Maple Lawn Nursing Home

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided adequate nutrition, monitored consumption, monitored or identify weight loss, completed assessments or notified the resident's provider or dietitian of weight loss, and did not evaluate the resident's care plan or initiate interventions to prevent further weight loss for one resident (Resident #14) in a sample of 17 residents. Review of the resident's weight records showed the resident lost 21.8 lbs. since 06/04/25, which was an 11.86 percent (%) weight loss in six months. The resident lost 15.2 lbs. since 10/01/25 (no weight for November documented) which was an 8.5% weight loss in two months. The resident experience significant weight loss with no staff identification, evaluation, notification, or intervention. The facility census was 59. [...]

Inspectors wroteBased on observation, interview and record review the facility staff failed to ensure a resident with dementia (Resident #14), in a review of 17 sampled residents received high-quality, compassionate, and individualized care that supports his/her dignity, well-being, and independence, while addressing the unique challenges posed by dementia. The facility failed to find the root cause and triggers for a resident's behavior and initiate non-pharmacological Interventions, use effective communication strategies, and provide appropriate guidance to staff for managing behavioral symptoms. The resident experienced lethargy, weight loss, physical altercations, agitation, and new skin breakdown. The facility census was 59. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety. The facility census was 59. Record review of the facility's Guideline & Procedure Manual, 2011 Edition, showed the following:-Clean Equipment - All equipment used in food preparation is clean and sanitary. Equipment is washed, rinsed and sanitized after each use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to ensure staff performed proper infection control practices when providing care to one resident (Resident #32), in a review of 17 sampled residents sampled, and for one additional resident (Resident #56). The facility failed to handle linens in a way to prevent contamination. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were awakened according to their preferences or according to how they were feeling that morning for one resident (Resident #57), in a review of 17 sampled residents, and three additional residents (Resident #14, #9 and #29). Per staff interview, for facility convenience, the facility had developed a get up list and early morning shower list for specific residents. This schedule was not consistent with the residents' plan of care. The facility census was 59. Review of the facility policy, Your Rights and Protections as a Nursing Home Resident, undated, showed the following:-As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure independently motorized exhaust ventilation units were free from a buildup of dust/debris. The census was 59. 1. Observations on 12/10/25 from 6:30 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive assessment, including a review of the clinical rationale and approved indication for use of psychotropic medications, for three residents (Residents #14, #69, and #41) with a diagnosis of dementia, in a review of five residents selected for review of unnecessary medications, prior to utilizing anti-psychotic medications to treat the residents' behaviors. The facility failed to consistently identify and implement non-pharmacological interventions to address the residents' behaviors. The facility failed to conduct a gradual dose reduction (GDR) or provide documentation a GDR was clinically contraindicated for one resident's (Resident #14) antidepressant medication. The facility census was 59. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment, were met for four certified nurse assistants (CNA)s, in a review of five CNAs who were employed by the facility for over one year. Review showed the staff failed to complete the required 12 hours of training per year as required to maintain their certification, including dementia management and resident abuse prevention training. The facility census was 59. Review of the facility Assessment, dated 11/20/25, showed the following education requirements:-Resident Rights on hire, annually and as needed;-Abuse, neglect, and exploitation on hire, annually and as needed;-Infection Control on hire, annually and as needed;-Changes in Condition as needed.-Staff shall complete education to maintain their certifications/licenses. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed follow facility's policy/procedure to notify the physician for one resident (Resident #10), in a review of 17 sampled residents, after the resident fell on the weekend and hit his/her head. The facility also failed to timely notify Resident #10's physician after the resident presented with a change in condition. The facility census was 59. Review of the facility's policy for contacting the physician, dated 10/16/24, showed the following:-The purpose of this policy is to give guidelines to nursing staff on contacting resident physicians or the on-call physician:-Notification of physicians in non-emergent situations: -Nursing staff will fax the physician to relay reports or status change information regarding the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report injuries of unknown origin for one resident (Resident #7), who was found to have bruising and blood on his/her body, in a review of 17 sampled residents, and failed to report bruises of unknown origin for one additional resident (Resident #57). The facility census was 59. Review of the facility's policy, Abuse and Neglect, dated 2025, showed the following: -Injuries of Unknown Origin: Defined as an injury that was not observed and/or the injury could not be explained. