Many Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain a safe, functional, and comfortable environment for 4 (Resident #1, Resident #3, R1, and R2) residents of 6 sampled residents reviewed for physical environment. The facility failed to provide transportation for residents to their appointments with a fully functional air conditioning system during the warm/hot weather climates.

Inspectors wroteBased on interview and record view, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R3) resident of 6 sampled residents reviewed for quality of care. The facility failed to transport R3 to a nephrologist appointment in a timely manner as ordered.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (Resident #1) resident of 6 sampled residents. The facility failed to ensure nursing staff accurately documented Resident #1's medication/treatment administrations.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the pureed meals for 13 Residents who receive pureed meals prepared by the facility kitchen.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions by: Failing to ensure safe food was served on the food line; and Failing to store clean dishes appropriately This failed practice had the potential to affect all 73 residents who receive food prepared from the facility's kitchen.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 2 (Resident #2 and Resident #81) of 2 residents reviewed for transfer/discharge. The total sample size was 33. Review of a facility policy on 03/11/2026 at 2:51 p.m. titled, Transfer or Discharge Notices with a revision date of 03/2025 revealed in part .Residents (or Resident Representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Notice of Transfer or Discharge (Anticipated) 2. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge: b. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that a person-centered plan of care was developed for 1 (Resident #6) of 33 sampled residents to reflect a diagnosis of Dementia. The facility had a total census of 73.

Inspectors wroteBased on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to asses a Central Venous Catheter for 1 (Resident #59) of 33 sampled residents.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #4) of 33 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure medical equipment was cleaned in between uses with multiple residents. This had to potential to affect 73 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (Resident #46) of 29 sampled residents. The facility failed to ensure medications were administered safely and timely by leaving Resident #46's medications at her bedside.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 4 (S11 CNA, S12 CNA, S13 CNA, and S14 CNA) of 5 (S11 CNA, S12 CNA, S13 CNA, S14 CNA, and S15 CNA) CNA personnel records reviewed.

Inspectors wroteBased on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 70.

Inspectors wroteBased on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The facility failed to follow the menu in regards to recipe and portion size to ensure nutritional adequacy of the meal for 6 (#57, #41, #4, #1, #36 and #23) of 6 residents (#57, #41, #4, #1, #36 and #23), who received pureed diets. Review of the facility's recipe book located in the kitchen for pureed diets revealed in part . P/PU4 (coded for pureed foods-no lumps, require no chewing). Beef Meatballs f/Frz (fresh/frozen) w/mushroom gravy. [NAME] Method: Puree; Serving Utensil: #8 scoop; Serving Size: ½ Cup. Preparation Step: IDDSI (International Dysphagia Diet Standardization Initiative) Pureed foods: The number of portions served should equal the same number of portions pureed. [...]

Inspectors wroteBased on observation and interview the facility failed to store and prepare food under sanitary conditions in accordance with professional standards of food service safety, as evidenced by failing to: 1. Properly store food items located in the facility's refrigerator, freezer, resident dining area, and kitchen area. 2. Store clean dishes in an area that would remain free of food debris. 3. Monitor and record the temperatures of a refrigerator that was used to store prepared meal items for residents, from 12/01/2024 to current (01/12/2025). 4. Test and document the dishwasher's sanitizing solution concentration for dinner dishes on 01/10/2025 and 01/11/2025, and breakfast dishes on 01/12/2025. 5. Ensure dietary staff wore proper hair covering.

Inspectors wroteBased on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (#71) out of 1 resident reviewed for discharge. The total sample size was 29.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#5) of 1 residents investigated for PASARR in a final sample of 29 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the implementation of a comprehensive person centered care plan for 1 (Resident #44) of 29 sampled residents. The facility failed to ensure Resident #44's NPO status was implemented.

