Loft Rehab of Decatur

Inspectors wroteBased on observation, interview, and record review the facility failed to answer call lights in a timely manner for five (R1, R4, R5, R7, R8) of five residents reviewed for call lights in a sample list of eight residents. Findings Include:On 6/26/26 at 8:11 AM, R8's call light was on, at 8:15 AM. V11 Certified Nursing Assistant (CNA) went into the room and shut off call light. This writer heard V11 tell R8 that R8's CNA is feeding other residents in the dining room and R8 would have to wait. On 6/26/2026 at 9:05 AM, R5 was in R5's room sitting in recliner watching TV. R5's call light was on floor on the right side of recliner out of R5s reach. On 06/25/26 at 08:17 AM, V3 (R1) family member, stated R1 called V3 at 03:44 AM on 6/11/26 stating that R1's call light had been on since midnight, and no one had answered it. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure incontinence care was provided per current standards of practice for three (R1, R5, and R6) of five residents reviewed for incontinence care in the sample list of eight residents. Findings Include:On 06/25/26 at 08:17 AM, V3 (R1's) family member, stated when family visited R1 on 6/7/26 in the morning hours, R1 told family R1 had not been checked for incontinence in 15 or more hours. R1 further stated to family that R1 was wearing two (2) incontinence briefs. V3 stated R1 was observed wearing two (2) incontinence briefs that were saturated with urine and staff was asked to change R1. On 6/26/2026 at 9:05 AM, R5 stated R5 has been recently had double depends (incontinence briefs) at night every so often. R5 does not recall who does it. R5 does not like wearing double depends (incontinence briefs) at night. [...]

Inspectors wroteBased on interview and record review the facility failed to protect residents' (R84, R10) right to be free from physical abuse by another resident (R70) for three of three residents (R84, R10, R70) reviewed for abuse in the sample list of 57 residents. This failure resulted in psychosocial harm of R84 as evidenced by R84 crying and avoidance of R70.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure relieving interventions, evaluate nutritional status, and prevent cross contamination during pressure ulcer treatments for one (R11) of four residents reviewed for pressure ulcers in the sample list of 57 residents. These failures resulted in R11 developing bilateral heel deep tissue injuries that deteriorated to stage three and stage four pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance committee meetings. The facility failed to provide documentation of its ongoing Quality Assurance & Performance Improvement Program meeting minutes for two quarters of 2025. This failure has the potential to affect all 91 residents. FindingsOn 5/4/26 at 09:25 AM, V1 Administrator provided Quality Assessment and Assurance (QAA) meeting attendance sheets for the first quarter 2026 and fourth quarter 2025 QAA meetings. V1 stated the QAA team meets quarterly to discuss issues/concerns. The January 2026 QAA meeting attendance signature sheet does not document the facility Administrator (administrator, owner, board member or other individual in a leadership role) was present for the meeting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their water management plan including an annual risk assessment, control measures, and testing protocols to reduce the risk of Legionella and other opportunistic pathogens in the facility's water systems. This failure has the potential to affect all 91 residents in the facility. Findings Include:The facility's Water Management Program, dated as revised 1/21/26, documents a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder. Control measures will be applied to address potential hazards at each control point. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document that narcotic medications were counted at the beginning and end of each shift and failed to destroy or send discontinued antibiotics back to the pharmacy. This failure affected 23 of 26 residents reviewed for medication storage on the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly labeled and stored for five (R97, R28, R81, R73, R22) of 26 residents reviewed for medication storage on a sample list of 57 residents.

Inspectors wroteBased on interview and record review the facility failed to provide bathing as scheduled for one (R9) of four residents reviewed for activities of daily living in the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide podiatry services for one (R8) of four residents reviewed for activities of daily living in the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply range of motion devices used for contractures for two (R57, R73) of 24 residents reviewed for range of motion on the sample list of 57 residents. On 5/3/26 at 9:27 AM, R57 was resting in a high back reclining chair in the room. R57's right hand was closed in a fist and bent towards R57's chest. R57 was not wearing a splint to the right hand. On 5/3/26 at 1:30 PM, V3 Licensed Practical Nurse stated she is not aware that R57 needs a brace and has never seen a brace for R57. At this time, V3 looked up R57's physician orders and stated that R57 does have an order for a brace. R57's physician order dated 9/30/25 documents an order to apply splint to right hand when resting, may take off for meals per therapy. On 05/04/26 at 10:50 AM, V5 Certified Nurse's Aide stated V5 has never seen a brace for R57. On 5/4/26 10: [...]

