 percent (%) for two residents (Residents #14 and #31) in a review of 15 sampled residents. There were 39 opportunities for errors with two errors, which resulted in an error rate of 5.13%. The facility census was 57. 1. Review of the facility policy titled, Administering Medications, revised 01/01, showed the following: -Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director; -Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing staff washed their hands and changed gloves when indicated by professional practices during eye drop administration and topical antifungal treatment to ensure the antifungal cream's tube tip was free of contamination for one resident (Resident #31) in a review of 15 sampled residents. Facility staff also failed to follow infection control practices while performing blood glucose monitoring for one sampled resident (Resident #45) and five additional residents (Resident #6, #1, #3, #11 and #52) when staff failed to appropriately sanitize the glucometer machine (machine that tests a droplet of blood for the amount of sugar it contains) after use. The facility census was 57. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate eligible residents with the pneumococcal vaccines as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines, for five residents (Residents #14, #30, #31, #36 and #46), in a review of 15 sampled residents and one additional resident (Resident #27). Further review showed there was no documentation the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. The facility census was 57. 1. Review of the facility policy titled, Pneumococcal Vaccine, revised October 2014, showed the following: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one resident's (Resident #25's) physician, in a review of 15 sampled residents, when the resident had a change in condition. The facility census was 57. 1. Review of the facility policy, titled, Physician Notification Policy and Procedure, revised May 24, 2011, showed the following: -Our facility shall promptly notify the resident's attending physician or practitioner of any clinical problems, changes in laboratory values, or changes in vital signs according to the guidelines laid out in the policy; -The nurse supervisor/charge nurse will notify the resident's attending physician or on-call practitioner when there has been: -A significant change in the resident's physical/emotional/mental condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a systematic process for evaluating if a recliner chair, implemented as an intervention to prevent falls for one resident (Resident #203), in a review of 15 sampled residents, was a restraint. The resident could not easily or intentionally exit or change his/her position from fully reclined to upright when in the chair. The facility also failed to identify the medical symptom the recliner was being used to treat, and failed to provide care planning and assessments on an ongoing basis to address the recliner and it's restraining properties. The facility census was 57. 1. During interview on 7/24/19 at 3:00 P.M. the Director of Nursing (DON) said the facility did not have a policy for restraints. 2. Record review of Primaris website regarding restraints, showed the following: [...]

Inspectors wroteBased on observation, interview and record record the facility failed to provide appropriate care, treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for two residents (Resident #45 and Resident #4 ) with an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) of 15 sampled residents. The facility identified three residents with indwelling catheters. The facility census was 57. 1. Review of the facility policy Urinary Catheter: Indwelling Catheter Care dated May 2019 showed the following: -When the indwelling catheter is no longer needed, remove it as soon as possible because of the risk for catheter-associated urinary tract infection; -Secure the drainage bag and tubing below the level of the bladder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to show adequate indications for use of an antipsychotic medication (a class of medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia and bipolar disorder) and hypnotic medication (commonly known as sleeping pills, are a class of psychoactive drugs whose primary function is to induce sleep and to be used in the treatment of insomnia (sleeplessness), or for surgical anesthesia) and monitor psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) use for one resident (Resident #203) in a review of 15 sampled residents. The facility census was 57. 1. [...]