Luxe Rehabilitation and Care Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, self-reported incident (SRI) review, hospital record review, death certificate review, and policy review, the facility failed to ensure residents were transferred safely and appropriately to prevent significant injury. This resulted in Immediate Jeopardy on [DATE] at approximately 6:00 P.M. when Resident #17, who was dependent of two staff members and the use of a mechanical sling lift for safety and the inability to bear weight, was transferred from her bed to her wheelchair by Certified Nursing Assistant (CNA) #400 and #402 without the use of a mechanical sling lift. Resident #17's legs became entangled in her wheelchair; however, this was not reported to additional staff or medical providers. [...]

Inspectors wroteBased on observation, resident interviews, staff interviews, work orders, and facility policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This affected twenty-five residents (#13, #22, #30, #31, #35, #36, #41, #47, #48, #51, #54, #56, #57, #58, #61, #62, #63, #64, #66, #67, #81, #105, #106, #140 and #145) of 142 residents. Facility census was 142.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain resident dignity for Resident #15. This affected one resident (#15) of three sampled residents. The facility census was 142.

Inspectors wroteBased on medical record review, staff interview, and observations, the facility failed to maintain comfortable hot water temperatures and homelike environment. This affected 13 residents (Resident #11, #13, #19, #23, #50, #59, #74, #83, #90, #99, #121, #122, #135) residing on the 200 unit and 16 residents (Resident #29, #40, #43, #61, #67, #69, #71, #91, #102, #125, #126, #128, #136, #142, #149, #150) on the 300 unit located in the facility's [NAME] home due to uncomfortable hot water temperatures and room [ROOM NUMBER] located in the facility's [NAME] home affecting Resident #14 due to hot water not working properly and to ensure room [ROOM NUMBER] where Resident #155 resided was free of deep black gouges on the floor. The facility census was 148.

Inspectors wroteBased on interview, record review and policy review, the facility failed to complete required minimum data set (MDS) assessments in a timely manner for Residents #7, #15, #60, and #147, failed to ensure the initial wound assessment accurately reflected wound characteristic for Resident #157, and failed to ensure the comprehensive assessment was accurate for Resident #8. This affected six ( Resident #7,#8,#15,#60,#147, and #157) of the 36 residents sampled for the annual survey. The facility census was 148.

Inspectors wroteBased on medical record review, staff interview, observations, and facility policy review, this facility failed to provide activities to meet the interest or needs of each resident residing on the facility's memory care units. This affected all 29 resident's (Resident # 11, 13, 19, 23, 29, 40, 43, 50, 59, 61,67, 69, 71, 74, 83, 90, 91, 99, 102, 121, 122, 125, 126, 128, 135, 136, 142, 149, 150) residing on the 200 and 300 unit in the [NAME] Wing. The facility census was 148.

Inspectors wroteBased on medical record review, staff interview, observations, and facility policy review, this facility failed to provide care and services related to pressure ulcer care. This affected 5 residents (Resident #11, #57, #108, #138, and #157) of the 7 residents reviewed for wound care. The facility census was 148.

Inspectors wroteBased on observations, staff interview, and facility policy review, this facility failed to ensure a food steam table located on the [NAME] Wing was free from buildup, ensure the snack fridge located at the [NAME] nurses station had open food items that were properly dated and failed to prepare food in a sanitary manner in the [NAME] Wing. This had to potential to affect 147 residents residing at this facility as one resident who was noted to receive nothing by mouth (NPO). The facility census was 148.

Inspectors wroteBased on medical record review, interviews and facility policy review, the facility failed to honor bathing preferences. This affected one resident (#108) of one resident reviewed for choices. The facility census was 148. Findings Include: Review of the medical record for Resident #108 revealed an initial admission date of 08/23/23 with the latest readmission date of 03/02/26 with the diagnoses including but not limited to chronic kidney disease, post-traumatic stress disorder, paraplegia, retention of urine, diabetes mellitus, mild intellectual disabilities, chronic pain, end stage renal disease, paranoid schizophrenia, major depressive disorder, spinal stenosis, need for assistance with personal care and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on closed record review, interview and facility policy review, the facility failed to notify the resident's representative of a change in condition. This affected one resident (#12) of 36 sampled residents. The facility census was 148. Findings Include:Review of the closed medical record for Resident #12 revealed an initial admission date of 02/03/26 with the diagnoses including but not limited to anemia, cystocele, osteoarthritis, diabetes mellitus, overactive bladder, chronic kidney disease, dementia, urinary tract infection, uterovaginal prolapse, spinal stenosis, osteoporosis, Alzheimer's disease and adult failure to thrive. Review of the resident's admission assessment with baseline plan of care dated 02/03/26 revealed the resident was alert and oriented to her name only. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to provide privacy during wound care. This affected one resident (#157) of one resident reviewed for privacy. The facility census was 148. Findings Include: Review of the medical record for Resident #157 revealed an initial admission date of 03/19/26 with the diagnoses including but not limited to dementia, anxiety disorder, abnormal weight loss, urinary tract infection, fracture of lower leg and senile degeneration of brain. Review of the resident's admission assessment with baseline care plan dated 03/19/26 revealed the resident was admitted to the facility with a stage III pressure ulcer to her sacrum measuring 11 centimeters (cm) by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold that measured 0.5 cm by 1.0 cm. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide notice to the office of the state long-term care Ombudsman for resident transfers or discharges. This affected two (Residents #144 and #146) of three closed records reviewed. The facility census was 148. 1. Review of the closed record for Resident #146 revealed an admission date of 02/17/26 with diagnoses including alcoholic cirrhosis, peptic ulcer, hepatic encephalopathy, and protein/calorie malnutrition. The resident was at the facility for two days before being transferred to the hospital on [DATE]. The resident did not return to the facility. (The family requested the resident go to a different facility). Review of an email dated 03/03/26 at 5:48 P.M. from Human Resources Director #274 revealed it stated please find the February transfers and discharges notice from the facility. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident assessments accurately reflected the number of pressure wounds present upon admission to the facility. This affected one (Resident #11) for wound care out of the 36 total sampled residents reviewed for accurate assessments. The facility census was 148.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed accurately for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTSD). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Review of the most recent PASARR documentation dated 01/26/26 revealed diagnoses of generalized anxiety and PTSD were not listed for Resident #8. Interview with Social Services Director #366 on 03/25/26 at 11:10 A.M. verified the PASARR dated 01/26/26 was missing additional diagnoses.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) was completed timely for a resident. This affected one (#8) of five residents reviewed for PASARR. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension and post-traumatic stress disorder (PTSD). Medical record review indicated Resident #8 had diagnosis of PTSD upon admission to facility. The PASARR was completed 10/31/25. Interview with Social Services Director #366 on 03/26/26 at 12:10 P.M. verified the PASARR dated 10/31/25 was not completed within 30-day timeframe from admission to the facility.