Inspectors wroteBased on interview and record review the facility failed to re-assess elopement risk, identify wandering/exit seeking as targeted behaviors, and develop a care plan for wandering/exit seeking behaviors and risk for elopement for one (R70) resident reviewed for elopement/wandering in the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during urinary catheter care for one (R9) of two residents reviewed for urinary catheters in the sample list of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document the refusal of protective arm sleeves on the treatment administration record for one (R73) of one resident reviewed for accidents on the sample list of 57 residents. On 5/3/2026 at 9:00 AM, R73 was sitting in a wheelchair in R73's room. R73's right arm was bent with R73's hand lying on R73's chest. R73 was wearing a sweater; R73's left arm was in the arm of the sweater but R73's right arm was bare. R73's physician order dated 7/2/2025 documents an order to apply protective arm sleeves when up in wheelchair as resident allows. On 5/3/2026 at 1:44 PM, R73 was sitting in R73's wheelchair in R73's room. R73 was not wearing protective arm sleeves. When asked if staff offered to apply the protective skin sleeves, R73 stated, no. [...]

Inspectors wroteBased on interview and record review the facility failed to implement fall interventions to prevent injury for one of three residents (R10) reviewed for falls in the sample list of 15. These failures resulted in R10 sustaining a fall with a head laceration that required staple closure. Findings Include: The facility's Fall Prevention Program dated 2/2/26 documents the facility will assess each resident's fall risk and implement interventions to decrease residents' risk of falls and subsequent injuries. R10's Medical Diagnoses list dated January 2026 documents R10 is diagnosed with abnormalities of gait and mobility, lack of coordination, muscle weakness, and altered mental status. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is moderately cognitively impaired and requires moderate staff assistance for transfers. [...]

Inspectors wroteBased on interview and record review the facility failed to administer multiple medications per physician order. This failure affected three of three residents (R13, R14, R15) reviewed for medication administration on the sample list of fifteen. Findings Include: The facility's Medication Error Policy dated 2/2/26 documents the facility shall ensure medications are administered according to physician orders. If medication errors occur, staff are to notify the physician, document the incident in the medical record, and report the incident to the appropriate supervisor. The Resident/Family Complaint Form dated 1/26/26 documents R13 filed a complaint stating she did not receive her evening medications on 1/23/26. On 2/5/26 at 11:48 a.m., V2, Director of Nursing (DON), stated residents on the Northeast Hall did not receive their evening medications on 1/23/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents right to dignified care for two of three residents (R1 and R3) reviewed for quality of care/abuse on the sample list of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to recognize and report allegations of abuse to the administrator for two (R1, R3) of three residents reviewed for abuse on the sample list of 15.

Inspectors wroteBased on interview and record review multiple facility staff had knowledge of allegations of rough care and derogatory comments, failed to report to the Administrator/Abuse Prevention Coordinator which resulted in a delay in initiating an investigation and failure to remove the alleged staff perpetrators. This failure had the potential to affect two of three residents (R1 and R3) reviewed for abuse on the sample list of 15.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right for dignity and respect. This failure affected one of three residents (R3) reviewed for Abuse on the sample of five. Findings Include: The Resident's Rights for People in Long Term Care Facilities pamphlet dated November 2018 documents the facility must treat residents with dignity and respect and must care for residents in a manner that promotes their quality of life. The State Report dated 12/8/25 documents R3 alleged a staff member (later identified as V11 Certified Nurse Assistant CNA) was rude to her and threw the container of sanitary wipes at her and told her she needed to clean someone else's feces off of the toilet seat before she used the bathroom. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property. This failure affected one of three residents (R4) reviewed for Abuse on the sample of five. Findings Include: The facility's Abuse, Neglect, and Exploitation policy dated 2/11/25 documents the facility develops and implements policies and procedures that prohibit and prevent abuse and misappropriation of resident property. The State Report Investigation dated 1/12/26 documents a staff member (later identified as V15 Certified Nurse Assistant) had taken a check from R4's check book without permission and had used the check to pay her rent. V15 had written the check and signed R4's name. The total amount was for $975.00. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two residents were properly secured in wheelchairs before transporting them in a van for two of three residents (R2, R5) reviewed for accidents in the sample list of five. This failure resulted in R2 falling from the wheelchair when the van suddenly stopped and suffering fractures to the humerus, fibula, and tibia with resulting pain and immobility.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of resident's medical records in a timely fashion following a request by resident's Power of Attorney for one of three residents (R1) reviewed for medical records requests on the sample list of five. Findings Include:R1's electronic medical record documents R1 resided at the facility from 4/16/25 until 4/23/25 when R1 was transported to the local hospital emergency department and R1 has not returned to the facility since that time. On 10/8/25 at 3:00PM V5, R1's family member stated (R1) is at (a different facility) now. I have asked and signed for (R1's) medical record from the facility, but I haven't gotten anything but the runaround. On 10/9/25 at 10:00AM V8, Medical Records stated (V5) did request (R1's) medical record in May. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clean comfortable rooms consisting of clean floors and rooms that are free of dirty dishes and debris for two (R1, R2) of three residents reviewed for comfortable homelike environment. Findings Include:On 7/21/25 at 10:00 AM initial tour of the facility hallways labeled 100, 200 and 300 observed to have several unmade beds, some beds observed without linen, some beds had soiled linen on the unmade bed. 1. R1's Minimum Data Set, dated on July 11, 2025, documents R1 as cognitively intact. On 7/21/25 at 1:15 PM R1 stated the staff does not make the bed daily, and often times there are dishes left over in his room from meals that he doesn't eat in the dining room. R1 stated that R1 prefers bed/sponge baths and staff do not change the sheets on the bed after wiping him down. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly secure R2's indwelling catheter tubing, document urinary output every shift, and provide a dignity cover to cover the urinary collection bag. R2 is one of one residents reviewed for urinary catheters. Findings Include:On 7/21/25 at 10:22 AM R2 is observed lying in bed with indwelling urinary catheter tubing dangling from the bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway. On 7/21/25 at 12:00 PM V4 confirmed R2 is lying in bed with indwelling urinary catheter tubing dangling from the right bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway. [...]