Inspectors wroteBased on interview and record review the facility failed to document a Discharge Summary when a resident was discharged from the facility for 1 (#71) out of 1 residents reviewed for discharge. The total sample size was 29.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#44) of 29 sampled residents by failing to use enhanced barrier precautions, when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse for 1 (#6) of 8 (#1, #2, #3, #4, #5, #6, #7 and #8) residents reviewed for abuse. The facility failed to protect Resident #6 from physical abuse by Resident #8. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 2 (Resident #5 and Resident #7) of 8 residents reviewed for abuse.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#4) of 8 (#1, #2, #3, #4, #5, #6 ,#7 and #8) sampled residents. The facility failed to place a fall mat at the bedside for resident #4.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to properly secure Resident #3's wheelchair prior to transporting the resident in 1 of the facility's 2 vans. This deficient practice resulted in an immediate jeopardy situation on 03/20/2024 at 9:50 a.m., when Resident #3 was placed in the facility's van, and her wheelchair was anchored/secured in the facility's van with only three of the four anchors required. While the van was in motion, Resident #3's wheelchair fell backwards, and Resident #3 hit the back of her head on the lift. Resident #3 sustained an abrasion with bleeding noted to the back of her head. [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure a Certified Nursing Assistant (CNA) was competent in skills and techniques necessary to assure resident safety for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to ensure that an untrained CNA (S4) was not allowed to secure Resident #3, who was wheelchair bound, in a facility van prior to transportation.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's right to be free from physical and sexual abuse, and psychosocial harm by another resident, for (#1) of 3 (#1, #2, and #3) residents investigated for abuse. This failed practice resulted in an actual harm situation on 12/27/2023 at 3:40 p.m., when Resident #2 put his hands under Resident #1's shirt, and on her breast. On 11/19/2023, Resident #2 tried to throw a coffee cup at Resident #1; however, staff intervened. On 12/26/2023, Resident #2 lurched towards Resident #1 when staff tried to take Resident #1 to provide care, and a CNA had to step between the residents. On 12/27/2023, Resident #2 put his hand under Resident #1's shirt and on her breast, became angry when he was redirected, and grabbed and pinched Resident #1 on her back, and through her clothes, leaving a reddened area on her back. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #2 was adequately supervised to protect Resident #1 and prevent physical and sexual abuse of Resident #1, for 1 (#2) of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 1 (#2) of 3 (#1, #2, & #3) sampled residents that addressed his possessiveness over another resident and his combative behaviors with staff related to this resident.

Inspectors wroteResident #69 A review of Resident #69's medical record revealed an admit date of 09/21/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left side, Essential Hypertension, and Major Depression Disorder. A review of Resident #69's Care Plan with a target completion date of 01/04/2024 read in part . Resident #69 has oxygen therapy: Monitor nebulizer treatment prior to and after treatment, Ipratropium-Albuterol solution as ordered, Monitor for signs and symptoms of respiratory distress and report to medical director as needed. An observation on 12/11/2023 at 10:34 a.m. revealed Resident #69's nebulizer mask dated 12/5/2023 hanging on the nebulizer machine, left open to air, and uncontained. An observation on 12/12/2023 at 9:30 a.m. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption and failed to ensure frozen food items were properly stored. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice as evidenced by failing to obtain an order for oxygen therapy for 1 (Resident #17) of 2 (#17 and #69) residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#13) of 4 (#6, #13, #26, and #64) residents reviewed for ADL care.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan 1 (Resident #11) of 1 sampled residents for edema. The facility failed to ensure Physician's Orders for an assistive device for support and positioning were implemented.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by: 1. Failing to ensure staff performed hand hygiene after touching contaminated areas during wound care for 1 (#56) of 1 residents observed for wound care. 2. Failing to ensure catheter tubing was kept off the floor for 1 (#17) of 1 resident reviewed for urinary catheter.

Inspectors wroteBased on record review and interview, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Resident #2 fell to the ground, and sustained an Acute Left Femur Fracture. This failed practice resulted in an actual harm situation for Resident #2 on 09/06/2023 at 9:00 a.m., when S4 CNA transferred the resident from the bed to a wheelchair without assistance of another staff, as indicated on Resident #2's plan of care. During the transfer, Resident #2 fell to the ground. Resident #2 complained of left knee pain with swelling noted, and an x-ray was obtained which revealed an Acute Left Femur Fracture. [...]