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in areas that are not normally vulnerable to trauma), or the number of injuries observed on a resident at one time, or the reoccurrence of injuries over time (pattern identified); [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #14 and #9), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the residents' health status and required interdisciplinary review and/or revision of the care plan. The facility census was 59. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a thorough nursing assessment of one resident (Resident #41), in a review of 17 sampled residents, when staff found the resident with a change in condition and was unresponsive. Staff failed to follow facility policy to immediately contact 911 when the resident had an emergent situation and was found unresponsive. The facility census was 59. Review of the facility's policy for contacting the physician, dated [DATE], showed the following:-The purpose of this policy is to give guidelines to nursing staff on contacting resident physicians or the on-call physician:-Notification of Physician in emergent/life threatening situations; -If a resident is having an acute change in condition, you must call the office and not fax. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide (NA) completed a state-approved training program within four months of hire. The facility census was 59. 1. Review of NA D's employee file showed a hire date of 02/18/25. Review of NA D's payroll showed the employee worked 205 hours as a NA from 11/12/25 to 12/15/25. Review of the facility's schedule for 12/11/25, showed NA D was scheduled for 11:00 P.M.-7:30 A.M. as a NA. During an interview on 12/16/25, at 4:00 P.M., NA D said he/she worked at the facility as an NA for since February 2025. He/She completed a training program but had not passed his/her test. During an interview on 12/09/25, at 11:30 A.M., the Administrator said NA D took the training course but failed the test twice. NA D was scheduled to test again. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program that monitored antibiotic use for two residents (Resident #2 and #32), in a review of 17 sampled residents. The facility had not had a designated Infection Preventionist or an active antibiotic stewardship program with tracking of infections or antibiotic use since November 2025. The facility census was 59. Review of the facility's policy, Antibiotic Stewardship, dated 10/15/24, showed the following: -Purpose: To ensure proper use of antimicrobials including appropriate treatment, duration of treatment and indication as well as ensuring that antibiotics are not used when contraindicated;-Policy: Nursing staff will not request antibiotics from attending physicians; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure inventories of schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule IV and V narcotic controlled substance medications, were reconciled by at least two qualified staff to ensure accountability for ten residents (Resident #4, 9, 5, 7, 8, 10, 6, 11, 12 and 13) that had narcotics held in the A-hall medication cart each shift per policy. The facility census was 61. Review of the facility policy, Accountability of Controlled Substances, revised 11/27/24, showed the following: -The controlled substance count is completed at the start of each shift; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on reporting allegations of abuse to the state agency immediately, but no later than two hours after the allegation was made for one resident (Resident #1), in a review of eight sampled residents. Resident #1 reported an allegation of abuse to Certified Nurse Aide (CAN) A on 06/15/25. CNA A reported the allegation to his/her charge nurse, Licensed Practical Nurse (LPN) D, who also reported the allegation to Registered Nurse (RN) B. No staff reported the allegation to the Director of Nursing (DON) or the Administrator until four days later. Additionally, when the administrator became aware of the allegation on 06/19/25 at 10:45 A.M., she did not notify the state agency of the allegation until 1:12 P.M. (greater than two hours). The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, per facility policy, for one resident (Resident #1), in a review of eight sampled residents. The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Investigations of Abuse/Neglect: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, was free from verbal abuse. The resident reported staff (Licensed Practical Nurse (LPN) D) raised his/her voice and told the resident to come on, come on while the resident tried to wheel himself/herself to the bathroom in a wheelchair. Resident #1, who had a diagnosis of aphasia (language disorder that affects a person's ability to communicate effectively), tried to communicate specific needs to LPN D, and when LPN D was not understanding what the resident was trying to say, the resident reached out to touch LPN D's hand so he/she would listen to the resident. LPN D continued to yell at the resident and threaten to call the police. The resident said the verbal abuse made him/her upset and scared of LPN D. The facility census was 63. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility. The facility census was 62. Review of the most current Facility Assessment, dated [DATE], showed the following: -Licensed beds: 109; -Average daily censes: 53; -23 residents required extensive assistance of two or more staff for activities of daily living (ADLs); -Services required: [...]