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse to the state survey agency for one (R4) of three residents reviewed for abuse on a sample list of eight.

Inspectors wroteFailures at this level required more than one Deficient Practice Statement. A. Based on interview and record review the facility failed to immediately notify the physician, complete a pain assessment, complete a physical assessment, and provide pain management when severe pain with redness and swelling to the left knee began suddenly and continued for five days for one (R401) of three residents reviewed for significant change in condition in the sample list of 27. These failures resulted in R401 experiencing severe pain from 3/9/25 to 3/14/25 when R401 was hospitalized with a left femur fracture which required surgical repair. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision/assistance when ambulating a resident to prevent a fall for one of four residents (R2) reviewed for accidents in the sample list of four residents. This failure resulted in R2 falling and suffering a fractured humerus when staff stepped away from R2 to untangle oxygen tubing.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement repositioning and incontinence cares every two hours, implement pressure relieving interventions, implement pressure ulcer treatments, identify pressure ulcers, monitor and assess pressure ulcers upon identification and weekly, and notify a physician and dietitian of newly identified and current pressure ulcers and deterioration for two (R52, R345) of six residents reviewed for pressure ulcers in the sample list of 48. These failures resulted in R52 developing left heel stage two and right heel stage three pressure ulcers and being hospitalized for an infection of the stage three pressure ulcer. R52 subsequently developed a coccyx pressure ulcer that deteriorated into a stage four pressure wound. This failure resulted in an Immediate Jeopardy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and mental/emotional abuse by staff members for two (R345, R195) of 32 residents reviewed for abuse on the sample list of 48 residents. This failure resulted in fear, emotional harm and mental anguish for both R345 and R195. Findings Include: 1. R345's care plan dated 2/11/25 documents R345 has medical diagnoses of COPD (Chronic Obstructive Pulmonary Disease), Asthma, History of Chronic Respiratory Failure, History of Fracture to the the Right Femur, Arthritis to right hand, Depression, Diabetes Mellitus, Anemia, Pneumonia, and Hypertension. R345's minimum data assessment dated [DATE] documents that R345 is cognitively intact and has no signs and symptoms of delirium. On 3/2/25 at 10:23 AM, R345 was sitting in his wheelchair in his room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a wound, prevent cross contamination during wound care, administer wound treatments as ordered, timely notify the physician of a dehisced surgical wound, monitor bowel movements and hydration, and implement bowel interventions for three (R52, R30, R41) of 24 residents reviewed for quality nursing care in the sample list of 48. These failures resulted in R52 and R41 developing bowel obstruction and fecal impaction requiring hospitalization and treatment. Findings Include: 1.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 is dependent on staff for toileting. R52's MDS dated [DATE] documents R52 has cognitive impairment and R52 is dependent on staff for toileting. [...]