Inspectors wroteBased on record review, observations, family interview, and staff interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care for each resident in the area of pain. This affected one (Resident #155) of four residents reviewed for pain. The facility census was 148. Review of the record for Resident #155 revealed an admission date of 03/17/26 and diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. A brief interview for mental status assessment conducted on 03/18/26 indicated a score of 15, intact cognition. Review of hospital records revealed the resident had a hospital stay from 03/03/26 to 03/17/26. The discharge summary stated the resident was admitted after a fall. She presented with a head hematoma, altered mental status, and left sided weakness. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop and implement a person-centered comprehensive care plan. This affected one (#8) of 36 residents reviewed for care planning. The facility census was 148. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to occlusion or stenosis of small artery, hypertension, and post-traumatic stress disorder (PTDS). Diagnoses of major depressive disorder and generalized anxiety were added 01/22/26 by the nurse practitioner. Medical record review of the most recent Minimum Data Set (MDS) assessment dated [DATE] validated diagnoses of major depressive disorder, generalized anxiety and PTSD. Recent care plan dated 03/11/26 revealed anxiety, depression and PTSD were not addressed in plan of care. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to develop a comprehensive care plan for a resident in the area of constipation. This affected one (Resident #78) of 36 residents whose care plans were reviewed. The facility census was 148. Review of the record for Resident #78 revealed an admission date of 08/08/22 with diagnoses including constipation (dated 02/15/22), diabetes, convulsions, panic disorder, and chronic kidney disease. Interview with Resident #78 on 03/24/26 at 9:14 A.M. revealed that she has a problem with constipation. She stated she thinks it is due to the narcotic pain pills she takes for her back pain. She stated the pain medication is taken as needed but she usually asks for and takes it twice daily. [...]

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to provide blood pressure medication as needed according to the physician ordered parameters. This affected one resident (#7) of five sampled for unnecessary medications. The facility census was 148.

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure indwelling urinary catheter collection bags were positioned below the bladder. This affected one resident (#108) of two residents reviewed for catheters. The facility census was 148. [...]

Inspectors wroteBased on medical record review, staff interview, observations, and facility policy review, the facility failed to address significant weight loss. This affected three residents (Resident #17, #29, #90) of the 6 residents reviewed for an adequate nutritional status. The facility census was 148.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a physician or practitioner order for supplemental oxygen was in place for a resident that used it continuously. This affected one (Resident #4) of three residents reviewed for respiratory care. The facility census was 148 residents.

Inspectors wroteBased on observations, family interview, staff interview, record review, and policy review, the facility failed to recognize, evaluate, and manage acute pain for a resident. This affected one (Resident #155) of four residents reviewed for pain. The facility census was 148. Review of the record for Resident #155 revealed an admission date of 03/17/26 and diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. Review of hospital records revealed the resident had a hospital stay from 03/03/26 to 03/17/26. The discharge summary stated the resident was admitted after a fall. She presented with a head hematoma, altered mental status, and left sided weakness. She was diagnosed with an acute traumatic subarachnoid hemorrhage enhanced by aspirin and an acute traumatic glenoid fracture (an injury to the shoulder socket). [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor medications by completing physician order laboratory work for residents. This affected two (Resident #2 and #3) of five residents sampled for unnecessary medications. The facility census was 148.1. Review of Resident #2's medical record revealed an admission date of 11/01/23 and diagnoses including schizophrenia, drug induced subacute dyskinesia, diabetes, dementia, hypothyroidism, hyperlipidemia, and normal pressure hydrocephalus. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] indicating the resident had severe cognitive impairment. Review of Resident #2's physician's orders revealed an order dated 01/25/24 for simvastatin 40 milligrams (MG) one tablet one time a day for hyperlipidemia. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents' medical records were complete and accurate to reflect correct information on the location and origin of a pressure ulcer and treatments were properly documented in the medical record when completed. This affected two (#58 and #135) of eight residents reviewed.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn during tracheostomy care of a resident in enhanced barrier precautions (EBP's) for a medically invasive device. They also failed to ensure staff performing tracheostomy care and treatment of a peg tube site performed proper hand hygiene, after removing disposable gloves, and before touching environmental surfaces in the resident's room. This affected one (#58) of one resident reviewed for tracheostomy care.