Inspectors wroteRefer to event id 84PV12 Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #3), received medications as ordered by the physician upon admission to the facility. Resident #1 did not receive medications due to some medications not being available from the pharmacy and because staff failed to accurately transcribe some medications from the resident's hospital discharge orders to the resident's medication administration record (MAR). Apixaban (blood thinner) was omitted from the MAR for 1/31/24 and 2/1/24 through 2/5/24 (10 missed doses). The resident subsequently had a decline which sent him/her to the hospital where he/she was diagnosed with a stroke. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one resident (Resident #1), in a review of five sampled residents. The census was 52. Review of the facility policy, Abuse/Neglect and Reporting Reasonable Suspicion of a Crime, last revised 1/5/17 showed: -It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect and injuries of unknown sources; -All allegations of mistreatment, abuse or neglect, and injuries of unknown sources will be reported and thoroughly investigated; -It is the responsibility of each covered individual who is an owner, operator, employee, manager, agent or contractor of the facility to report an incident or situation which may be considered a reasonable suspicion of a crime; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent cross contamination to other food items. Staff failed to discard food that was expired or showed visible signs of deterioration, failed to store and handle food products to maintain quality and free from potential contaminants, and failed to label and date opened food items. Staff failed to ensure foodware and drinkware was handled appropriately and protected from moisture, debris, and other contaminants and surfaces and equipment were properly cleaned and sanitized. Staff failed to ensure hygienic practices when preparing and serving food and beverages to residents and employ proper hand hygiene and surface sanitization practices. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Resident #8), in a review of 15 sampled residents and for two additional residents (Resident #23 and #52). Staff failed to correctly apply a splint per physician's orders for Resident #8, failed to follow medication administration guidelines for Resident #23, and failed to follow physician's orders and medication guidelines to rinse the mouth following administration of an inhaled medication for Resident #52. The facility census was 51. 1. Review of Resident #8's physician orders, dated 6/15/23, showed the resident was to have both hand splints/palm protectors on while in bed, off when the resident was out of bed, apply and monitor each shift. Review of the resident's care plan, dated 6/22/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to check two dependent residents (Residents #5 and #32) for incontinence according to their plan of care, and failed to provide complete incontinence care to one resident (Resident #17) in a review of 15 sampled residents,. The facility census was 51. Review of the facility policy, Perineal Care, dated 01/26/11, showed the following: -Perineal care is the washing of the genital and rectal areas of the body. Perineal care is usually called peri care; -Peri care prevents skin breakdown of the perineal area, itching, burning, odor and infections. Peri care is very important in maintaining the resident comfort. -All areas that have been touched by the attends/pad (adult protective brief or the cloth pad under the resident) must be washed; -Wash across the abdomen, be sure to lift and wipe all folds, rinse then dry; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses residents or resident behaviors to justify the implementation or continued used of antipsychotic medications for three residents with a diagnosis of dementia (Residents #11, #17, and #32), in a review of 15 sampled residents. The facility census was 51. A review of the facility policy, Psychotropic Medication, dated 10/10/13, showed the following: -Policy: the facility will make every effort to comply with state and federal regulations to the monitoring and use of psychopharmacological medication, this will include regular review for the continued need, appropriate dosage, side effects, risks and/or benefit. The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the diet spreadsheet menu. Staff also failed to have recipes readily available for staff to utilize when preparing food items listed on the diet spreadsheet menu. The facility census was 51. The facility did not have a policy related to preparing and serving food according to the diet spreadsheet menu or availability of recipes. 