Inspectors wroteBased on interview and record review the facility failed to identify significant weight loss, notify a physician or registered dietician regarding significant weight loss or implement interventions to prevent further weight loss for one of five residents (R45) reviewed for Nutrition on the sample list of 48. This failure resulted in continued weight loss even after a severe weight loss was identified. Findings Include: The facility's Weight Monitoring policy dated 2/10/25 documents Based on the resident's comprehensive assessment; the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to effectively manage pain by failing to accurately assess for pain, notify the physician of pain and implement orders for pain medications for two (R52, R84) of two residents reviewed for pain in the sample list of 48. This failure resulted in R52 experiencing uncontrolled pain as evidenced by moaning, grimacing, tearfulness, clenched fists and complaints of pain. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents, resulting in long call light response times and wound treatments and assessments not being completed timely for eight (R41, R7, R58, R66, R84, R79,R40, R52) of 32 residents reviewed for staffing out of a sample list of 48. Findings Include: The undated Facility Assessment documents the facility will follow Federal minimum staffing standards. Facilities with higher acuities and needs may need to adjust their staffing numbers higher than the minimum standard. The undated Facility Assessment documents the facilities daily Certified Nursing Assistant (CNA's) needs are 24 CNAs for a resident census of 97. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to post daily, up-to-date, nurse staffing information. This failure has the potential to affect all 97 residents residing in the facility. Findings Include: On 3/3/25 at 10:28 AM posted staffing in case near front entrance dated 2/28/25. On 3/5/25 at 9:15 AM and 4:00 PM posted staffing in case near front entrance remains dated 2/28/25. On 3/4/25 at 3:51 PM V2 Interim Regional Director of Nurses (DON) confirmed Posted Daily Staffing should be updated daily. Throughout the survey concerns were identified related to staffing, showers, cold food, turning and repositioning, toileting, incontinence care, infection control, and call light wait times. The Resident Council Meeting Minutes dated 1/27/25 and 2/14/25 both document resident concerns with call light wait times. [...]

Inspectors wroteBased upon interview and record review the facility failed to employ a qualified Social Worker on a full-time basis in a facility of 150 beds. This failure has the potential to affect all 97 residents who reside in the facility. Findings Include: The facility's undated Facility Assessment documents there are 150 licensed beds in the facility. This assessment also documents the facility requires one full time social worker on staff. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 3/2/25, documents there are 97 residents residing in the facility. On 3/6/25 at 1:30 PM, V1 Administrator stated V32 Social Service Director, is covering Activities and Social Services. V1 confirms V32 does not meet the qualifications to be a Social Worker in the facility. V1 stated V32 does not have a degree in Social Work or Human Services.

Inspectors wroteBased on interview and record review, the facility failed to implement their water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 97 residents in the facility. Findings Include: The facility's Water Management Plan dated 2023, fails to fully document the required facility water system risk assessment where Legionella and other pathogens could grow and spread in the facility water system. The facility failed to implement any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to record all financial transactions for five (R60, R11, R74, R347 and R18) of seven residents reviewed for resident funds on the sample list of 48 residents. Findings Include: On 3/4/25 at 9:55 AM, stapled plastic pill pouches containing money were taped to the underside of the lid of the narcotic section of the medication cart. R60, R347, R74, and R18's names were written in marker on the outside of the pill pouches. R60's pouch contained $2.00, a pill pouch with a dark black marker was labeled lost and found 2.00, R347's pouch contained $5.00, R18's pouch contained $1.00, R74's pouch contained $5.00, and an nonlabeled unknown pouch contained $21.00. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide showers as scheduled and failed to provide shaving, nail care, and grooming for four of four residents (R18, R41, R70, and R195) reviewed for showers and hygiene/grooming on the sample list of 48. Findings Include: The facility's Activities of Daily Living Policy dated 2/10/25, documents a resident who is unable to carry out activities of daily living will receive the necessary care to maintain grooming and personal care. 1. R18's Minimum Data Set (MDS) dated [DATE], documents R18 is dependent for personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an adequate indication for the use of a psychotropic medication, failed to try non-pharmacological interventions prior to administering a psychotropic medication, failed to do behavior tracking for multiple months after starting a psychotropic medication, and failed to attempt a gradual dose reduction of a psychotropic medication for two of four residents (R71, R46) reviewed for Psychotropic Medications on the sample list of 48. Findings Include: The facility's Use of Psychotropic Medications policy dated 2/10/25, documents a chemical restraint refers to any drug used for discipline or makes it more convenient for staff to care for a resident, and not required to treat medical symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was palatable and food temperatures were satisfactory, and failed to ensure meals were served timely, for five (R79, R58, R47, R30, R84) of five residents reviewed for food satisfaction on the sample list of 48. Findings Include: The facility's Food Temperatures policy revised 2/12/25 documents to ensure food safety, hot food will be held and served at a temperature no lower than 135 degrees Fahrenheit (F). A resident council meeting was conducted on 3/03/25 at 10:03 AM. R79 stated the food doesn't taste good and it's served cold both in the dining room and when eating in her room. R79 stated there is no way for them to keep the food hot since it is on open racks. They don't have the staff to pass the trays timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to dignified activities of daily living. This failure affects one of nine residents (R195) reviewed for dignity on the sample list of 48. Findings Include: The facility's Promoting/Maintaining Resident Dignity Policy dated 2/12/25 documents it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality and all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was in reach for two (R58, R345) of 32 residents reviewed for call lights out of a sample list of 48. Findings Include: The facility's Call Light: Accessibility and Timely Response policy revised 2/6/25 documents all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 1. R58's Minimum Data Set (MDS) dated [DATE] documents R58 is cognitively intact. The same MDS documents R58 needs partial/moderate assist of one staff member to transfer or ambulate. On 03/02/25 at 10:31 AM, R58 was sitting in his wheelchair in his own room. R58's untouched breakfast tray was in front of R58 on the bedside table with eggs, toast, oatmeal, and milk. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to review and accurately record physician's orders for life sustaining treatment for one (R30) of 32 residents reviewed for advance directives in the sample list of 48. Findings Include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy dated 2/10/25 documents on admission the facility will determine if the resident has an advance directive, copies of the advance directive will be placed in the resident's chart and communicated to staff, and the facility will review advance directives with the resident or representative as part of the care planning process. On 3/02/25 at 12:22 PM R30 stated R30 has a Do Not Resuscitate order. R30's Minimum Data Set, dated [DATE] documents R30 as cognitively intact. R30's Hospital Discharge Orders dated 2/15/25 document R30's code status as full code. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a bed that was comfortable and in working condition for one (R346) of 32 residents reviewed for environment on a sample list of 48 residents. Findings Include: R346's skilled nursing assessment documents that he is alert and oriented. R346's care plan dated 3/2/25 documents R346 requires assistance with bed mobility due to fracture, infection of the right femur, and a diagnosis of low back pain. On 3/5/25 at 8:35 AM, R346's was lying in bed on his back. The right side of the head of the bed was elevated approximately 30 degrees. The left side of the head of the bed was elevated approximately 20 degrees. R346 stated that his bed was broke and has been since 1:00 AM that morning. R346 stated he has been laying in the same position since 1:00 AM and he is uncomfortable. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement it's abuse policy by failing to investigate and report an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of 48 residents. Findings Include: The facility's abuse policy with a revision of 2/11/25 documents the facility will prevent and prohibit abuse. This policy documents verbal abuse as a type of abuse. This policy documents the facility will notify the state agency within 24 hours of receiving an allegation of abuse. This policy documents that allegations of abuse will be immediately investigated. On 3/2/25 at 10:23 AM, R345 stated he was verbally abused by V26 Licensed Practical Nurse on 2/23/25. On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 was rude to R345 which upset R345. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the state agency of an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of of 48 residents. Findings Include: On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 Licensed Practical Nurse was rude to R345 and made R345 upset. V1 stated she did not notify the state agency until 3/3/25. The facility's report to the state agency dated 3/3/25 documents that the state agency was not notified regarding R345's allegation of verbal abuse by V26 until 3/3/25.