Inspectors wroteBased on review of facility open payables log, review of Administrator job description, and interviews, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently including compliance with all financial obligations for the delivery of care to attain and maintain the highest practicable well being of each resident. This affected 133 of 133 residents residing in the facility.

Inspectors wroteBased on record review, self-reported incident (SRI) review, and interview, the facility failed to complete thorough investigations after allegations of abuse. This had the potential to affect one resident (#131) of two residents reviewed for allegations of abuse. The facility census was 133.

Inspectors wroteBased on medical record review, staff interview, policy review, and guardian interview, the facility failed to have evidence that a transfer from the facility was necessary for the resident's welfare and the resident's needs could not be met in the facility. This affected one resident (#135) of three residents reviewed who were transferred to other nursing facilities. The facility census was 133.

Inspectors wroteBased on medical record review, staff interview, policy review, and guardian interview, the facility failed to provide notice before transfer to another facility to include the reason for the transfer and include appeal rights This affected one resident (#135) of three residents reviewed who were transferred to other nursing facilities. The facility census was 133.

Inspectors wrote2. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and hypertension. Review of a quarterly MDS 04/01/25 revealed Resident #18 had moderately impaired cognition and had no behaviors. Review of a care plan updated on 06/14/25 revealed Resident #18 was at risk for falls related to cognitive function, decreased mobility, current hospital stay, weakness, acute chronic encephalopathy, hypertension, hypocalcemia, cognitive impairment, and self-care deficit with a goal to be free from injury. Interventions included but were not limited to keep urinal at bedside (06/14/25), place a bedside toilet in room (06/04/25), and a please call don't fall sign in room (02/23/25). Observation on 06/18/25 at 12:34 P.M. revealed Resident #18 was sitting in his bed, eating. [...]

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to provide clean and sanitary resident equipment, such as bedrails and wheelchairs. This affected one (Resident #1) of six residents reviewed for cleanliness of resident equipment. The facility census was 130 residents.

Inspectors wroteBased on medical record review and staff interview, this facility failed to ensure residents responsible party participated in care planning. This affected one (Resident #279) of the five residents reviewed for care planning. The facility census was 134.

Inspectors wroteBased on medical record review, fall investigation review, staff interview, and facility policy review, this facility failed to ensure the appropriate resident representative was notified of a fall incident when it occurred. This affected one (Resident #285) of the five residents review for notification of change. The facility census was 134.

Inspectors wroteBased on medical record review, staff interview, medication administration observation, and facility policy review, this facility failed to ensure their medication error rate was less than 5% when there was noted 5 medication errors of the 43 medication that was administered resulting in a 11.9% error rate. This affected three (Resident #33, #147, and #143) of the four resident observed for medication administration. The facility census was 134.

Inspectors wroteBased on medication administration observation, staff interview, and facility policy review this facility failed to ensure infection control measures were maintained while administering medication. This affected three (Resident #33, #147, and #143) of the four residents observed for medicating administration. The facility census was 134.

Inspectors wroteBased on facility personnel and criminal background check records review, medical record review, review of the new hire application form, interview, and facility policy review, the facility failed to complete criminal background checks as required for all new employees. This had the potential to affect all 139 residents residing in the facility. Additionally, the facility failed to implement their abuse policy regarding reporting, ensuring resident safety, and thoroughly investigating alleged incidents as required. This affected one resident (Resident #8) of three residents reviewed for abuse. Findings Include: 1. Review of facility bureau of criminal investigation (BCI) log, dated 09/01/24 to 01/15/25, revealed no indication whether federal background checks had been completed for any new hires that had not lived in this state for the last five years prior to hire at the facility. [...]

Inspectors wroteBased on observations, resident interview, review of training records, review of meal monitoring records, and staff interview, the facility failed to ensure there was sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. This could affect 137 of 139 residents in the facility (Residents #61 and #122 receive nothing by mouth).

Inspectors wroteBased on observations, resident interview, staff interview, and review of meal monitoring records, the facility failed to ensure meals were served at regular times and in accordance with resident needs and preferences. This could affect 137 of 139 residents in the facility (Residents #61 and #122 do not receive nutrition by mouth).