1. Review of the Diet Orders, obtained 10/30/23, showed the following: -Thirty-four residents with a physician-ordered regular diet; -Twelve residents with a physician-ordered mechanical soft diet; -Five residents with a physician-ordered heart healthy diet; -Two residents with a physician-ordered consistent carbohydrate (CCHO) diet; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a physician order for a mechanical soft diet (a texture-modified diet that restricts foods that are difficult to chew or swallow) received food items with the proper texture. The facility census was 51. Review of the facility policy, Dental Soft (Mechanical Soft) Diet, dated 2022, showed the following: -The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods; -The diet consists of food of nearly regular textures but excludes very hard, crunchy, or hard to chew foods; -Foods should be moist and fork tender; -Dry, hard crusty breads are excluded; -Vegetables are cooked soft, moist, and fork tender with no large chunks or pieces; -All vegetables should be chopped or diced into bite-size pieces (0.5 inches or smaller). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for three residents (Residents #8, #17, and #32), in a review of 15 sampled residents. The facility census was 51. Review of the facility's undated hand hygiene policy showed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #3, #33, #37 and #40), in a review of 15 sampled residents, and for two additional residents (Residents #11 and #27) who used bed rails. The facility census was 51. Review of the Food and Drug Administration (FDA) document titled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition two residents (Resident #5 and Resident #32), who were identified as at risk for developing pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. It can present as intact skin or an open ulcer and may be painful. It occurs as a result of intense or prolonged pressure or pressure in combination with shear), in a review of 15 sampled residents, according to facility policy and the residents' plan of care. The facility census was 51. Review of the facility policy Resident Turning and Repositioning, last reviewed on 9/4/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the areas within the rangehood, the wall behind the range, griddle and deep fat fryer, the metal backspash for the range and griddle, and the suppression nozzle over the deep fat fryer were free from a buildup of grease and debris. The facility also failed to ensure the wall behind the range, griddle, and deep fat fryer was maintained with an easily cleanable surface. The facility census was 69. Observation on 2/24/20 at 10:08 A.M. showed the wall behind the deep fat fryer, griddle, and range had a heavy buildup of yellow grease. The wall was constructed with drywall, covered with paint. The drywall compound and paint was cracked and peeling in areas above the deep fat fryer. The metal backsplash behind the range and the griddle had a heavy buildup of grease and debris. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the residents' environment clean and in good repair. The facility census was 69. Review of the facility Housekeeping Cleaning Policy dated 4/30/18 showed the following in part: -Primary purpose was to perform day-to-day activities of housekeeping and assure the facility was maintained in a clean, safe and comfortable manner; A. Follow cleaning schedule; B. Clean floors. Inspect furnishings for wear or defects and report to supervisor; C. Cleans all bathrooms in facility. Disinfect all walls, floor, fixtures; J. Curtains or drapes that were soiled need to be removed cleaned and replaced. Check for wear and defects and report to supervisor. 1. Observation on 2/24/20 at 2;40 P.M showed a section of missing tile in the hallway between rooms #114 and #113 on Walnut Lane. Observation on 2/24/20 at 2:45 P.M. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies consistent with the requirements for reporting. The facility census was 53. 1. Review of the document Abuse /Neglect and Reporting Reasonable Suspicion of a Crime Policy and Procedures dated, 1/5/17 showed the following: Policy: It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect, injuries of unknown origin and misappropriation or stealing of resident property or money. Abuse/Neglect Procedures: The facility will not permit residents to be subjected to abuse or neglect by anyone, including staff members, other residents, consultants, volunteers, vendors and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #27, #17 and #162) in a review of 18 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition (improvement or decline) which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 69. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the facility followed the Resident Assessment Instrument (RAI) User's Manual while completing the MDS assessment. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for six of 18 sampled residents (Resident #7, #8, #11, #17, #27, and #162). The facility census was 69. During interview on 3/26/20 at 6:15 P.M. the MDS Coordinator said the facility followed the RAI 3.0 process for completion of all MDS assessments. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff performed Activities of Daily Living for seven dependent residents (Resident #27, #59, #7, #36, #41, #60 and #162) of 18 sampled residents. The facility census was 69. During interview on 2/26/20 at 6:60 PM the Director of Nursing (DON) said they did not have a policy regarding staff providing residents' morning and bedtime ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the facility policy Perineal Care dated 1/26/11 showed the following: -Perineal care is washing of the genital and rectal areas of the body. Perineal care was usually called peri care. Peri care prevented skin breakdown of the perineal area, itching, burning, odor, and infections. Pericare was very important in maintaining the resident's comfort; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foot pedals were in place on wheelchairs during transportation for three residents (Resident #60, #162 and #41), failed to ensure staff used proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair) transfers for two residents (Resident #7 and #41) and failed to consistently implement, evaluate and modify care plan interventions to prevent falls, in accordance with current standards of practice, for one resident (Resident #59) who had a history of repeated falls in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Fall Prevention Program dated 7/13/12 showed the following: This is to be used as a guideline for the preventions of falls/injuries related to falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess, obtain informed consents, and reassess the safety and effectiveness of cane rails, one-quarter length bedrails and one-half length bedrails in use for five residents (Resident #11, #27, #36, #40, and # 55) of 18 sampled residents who had bedrails in place on their beds. The facility census was 69. Review of the facility's Bed Rail Checks, Installation and Removal policy dated 6/22/17 showed the following: -Bedrails were defined as any device that could be attached to one or both sides of a bed for the purpose of fall restraint or mobility assist; -All bedrail installations would be monitored and checked monthly by support services staff to eliminate hazards or entrapment of any kind, and review quarterly by support services supervisor and/or administrator; [...]

Inspectors wroteBased on observation and interview the facility failed to ensure medications were stored/destroyed appropriately. The facility census was 69. Review of the facility policy Destruction of expired/opened and used medication (not controlled) dated [DATE] showed : All medication will be collected weekly from the units and given to the nursing office for destruction or credit. Controlled medications are destroyed on site- see policy. Destruction and Returned for Credit: 1.) Medication will be counted and logged into Omniview web portal; 2.) Record are available on web site. Boxes are kept in the nursing office and pharmacy transporter picks them up weekly. Review of the facility policy Destruction of controlled substances dated [DATE] showed the following: This is a guideline for use in the destruction of all controlled substances for our facility: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' medications were secured in a locked cart or cabinet when left unattended during a medication pass. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 showed the following in part: -Read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident; -Medication carts should not be left unattended. If you needed to step away, make sure the cart was locked and the computer screen was on lock out. 1. Observations on 2/24/20 showed the following: -At 3:41 P.M. Licensed Practical Nurse (LPN) R parked the medication cart against the C-hallway wall and obtained and prepared Resident #300's medications from the medication cart for administration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for eight residents (Resident #41, #60, #162, #27, #59, #7, #34 and #36) in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Handwashing/Hand Hygiene undated, showed the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to pull the privacy curtains and close the door leading to the hallway to allow for privacy while providing toileting, incontinence care and dressing for two of 18 sampled residents (Resident #7 and #162). The facility census was 69. Review of the facility policy Quality of Life, Dignity and Privacy dated 3/13/12 showed the following: Each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality; 1. Residents would be treated with dignity and respect at all times; 3. Residents would be groomed as they wished as long as adequate hygiene was maintained; 9. Staff would promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure one additional resident (Resident #21) was free from significant medication errors. Staff failed to prime (remove the air) from the Humalog Kwikpen (prefilled pen of fast acting insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration), needle as instructed by the manufacturer prior to administration of the physician prescribed dose resulting in administration of less than the ordered dose of Humalog. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 directed staff to read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident. [...]