Inspectors wroteBased on interview and record review, the facility failed to immediately investigate an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of 48 residents Findings Include: On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 Licensed Practical Nurse was rude to R345 and made R345 very upset. V1 stated she did not investigate this as an allegation of abuse until 3/3/25. The facility's report to the state agency dated 3/3/25 documents that an investigation regarding R345's allegation of verbal abuse by V26 was initiated on 3/3/25.

Inspectors wroteBased on interview and record review the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) level II evaluation for one of two residents (R85) reviewed for PASARR II completion on the sample list of 48. Findings Include: R85's Clinical Census dated March 2025 documents R85 was admitted to the facility on [DATE]. R85's Medical Diagnoses List dated March 2025 documents R85 is diagnosed with Generalized Anxiety Disorder and Post Traumatic Stress Disorder. Both diagnoses have been in place since 10/5/16. R85's PASARR Level 1 dated 12/3/24 documents no Level II evaluation is required due to R85 not having any Significant Mental Illness (SMI) diagnosis. [...]

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to obtain daily weights for one of two residents (R59) reviewed for weights on the sample list of 48. Findings Include: R59's Medical Diagnoses List dated March 2025 documents R59 is diagnosed with Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease Stage 4. R59's Physician Order Sheet (POS) dated March 2025 documents a physician order on 10/3/24 for daily weights, every day shift, notify the physician if there is a weight gain greater that three pounds in 24 hours or a weight gain greater than five pounds in seven days. R59's Care Plan dated 11/22/24 documents R59 is at risk for fluid volume overload related to Chronic Kidney Disease Stage 4. Interventions include to monitor/document and report any signs or symptoms of fluid overload including sudden weight gain. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor risk of bleeding related to medication use for one (R15) of seven residents reviewed for unnecessary medications in the sample list of 48 residents. Findings Include: The facility's Anticoagulants High Risk Medications policy dated 2/10/25 documents risks associated with antiplatelet and anticoagulant use includes bleeding and hemorrhage, drop in hematocrit and blood pressure, and thromboembolism. This policy documents that resident's care plan should include interventions to minimize risk of adverse consequences. R15's Physician Order dated 2/19/25 documents administer Eliquis (anticoagulant) 2.5 milligrams (mg) by mouth twice daily. R15's Physician Order dated 2/20/25 documents administer Clopidogrel Bisulfate (antiplatelet) 75 mg by mouth daily. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement resident centered interventions to prevent skin breakdown and worsening of pressure sores and failed to notify the wound physician and dietician of new open areas for one resident (R2) of three residents reviewed for pressure ulcers in a sample list of five residents. These failures resulted in R2 developing a stage four pressure area to R2's right ischium and unstageable pressure areas to R2's bilateral heels. The Immediate Jeopardy began on 1/20/25 when the original open area was observed to R2's Right Gluteal Fold and the wound nurse practitioner was not notified. V1 Administrator was notified of the Immediate Jeopardy on 2/20/25 at 4:00PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours for six of fifty-five days reviewed for RN staffing. This failure has the potential to affect all 95 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate facility assessment which is reviewed no less than annually and is updated as needed. This failure has the potential to affect all residents who reside in the facility. Findings Include: The facility census dated 2/6/25 documents 95 residents reside at the facility. The Facility Assessment does not document date or time the interdisciplinary team met to review the facility assessment or document it had been reviewed at least annually. The assessment does not address the direct care staff needed to meet the needs of the resident population by shift. On page ten of the assessment under the resident need Behavioral symptoms and cognitive performance the number recorded was zero. [...]