Inspectors wroteBased on interview and personnel file review the facility failed to ensure employment of a full-time, qualified social worker. This had the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on observations, medical record review, interview, and facility activity calendar review, the facility failed to schedule activities to meet the needs of the residents on the memory care unit. This affected 21 of 21 memory care residents (Residents #9, #13, #27, #30, #32, #40, #41, #46, #49, #76, #78, #84, #86, #92, #96, #98, #129, #136, #139, #141) and Resident #107 who was not in the memory care unit. The facility census was 139. Findings Include: Review of Memory Care Activity Calendars, dated November 2024 to January 2025, revealed there were no activities scheduled for the weekends. Observations on 01/15/25 from 9:10 A.M. to 9:30 A.M. found no activities occurring in the memory care unit. Staff were assisting residents with their breakfast and morning hygiene routines; there were no activity staff in the memory care unit. [...]

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure a resident received adequate treatment and care and the physician was notified at the time of a change in condition. This affected one of 17 sampled residents (Resident #145). The facility census was 139.

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to ensure all residents followed safe smoking provisions and failed to assess residents for safe smoking prior to smoking while residing in the facility. This affected five (Residents #4, #5, #6, #11, and #94) of five residents reviewed for smoking. The facility identified Resident #4, #5, #6, #11 and #94 as the only residents who smoked. The census was 139. Findings Include: 1. Observations on 01/14/25 at 1:30 P.M. and 1:40 P.M., there were used cigarette butts found in the trash can of each building's front porch. The trash cans were not safe for smoking materials to be disposed in. Also, the trash cans were lined with plastic trash bags. This was confirmed by Licensed Practical Nurse (LPN) #131 and the Administrator. Observation on 01/14/25 at 1:40 P.M. [...]

Inspectors wroteBased on observations, review of menus/spread sheets, and staff interview, the facility failed to ensure menus were followed. This affected 11 of 137 residents (Residents #9, #25, #27, #30, #40, #49, #86, #92, #98, #129, and #136) residing in the facility and receive nutrition from the kitchen. The facility identified two residents (Resident #61 and #122) who received nothing by mouth.

Inspectors wroteBased on observations, meal test tray, staff interview, policy review, and resident interview, the facility failed to ensure meals were palatable, appetizing and served at appropriate temperatures. This affected six of six residents interviewed regarding food temperatures/palatability (Residents #1, #8, #63, #67, #70, and #116). The facility census was 139.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure a resident received food prepared in a form to meet their individual needs. This affected one (Resident #86) of ten residents observed during the lunch meal service. The facility census was 139.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to notify resident representatives when there was a significant change in resident condition. This affected two (Resident #86 and #145) of 17 sampled residents. The facility census was 139.

Inspectors wroteBased on medical record review, interview, facility investigation review, and policy review, the facility failed to report an allegation of abuse to the state survey agency. This affected one (Resident #8) of three residents reviewed for abuse. The census was 139. Findings Include: Resident #8 was admitted to the facility on [DATE]. Her diagnoses included acute and subacute hepatic failure, type II diabetes, major depressive disorder, cirrhosis of liver, morbid obesity, heart failure, chronic hepatic failure, history of falling, toxic liver disease, altered mental status, hepatic encephalopathy, and unspecified severe protein calorie malnutrition. Review of her minimum data set (MDS) assessment, dated 11/07/24, revealed she was cognitively intact. Review of Resident #8 medical records found she changed rooms on 12/23/24. [...]

Inspectors wroteBased on facility medical record review, resident interview, staff interview, facility investigative documents review, and facility policy review, the facility failed to complete a thorough investigation of an abuse allegation. This affected one (Resident #8) of three residents reviewed for abuse. The census was 139. Findings Include: Resident #8 was admitted to the facility on [DATE]. Her diagnoses included acute and subacute hepatic failure, type II diabetes, major depressive disorder, cirrhosis of liver, morbid obesity, heart failure, chronic hepatic failure, history of falling, toxic liver disease, altered mental status, hepatic encephalopathy, and unspecified severe protein calorie malnutrition. Review of her minimum data set (MDS) assessment, dated 11/07/24, revealed she was cognitively intact. Review of Resident #8 medical records found she changed rooms on 12/23/24. [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide pharmacy services to ensure medications were available to be administered per physician orders. This affected two (Residents #39 and #71) of five residents observed for medication administration The facility census was 139.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure a resident's drug regimen was free from unnecessary medications when his blood pressure was not adequately monitored. This affected one (Resident #7) of five residents observed during medication administration. The facility census was 139.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure medications were properly stored. This affected one (Resident #71) of five residents observed for medication administration. The facility census was 139.

Inspectors wroteBased on closed medical record review, hospital record review, interview, and facility policy review, the facility failed to ensure Resident #139, who was admitted to the facility on [DATE] was provided antibiotics timely and as ordered at the time of hospital discharge and failed to ensure laboratory testing associated with the antibiotic use was completed as required to properly treat the resident's osteomyelitis and to prevent complications. Actual harm occurred on 10/01/24 when Resident #139 was transferred to the hospital for treatment of Vancomycin toxicity and acute kidney injury after the facility failed to monitor the antibiotic through laboratory testing. This affected one resident (#139) of eight residents reviewed for laboratory monitoring/testing. The facility census was 137.

Inspectors wroteBased on observation, record review, insulin pen needle user guide review, facility policy review and interview, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 14.8% and included 4 medication errors of 27 medication administration opportunities. This affected two residents (#17 and #61) of two residents observed during medication administration. The facility census was 137.