Inspectors wroteBased on interview and record review the facility failed to answer call lights in a timely manner for two of three residents (R1, R2) reviewed for call light wait times in the sample of five. Findings Include: The facility's Call Lights: Accessibility and Timely Response policy dated 1/5/25 documents all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility Resident Council Meeting Minutes dated 1/27/25 document complaints of call lights taking 30 minutes or longer to be answered. Residents voiced that the staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident's need. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide safe transfers for two of three residents (R1, R2) reviewed for transfers in the sample of five. Findings Include: The facility's Safe Resident Handling/Transfers policy dated 12/15/24 documents all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Two staff members must be utilized when transferring residents with a mechanical lift. 1. R1's Medical Diagnoses List dated February 2025 documents R1 is diagnosed with Ischemic Heart Disease, Congestive Heart Failure, Type II Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Asthma, Chronic Kidney Disease, Major Depression, Hypertension, Anxiety, Pain, Insomnia, and Obesity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms were clean. This failure affects six (R1, R2, R4, R5, R9, R10) of ten residents reviewed for housekeeping in the sample of ten.

Inspectors wroteBased on observation and interview the facility failed to ensure a sink was properly secured to the wall for one (R4) of three residents reviewed for a safe, clean, and homelike environment on the sample list of nine. Findings Include: On 8/28/2024 at 10:30 AM, R4 was sitting in a recliner with a cabinet type sink directly to R4's left side. The sink top was not secured to the cabinet base, with the left side of the sink hanging off of the cabinet approximately 1 inch and the entire sink top not secured to the wall with an approximate one inch gap from the back of sink to wall. The sink was unstable and wobbled when touched. At this time, R4 stated R4 never grabs onto the sink from R4's recliner because it is too unsteady. R4 stated a maintenance man was here 2-3 weeks ago and said it needs resealed and then never resealed it. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement a call light intervention for a resident with a recent fall. This failure affected one of three residents (R6) reviewed for falls on the sample list of nine.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on five of fourteen days reviewed for RN staffing. This failure has the potential to affect all 92 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered in a timely manner and was within reach for residents. This failure affects three of four residents (R2, R3, R6) reviewed for call lights on the sample list of six. Findings Include: Call lights: Accessibility and Timely Response Policy dated 8/1/2019 on line 9 states process for responding to call lights: A. Response times should be a Priority. 1. R2's admission Record dated 1/18/24 documents R2 is diagnosed with Abnormalities Of Gait And Mobility, Gout, and Morbid (Severe) Obesity. R2's Care Plan dated 03/11/2024 documents R2 is dependent on staff for physical needs and is at risk for falls. The Care Plan documents staff should encourage the resident to use bell to call for assistance. [...]

Inspectors wroteBased upon interview and record review the facility failed to follow their narcotic destruction policy for one (R4) of four residents reviewed for medication errors out of a sample of six residents.

Inspectors wroteBased on interview and record review the facility failed to notify a patient representative of an X-ray result for one of three residents (R1) reviewed for notification of changes in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to implement a fall prevention intervention for one of three residents (R2) reviewed for falls in the sample list of six.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of two residents (R1, R2) by not providing timely incontinence care out of three residents reviewed for incontinence cares in a sample list of five residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their Abuse Prevention Policy by not immediately suspending a staff member accused of abuse of one (R1) resident out of one resident reviewed for abuse in a sample list of five residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident equipment in safe functioning order for one (R1) resident out of three residents reviewed for Physical Environment in a sample list of five residents.

Inspectors wroteBased on record review and interview the facility failed to maintain accurate and complete medical records by failing to transcribe a physician order for blood glucose monitoring, and failed repeatedly to document the blood glucose measurement in R12's medical record. R12 is one of three residents review for blood glucose monitoring on the sample list of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care in a timely manner to maintain residents dignity, for one of three residents (R13) reviewed dignity/call lights on the sample list of 13.