Inspectors wroteBased on interviews, observations, record reviews, and facility policy review, the facility failed to complete vital signs and a transfer form when change of condition was required for Resident #115. This affected one resident (#115) for change of condition and the facility also failed to order daily weights for Resident #442 after surgery upon readmission affecting one resident (#443) reviewed. The facility census was 140.

Inspectors wroteBased on observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess an identified pressure area and implement interventions to prevent a stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling pressure ulcer to the interdigit of the left fourth and fifth toe and the left fifth toe) for Resident #38. In addition, the facility failed to accurately assess an identified pressure area and implement interventions to prevent worsening of a right heel pressure ulcer for Resident #49. [...]

Inspectors wroteBased on observation, record review, fall investigation review, staff interview and safety belt installation instructions, the facility failed to properly secure one resident (Resident #38) during a transport in the facility's bus. Actual harm occurred on 05/06/24 when Resident #38 who was in a manual wheelchair was placed in the facility bus for transport. The wheelchair was secured with the wheelchair tie down and belts, however, the resident was not secured as recommended with both a torso and pelvic seat belt. The resident slid out of the wheelchair onto the floor of the bus and sustained a left femoral shaft fracture and left great toe fracture. This affected one (Resident #38) of six residents reviewed for falls. The facility census was 140. Findings Include: [...]

Inspectors wroteBased on observations, interviews, record reviews and facility policy review, the facility failed to ensure residents received oral fluids between meals. This affected three residents (#10, #33, and #41) out of three residents reviewed for hydration. The facility also failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range when Resident #130's weekly weight were not completed as ordered after having weight loss. This affected one (Resident #130) of eight residents reviewed for nutrition The facility census was 140.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure pureed foods were prepared to the correct texture. This had the potential to affect nine (#7, #10, #18, #23, #40, #41, #94, #115, and #391) of nine residents who received pureed texture diets. The facility census was 140.

Inspectors wroteBased on observations, interviews, and facility policy reviews, the facility failed to ensure the kitchen was maintained in a clean manner, garbage cans were clean and the kitchen was pest free. This had the potential to affect 139 of 140 residents who received meals in the facility. The facility census was 140.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure garbage cans were clean and the kitchen was pest free. This had the potential to affect 139 of 140 residents who received meals in the facility. The facility census was 140.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents' rooms and mobility devices were properly maintained and not in a state of disrepair. This affected four (Resident #15, #68, #70, and #115's) of the 34 residents sampled. The facility census was 140.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident rooms had sufficient space. This affected one (Resident #66) of one resident reviewed for accommodations of physical needs. The facility census was 140.

Inspectors wroteBased on record review and interviews, the facility failed to assist residents in locating missing items. This affected one (#4) of one resident reviewed for missing items. The facility census was 140.

Inspectors wroteBased on interview ,record review, and facility policy review, the facility failed to investigate an allegation of abuse. This affected one (Resident #4) of one resident reviewed for abuse. The facility census was 140.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete a level one Pre-admission Screening/Resident Review (PASARR) and did not list psychosis disorder on the serious mental illness section to be reviewed for a level two. This affected one resident (#86) of two reviewed for PASARR. The facility census was 140.

Inspectors wroteBased on record review and interview, the facility failed to screen a resident for serious mental illness and intellectual disabilities on a resident review (PASRR). This affected one (Resident #66) of two residents reviewed for PASRRs. The facility census was 140.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure care plans were complete and comprehensive for residents with existing pressure ulcers to include appropriate interventions for offloading pressure and turning/ repositioning to promote healing of the pressure ulcers. This affected two (Resident #49 and #107) of five residents reviewed for pressure ulcers. The facility census was 140.

Inspectors wroteBased on staff and resident interview, record review, and facility policy review, the facility failed to develop comprehensive care plans with the resident in attendance with an interdisciplinary team for Resident #105, and revise a nutritional care plan to include gastrostomy tube placement for Resident #115. This affected one (Resident #105) of four residents reviewed for care planning and one (Resident #115) of three residents reviewed for tube feeding. The facility census was 140.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure enteral tube feeding bottles were dated and timed when they were hung during administration for a resident receiving nightly nocturnal tube feedings. This affected one (Resident #115) of three residents reviewed for tube feedings. The facility census was 140.

Inspectors wroteBased on observation, staff interview, policy review, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice when they did not have an order for oxygen for Resident #54 and did not provide oxygen at the ordered rate for Resident #78. This affected two (Resident #54, and #78) of two residents reviewed for respiratory care. The facility census was 140.

Inspectors wroteBased on staff interview, and record review the facility failed to provide or obtain laboratory services only when ordered by a physician when they did not draw a hemoglobin A1C, complete blood count, comprehensive metabolic panel, and Depakote level quarterly in June for Resident #85 and when a basic metabolic panel was not drawn as ordered for Resident #443. This affected two (Resident #85, and #443) of six Residents reviewed for laboratory values. The facility census was 140.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor and did not increase his risk for infection. This affected one (Resident #115) of one residents reviewed for indwelling urinary catheters. The facility census was 140.

Inspectors wroteBased on observations, staff interviews, review of the local health department inspection reports, and facility policy review, the facility failed to ensure the kitchen was properly cleaned and sanitized prior to completing food preparation. The deficient practice had the potential to affect 127 residents who receive food from the kitchen. There was one resident (Resident #123) who was identified as having an ordered nothing by mouth (NPO) diet.