Inspectors wroteBased on interview and record review the facility failed to follow Physician's Order for blood glucose monitoring and document blood glucose results for one of three residents (R1) reviewed for following physician's orders in the sample list of 13.

Inspectors wroteBased on observation, interview and record review the facility failed repeatedly to implement fall interventions for two of four residents (R2 and R3), reviewed for falls/interventions on the sample list of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance with morning care in a timely manner, to maintain resident's dignity, for one of thirteen residents (R9) reviewed dignity/call lights on the sample list of 13.

Inspectors wroteBased on interview and record review the facility failed to document grievance resolution plan/ report resolution to resident/resident council. This failure has the potential to affect all residents who reside at the facility. Findings Include: The facility's Long Term Care Application for Medicare and Medicaid documents the Census as 84. The facility's policy Resident/Family Grievance Policy and Procedure revised 12/6/23 states In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written conclusion will include at minimum: The date the grievance was received. The steps taken to investigate the grievance. A summary of pertinent findings. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the required members attended quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with dignity while providing cares by being on their cell phones during cares, not pulling outside curtains prior to starting personal care, standing while providing dining assistance and failing to serve all residents at the dining table at the same time for seven of 18 residents (R7, R39, R44, R61, R63, R68, and R234) reviewed for dignity on the sample list of 50. Findings Include: The facility Promoting/Maintaining Resident Dignity Policy dated 12/5/23 documents it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete residents' psychotropic medication assessments, ensure justification for use of psychotropic medications, identify targeted behaviors, monitor behaviors, and develop and implement non-pharmacological interventions to assist residents with behavior management. These failures affect four of five residents (R5, R37, R68, and R287) reviewed for unnecessary medications on the sample list of 50. Findings Include: The facility's Use of Psychotropic Medication Policy dated 9/27/23 documents resident are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure palatability of food and follow their menu for pureed food for 6 of 18 residents (R6, R18, R23, R36, R50, and R68) reviewed for food palatability on the sample list of 50. Findings Include: 1) On 4/21/24 at 10:22 AM, R68 was eating breakfast in R68's room and stated, R68 had just received her breakfast tray about 10 minutes ago. R68 stated the scrambled eggs were cold, and the sausage patty was as hard as asphalt. The sausage patty was dark brown and appeared very dry. R68 attempted to cut the sausage patty and was not able to. R68 also stated, the food is always late so it's cold. On 4/23/24 at 12:50 PM, a test tray was delivered to the surveyor after all trays on R68's hall cart, which included lunch trays for R6, R18, R23, R36, R50 and R68) were delivered. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to utilize isolation for clostridium dificile, failed to utilize enhanced barrier precautions for residents who and failed to monitor high risk water sources for the presence of Legionella. These failures affect six residents (R65, R38, R187, R45, R62, R39) and have the the potential to affect all 84 residents who reside in the facility. FIndings Include: The Long Term Care Application for Medicare and Medicaid dated 4/24/24 documents 84 residents in the building. 1) The facility's Water Management Program dated 12/26/23 documents it is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, Nontuberculous Mycobacteria, and Fungi) in the facility's water systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess for safe self administration of medication for one of one resident (R287) reviewed for self administration of medication in the sample list of 50.

Inspectors wroteBased on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatment in the medical record for 1 of 24 residents (R41) reviewed for advance directives in the sample list of 50.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman, resident and resident representative, in writing, about a hospital transfer for two of two residents (R61, R83) reviewed for hospitalizations on the sample list of 50. Findings Include: 1) R61's ongoing Census documents R61 was hospitalized from [DATE] - 10/13/23. R61's medical record does not document that R61, V20 (R61's resident representative), or the Ombudsman was notified in writing of R61 being sent and admitted to the hospital. On 4/21/24 at 12:27 PM, V20 stated that when R61 was sent to the hospital in October or November 2023, the facility called V20 to report the transfer but did not send V20 anything in writing. 2.) R83's progress notes document admission to the facility on 1/15/24. R83's progress notes document discharge to the hospital on 2/29/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy to the resident and/or resident representative for two of two residents (R61, R83) reviewed for bed holds on the sample list of 50. Findings Include: The facility Bed Hold Notice Upon Transfer Policy dated 12/23/22 documents at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. 1) R61's ongoing Census documents R61 was hospitalized from [DATE] - 10/13/23. R61's medical record does not document that R61 and/or V20 (R61's resident representative) were provided a bed hold policy nor is there a copy of the bed hold policy in R61's medical record. On 4/21/24 at 12: [...]