Inspectors wroteBased on record review, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to protect residents from resident-to-resident physical abuse. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents.

Inspectors wroteBased on record review, review of facility Self-Reported Incidents (SRIs), resident representative interview, staff interview, and review of the facility policy, the facility failed to conduct thorough abuse investigations and failed to protect residents from abuse during pending abuse investigations. This affected one (Resident #93) of three residents reviewed for abuse. The facility census was 126 residents.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure a plan of care and interventions were implemented for the areas of fall risk and incontinence. This affected two (Residents #104 and #120) of four residents sampled. The facility census was 126.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents received care in accordance with the care plan in order to prevent falls. The facility also failed to investigate resident falls to determine the root cause of the fall and implement interventions to prevent recurrence. This affected two (Residents #36 and #120) of four residents reviewed for falls and accidents. The facility census was 126.

Inspectors wroteBased on observations, record review, staff and family interview, and facility policy review, the facility failed to ensure concerns brought up during resident council were addressed timely. This affected 10 Residents (#30, #40, #72, #75, #81, #101, #105, #108, #111, #113) that regularly attend resident council meetings. Facility census was 130.

Inspectors wroteBased on observations, record review, staff and family interviews, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected three Residents (#92, #94, and #121) of three reviewed for environment. Facility census was 130.

Inspectors wroteBased on review of personnel files, review of tuberculosis (TB) questionnaires, review of the TB risk assessment, staff interview, and facility policy review, the facility failed to complete annual TB questionnaires or TB tests for three staff (Receptionist #401, Receptionist #405, and Receptionist #409). This affected three out of three staff reviewed for annual TB questionnaires or testing and had the potential to affect all 134 residents who resided in the facility. Findings Include: Review of the personnel file for Receptionist #401 revealed a hire date on 06/10/78. The most recent TB screening questionnaire was completed on 06/01/16. Review of the personnel file for Receptionist #405 revealed a hire date on 11/08/21. The most recent TB screening questionnaire was completed on 11/08/22. Review of the personnel file for Receptionist #409 revealed a hire date on 12/18/17. [...]

Inspectors wroteBased on staff interviews, review of personnel files, review of written staff statements, review of timecard punches, and facility policy review, the facility failed to conduct a thorough investigation of Former State Tested Nurse Aides (STNAs) #202 and #204 leaving the facility while on duty to ensure the residents that Former STNAs #202 and #204 were assigned to care for were not adversely affected or subject to any type of abuse, neglect, or misappropriation as a result of the incident. The deficient practice had the potential to affect all 23 residents who resided on [NAME] Wing, Unit 1 (Residents #131, 161, 187, 243, 246, 253, 263, 272, 275, 283, 284, 286, 291, 293, 295, 303, 305, 309, 311, 315, 317, 324, and 327). The facility census was 134. Findings Include: [...]

Inspectors wroteBased on closed record review, staff interviews, review of inventory lists, and facility policy review, the facility failed to protect one resident's (Resident #161) personal belongings from being lost or stolen. This affected one (Resident #161) of three residents reviewed for grievances and missing items. The facility census was 134. Findings Include: Review of the closed medical record for Resident #161 revealed an initial admission on [DATE], a readmission date on [DATE], and a discharge date due to death on [DATE]. Medical diagnoses included acute and chronic respiratory failure, Bipolar Disorder, chronic obstructive pulmonary disease (COPD), heart failure, type II Diabetes Mellitus, and dependence on supplemental oxygen. Review of the inventory lists for Resident #161 revealed the most recent inventory of personal effects was dated [DATE]. Inventory included: [...]

Inspectors wroteBased on record reviews, resident and staff interviews, the facility failed to properly treat non pressure skin issues for two residents (#721, #187) out of three reviewed for skin areas. The facility also failed to provide an incentive spirometer to treat a collapsed lung for one resident (#151) out of one resident reviewed. The facility also failed to ensure an as needed cough syrup with codeine was reordered timely and readily available as well as administering medications appropriately this affected two residents (#151 and #187) of three residents reviewed. The facility census was 134.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide proper care and services to treat pressure ulcers for three (Resident #187, #736 and # 812) of four residents reviewed for pressure ulcers. The facility census was 134.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure fall prevention interventions were in place for Resident #187. This affected one (Resident #187) of three residents reviewed for fall prevention interventions. The facility census was 134.

Inspectors wroteBased on closed record review, staff interview and review of discharge instructions, the facility failed to ensure daily weights were completed as ordered and failed to ensure Resident # 121 received the appropriate diet. This affected one resident (Resident # 121) out of three residents reviewed for nutrition. The facility census was 134.

Inspectors wroteBased on observation, medical record review, and staff interview , the facility failed to administer medications in accordance with physicians orders producing a medication error rate greater than five percent. This resulted in four medication errors out of 25 opportunities for a medication error rate of 16 percent. This affected two (Resident #53 and Resident #122) of three residents observed for medication administration. The census was 123.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, facility policy review, and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer treatment plan for Resident #7 who developed an in-house pressure ulcer. Actual Harm occurred on 01/05/24 when Resident #7, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for activities of daily living was transferred to the hospital due to family concerns with the resident's left heel wound, which was swollen and warm to touch and the resident was not acting right. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication. This affected one (Resident #7) of three residents reviewed for antipsychotic medication use. The facility census was 120.

Inspectors wroteBased on medical record review, resident and staff interviews, and facility policy review, the facility failed to report to the state agency a suspected incident of sexual abuse involving Resident #13 and Resident #59. This affected two residents (Residents #13 and #59) of three residents reviewed for abuse. The facility census was 114.

Inspectors wroteBased on medical record review, resident and staff interviews, and facility policy review, the facility failed to timely and thoroughly investigate a suspected incident of sexual abuse which involved two residents (Residents #13 and #59). The deficient practice affected two residents (Residents #13 and #59) of three reviewed for abuse. The facility census was 114.

Inspectors wroteBased on medical record review, staff and resident interviews, review of hospital records, and facility policy review, the facility did not ensure adequate skin assessments were completed to identify bruising in a timely manner on Resident #115 who was later diagnosed with a hip fracture. This affected one resident (#115) of three residents reviewed for incidents/accidents. The facility census was 114. Findings Include: Review of the closed medical record for Resident #115 revealed an admission date of 03/30/17 with medical diagnoses including chronic obstructive pulmonary disorder (COPD), cerebral infarction (stroke), muscle weakness, encephalopathy (any brain disease that alters brain function or structure), and difficulty in walking. Resident #115 was discharged to the hospital on [DATE] and did not return to the facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly manage Resident #1 and #3 pain. Actual harm occurred on 06/07/23 when Resident #3 verbalized pain during wound care treatment including yelling out, grimacing, and indicating the treatment felt like knives stabbing her foot and the nurse continued treatment without addressing the pain. This affected two residents (#1 and #3) out of the three residents reviewed for pain management. The facility census was 121.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for four residents (#12, #15, #19, #82) in the area of respiratory care, accidents, braces, dialysis and bowel and bladder. This affected four residents (#12, #15, #19, #82) of 28 sampled residents. The facility census was 121. Findings Include: 1. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure Resident #1, #12, #51, #325, who required assistance with activities of daily living (ADL) received nail care, shaving assistance and showers. This affected four residents (Resident #1, #12, #51, #325) of five residents reviewed for ADL. The facility census was 121. Findings Include: 1. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications for Resident #15, #29, and #76, and failed to adequately monitor/track behaviors and side effects for Resident #80 who utilized psychotropic medications. This affected four (Residents #15, #29, #76, and #80) of five residents reviewed for unnecessary medications. The census was 121. Findings Include: 1. Resident #29 was admitted to the facility on [DATE]. Her diagnoses were other disorders of lung, pneumonia, acute respiratory failure with hypercapnia, hyperosmolality and hypernatremia, dementia, hyperlipidemia, wheezing, hypertension, anxiety disorder, edema, osteoarthritis, insomnia, vitamin D deficiency, opioid use, and other reduced mobility. [...]

Inspectors wroteBased on observation, staff interview, resident interview the facility failed to ensure food was served at the preferred temperature. This affected two residents (Resident #51 and Resident #72) with the potential to affect all 18 residents on the facility [NAME] 200 hall. Findings Include: On 06/05/23 at 11:34 A.M., interview with Resident #72 revealed the eggs were always cold. On 06/05/23 at 2:59 P.M., interview with Resident #51 revealed the food were always cold, especially breakfast. Observation on 06/08/23 at 7:58 A.M. of the [NAME] 200 hallway revealed the meal cart was delivered on the hallway. At 8:01 A.M. the Diet Tech #339 started to deliver the breakfast trays. At 8:02 A.M. an unknown State Tested Nursing Assistant (STNA) on the hallway started to pass the meal trays. AT 8:14 A.M. the last meal tray was delivered. [...]