Inspectors wroteBased on interview and record review, the facility failed to insure that a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R57) of one residents reviewed for PASARR level II screenings, from a total sample list of 50 residents reviewed. Findings Include: R57's level I PASARR dated 10/22/21 documents that a level II PASARR is not required. R57's diagnosis sheet dated 8/28/23 documents a diagnoses of Schizoaffective Disorder. R57's progress notes dated 1/10/24 document that R57 is seeing psychiatry for mental health issues. On 4/22/24 at 11:45AM V1 Administrator said that a level two was initiated but not completed. We should have followed up on it.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a baseline care plan for 1 of 24 residents (R39) reviewed for baseline care plans in the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with shaving for one resident (R187) of two residents reviewed for ADL (Activities of Daily Living) assistance in a sample list of 50. Findings Include: The facility's policy Activities of Daily Living (ADLs) revised 12/5/23 states A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and person oral hygiene. R187's Minimum Data Set (MDS) dated [DATE] documents R187 was cognitively in tact and required partial to moderate assistance with ADLs. On 04/21/24 at 02:53 PM, R187 was observed in her bed. R187's arms were very edematous from the shoulders to the finger tips. R187 had long unkept chin whiskers. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent potential cross contamination during wound treatment, failed to complete a skin risk assessment on admission, and failed to complete wound treatments as ordered, for one of four residents (R39) reviewed for pressure ulcers in the sample list of 50.

Inspectors wroteBased on observation, interview and record review the facility failed to provide securement for urinary catheter tubing, failed to provide catheter care/perineal care per the facility policy, and failed complete catheter care daily for two (R62 and R37) of three residents reviewed for urinary catheters from a total sample of 50.

Inspectors wroteBased on observation, interview and record review the facility failed to intervene following a significant weight loss for one resident (R66) of four residents reviewed for nutrition in a sample list of 50. Findings Include: R66's Care Plan updated 3/26/24 includes the following diagnoses: Sepsis, Falls, Recent Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. R66's Minimum Data Set (MDS) dated [DATE] documents R66 is cognitively intact. R66's Progress Note dated 4/17/24 at 9:13 PM documents noted to have an open area to midspine. On 4/21/24 at 12:30 PM, R66 stated You can't get a substitute if you don't like the food. I lost 13 pounds. I don't always care for the food here. One night for Supper I asked for a cheese burger since it is on the alternate menu. It was after 9:00PM when I finally got a cold greasy grilled cheese wrapped in foil. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for weekly weights and enteral nutrition, document the amount of enteral feeding administered to the resident, ensure open enteral feedings were disposed of after 24 hours, and change enteral feeding supplies daily for one of three residents (R65) reviewed for enteral nutrition on the sample list of 50. Findings Include: The facility Care and Treatment of Feeding Tubes Policy dated 12/19/23 documents feeding tubes will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding Tubes will also be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication and assessments with the dialysis center for one of two residents (R36) reviewed for dialysis on the sample list of 50. Findings Include: The facility Special Needs - Dialysis Policy dated 12/14/23 documents the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive care plan and the resident's goals and preferences, to meet the special medical, nursing mental and psychosocial needs of residents receiving dialysis. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report. [...]

Inspectors wroteBased on interview and record view, the facility failed to offer and/or administer the influenza and pneumococcal vaccine to one of five residents (R61) reviewed for vaccinations on the sample list of 50. Findings Include: R61's ongoing Census documents R61 was admitted to the facility on [DATE] and is 88years old. R61's Medical Record does not contain any consents or declination for the influenza or pneumococcal vaccination, or a listing of vaccinations received prior to admission. On 4/23/24 at 2:32 pm, V18 Infection Preventionist provided immunization consents dated 4/23/24 that documents R18 would like both the influenza and pneumococcal vaccination. V18 explained V18 was not able to find the consents from the time of admission so V18 had R61 sign them today. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and administer the COVID-19 immunization for one of five residents (R61) reviewed for vaccinations on the sample list of 50. Findings Include: R61's ongoing Census documents R61 was admitted to the facility on [DATE] and is 88years old. R61's Medical Record does not contain any consents or declination for the COVID-19 immunization. or a listing of historical immunizations that R61 had prior to admission. On 4/23/24 at 2:32 pm, V18 Infection Preventionist provided an immunization consent for the COVID-19 immunization dated 4/23/24 that documents R18 would like to receive the COVID-19 immunization. V18 explained V18 was not able to find the original consent from the time of admission so V18 had R61 sign it today. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to recognize/remove an accident hazard to prevent a residents injury and investigate a potential root cause for a residents acute fracture. These failures affect two (R1, R3) of 3 residents reviewed for accidents in a sample list of four. R1 sustained a laceration to R1's leg requiring 21 sutures to close.

Inspectors wroteBased on interview and record review the facility failed to investigate a fracture of unknown origin for a resident. This failure affects one resident (R3) of three residents reviewed for accidents in a sample list of four.