Inspectors wroteBased on record review and interviews, the facility failed to honor Resident #1 and Resident #51's shower preferences. This affected two residents (Resident #1 and #51) of three residents reviewed for choices. The facility census was 121. Findings Include: 1. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to have accurate and consistent advanced directives. This deficient practice affected one resident (Resident #8) out of two residents reviewed for advanced directives. The facility census was 121.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to complete a thorough and adequate investigation for misappropriation. This affected one (Resident #19) of one resident reviewed for abuse, neglect, and misappropriation. The census was 121. Findings Include: Resident #19 was admitted to the facility on [DATE]. Her diagnoses were mild intellectual disabilities, moderate intellectual disability, old myocardial infarction, adult failure to thrive, hypo-osmolality and hyponatremia, major depressive disorder, paraplegia, Down's syndrome, convulsions, insomnia, neuromuscular dysfunction of bladder, bipolar disorder, heart disease, edema, anxiety disorder, opioid use, schizophrenia, acute kidney failure, hypertension, type II diabetes, psychosis, unspecified intellectual disabilities, hypertensive heart disease, hyperlipidemia, and hemiplegia. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #103 and Resident #120's assessments were accurate. This affected two (Residents #103 and #120) of 24 residents reviewed for assessments. The census was 121. Findings Include: 1. Resident #120 was admitted to the facility on [DATE]. Her diagnoses were interstitial pulmonary disease, nausea with vomiting, osteoarthritis, drug induced hypoglycemia, type II diabetes, hypertension, major depressive disorder, anxiety disorder, hypothyroidism, dementia, insomnia, anemia, shortness of breath, and opioid use. Review of her Minimum Data Set (MDS) assessment, dated 03/14/23, revealed she was cognitively intact. Review of Resident #120 MDS assessment, section A, revealed she was discharged to an acute hospital on [DATE]. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected two (Resident #60 and Resident #76) of two residents reviewed for PASARR documents. The census was 121. Findings Include: 1. Resident #60 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Resident #60's diagnoses included chronic obstructive pulmonary disease, dementia, flaccid hemiplegia left dominant side, atrial fibrillation, subarachnoid hemorrhage, idiopathic neuropathy, major depressive disorder, post-traumatic stress disorder (PTSD), Epilepsy, Schizophrenia, hemiplegia and hemiparesis. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 04/30/23, revealed he was cognitively intact. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the State mental health agency. This affected two (Resident #60 and Resident #76) of two residents reviewed for PASARR documents. The census was 121. Findings Include: 1. Resident #60 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Resident #60's diagnoses included chronic obstructive pulmonary disease, dementia, flaccid hemiplegia left dominant side, atrial fibrillation, subarachnoid hemorrhage, idiopathic neuropathy, major depressive disorder, post-traumatic stress disorder (PTSD), Epilepsy, Schizophrenia, hemiplegia and hemiparesis. Review of Resident #60's Minimum Data Set (MDS) assessment, dated 04/30/23, revealed he was cognitively intact. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure Resident #325's tracheostomy and nasogastric tube was addressed in the baseline plan of care. This affected one resident (Resident #325) of one resident received for tracheostomy and one of one resident for nasogastric (NG) tube. The facility census was 121. Findings Include: Review of the medical record for Resident #325 revealed an initial admission date of 05/31/23 with the diagnoses including malignant neoplasm of thyroid gland, secondary malignant neoplasm of intrathoracic, hypertension, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease, benign neoplasm of pituitary gland, nontoxic multinodular goiter, diaphragmatic hernia, basal cell carcinoma of skin, osteoarthritis, tracheostomy status, constipation, hypothyroidism, dry eye syndrome and pain. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to appropriately revise resident care plans. This affected two (Resident #15 and #29) of 24 residents reviewed for care plans. The census was 121. Findings Include: 1. Resident #29 was admitted to the facility on [DATE]. Her diagnoses were other disorders of lung, pneumonia, acute respiratory failure with hypercapnia, hyperosmolality and hypernatremia, dementia, hyperlipidemia, wheezing, hypertension, anxiety disorder, edema, osteoarthritis, insomnia, vitamin D deficiency, opioid use, and other reduced mobility. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 05/19/23, revealed her cognitive assessment could not be completed due to her inability to adequately answer the questions. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure adequate monitoring of a change in a residents condition, failed to ensure interventions to prevent skin alterations were adequately implemented, and failed to ensure a brace was applied as ordered. This affected three residents (Resident #15, #19, and #98) of three residents reviewed for quality of care. The facility census was 121.

Inspectors wroteBased on observation, record review and interviews, the facility failed to properly identify Resident #12's medical condition to ensure a proper catheterization treatment plan was in place. This affected one resident (Resident #12) of one resident reviewed for catheter care. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #12's oxygen was humidified and respiratory equipment and supplies were stored and maintained properly. This affected one resident (Resident #12) of three residents reviewed for respiratory care.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication was maintained for Resident #82 between the facility and the hemodialysis center. This affected one resident (Resident #82) of one reviewed for dialysis. Findings Include: Review of the medical record for Resident #82 revealed an initial admission date of 12/02/22 with the latest readmission of 05/30/23 with the diagnoses of other disorders of lungs, protein-calorie malnutrition, sepsis due to Escherichia coli (Ecoli), toxic encephalopathy, hypertension, end stage renal disease (ESRD), urinary tract infection, diabetes mellitus, hyperlipidemia, hypothyroidism, atrial fibrillation, major depressive disorder, anemia, dysphagia, dependence on renal dialysis, anorexia, constipation, dry eye syndrome and pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #87's medications were available for administration. This affected one resident (Resident #87) out of five residents reviewed for medication administration.

Inspectors wroteBased on staff interview, record review, and review of pharmacy recommendations, the facility failed to ensure pharmacy recommendations were accurately addressed. This affected one resident (#15) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 121.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (#80) was properly monitored for side effects of anticoagulant use. This affected one of five residents reviewed for unnecessary medications. Findings Include: [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure the medication error rate was below five percent during medication administration. There were four medication errors out of 26 opportunities observed, resulting in 15.38% (percent) medication error rate. This affected two residents (#31 and #80) observed during medication administration. The facility census was 121.

Inspectors wroteBased on interviews, record reviews, and review of facility policy review, the facility failed to ensure Resident #26 was free from significant medication error. This affected one resident (#26) out of five residents reviewed for medication administration.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure medications were appropriately stored. This affected two residents (#51 and #98) who were observed to have medications unattended by staff at bedside during the annual survey. The facility census was 121.