Maplewood Center

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two of seven sampled residents (Resident (R) 3 and R11) reviewed for falls were left in a safe position while staff stepped away from the resident's bedside, resulting in R3 and R11 falling from the bed and sustaining injuries. In addition, the facility failed to ensure that staff were aware of R1's change in mode of transfer to ensure safe transfers.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to ensure that injuries of unknown origin were reported to the state agency for one of one sampled resident (Resident (R) 1) out of a total sample of 18 residents. This failure had the potential to result in unidentified abuse, incomplete investigations, and the continuation of unidentified injuries.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure one of two residents (Resident (R) 2), during one of three opportunities for the provision of incontinence care, received incontinence care in a manner that prevented cross-contamination from a dirty area to a clean area. This failure had to the potential to result in urinary tract infections.

Inspectors wroteBased on document review and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 99 current residents. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents.

Inspectors wrote7.) R100's diagnoses include chronic respiratory failure, dependence on respirator (ventilator), Encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), Quadriplegia (paralysis of all four limbs), and Guillain-Barre syndrome (rare neurological disorder where the body's immune system attacks the peripheral nervous system). R100's admission MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Speech clarity is assessed as no speech. For functional limitation in range for motion R100 is assessed as having upper extremity and lower extremity impairments on both sides. Toileting hygiene & roll left, and right are assessed as being dependent and chair/bed to chair transfer was not attempted due to medical conditions or safety concerns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R78, R100, and R11) of 4 residents reviewed for pressure injuries. * R78 was originally admitted to the facility on [DATE] with multiple pressure injuries. On 2/23/25, R78 was discharged to the hospital and was readmitted on [DATE]. Upon readmission, the facility did not comprehensively assess R78's pressure injuries until 3/13/25 during wound rounds,7 days later. Multiple observations were made of R78's feet/heels resting directly on the air mattress and not being offloaded. [...]

Inspectors wroteBased on interview and record review the facility did not ensure nursing staff had the competencies and skill sets necessary to care for resident's needs for 1 (R414) of 1 resident with a chest tube (a plastic catheter inserted between the ribs to drain air, fluid, or blood from the pleural space around the lungs, heart, or esophagus) and PICC (a long flexible tube inserted into an arm vein and threaded into a large vein near the heart) line, 20 of 20 residents that utilize ventilators and tracheostomies, and all 108 of 108 residents for general nursing competencies. *Review of 16 staff indicate they did not have competencies for providing care of a chest tube and PICC line for R33. *20 residents in facility that are on ventilators and have tracheostomies, 12 of 47 staff members reviewed had incomplete competencies for ventilator and tracheostomy care. [...]

Inspectors wroteBased on interview and record review, the facility did not develop, implement and maintain an effective training program for all new and existing staff based on their facility assessment potentially affecting 108 of 108 residents in the facility. The facility did not have a training policy and procedure for new staff or continued training for existing staff.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 of 5 direct care staff chosen at random received effective communication training potentially affecting all 108 residents in the facility. Certified Nursing Assistant (CNA)-NNNN, CNA-OOOO, and CNA-BB did not receive effective communication training.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 direct care staff chosen at random received resident rights training potentially affecting all 108 residents in the facility. Certified Nursing Assistant (CNA)-BB did not receive resident rights training annually.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 of 5 direct care staff chosen at random received QAPI (Quality Assurance and Performance Improvement) training with the potential to affect all 108 residents in the facility. Licensed Practical Nurse (LPN)-AAAA, Registered Nurse (RN)-MMMM, Certified Nursing Assistant (CNA)-NNNN, CNA-OOOO, and CNA-BB did not receive QAPI training as a new hire or annually.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 direct care staff chosen at random received infection control training with the potential to affect all 108 residents in the facility. Certified Nursing Assistant (CNA)-BB did not receive infection control training annually.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 5 CNAs (Certified Nursing Assistants)(CNA) reviewed completed the required annual 12 hours of educational training. CNA-V, CNA-W, and CNA-Y did not receive the annual 12 hours of educational training. This had the potential to affect all 108 Residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 4 of 5 direct care staff chosen at random received behavioral health training potentially affecting all 108 residents in the facility. Registered Nurse (RN)-MMMM, CNA-NNNN, CNA-OOOO, and CNA-BB did not receive behavioral health training.

Inspectors wroteBased on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 5 (R34, R105, R78, R73, & R38) of 6 residents. The base of R34, R105, R78, R73, & R38's tube feeding poles were observed with dried feedings on multiple days.

Inspectors wrote2.) R73's nurses note dated 2/28/25 at 4:05 a.m. indicates R73 was transferred to the hospital for a change in condition. Note indicates unit nurse will update POAH (power of attorney health) and will call the hospital for nurse to nurse report. R73's nurses note dated 3/1/25 at 12:35 a.m. by Registered Nurse (RN)-X documents F/U (follow up): Call place to [hospital initials], update; pt (patient) admit w/ (with) acute Hypoxia 2/2 (secondary to) Chronic Resp (respiratory) failure. R73 was readmitted on [DATE]. Surveyor was unable to locate in R73's medical record R73 or R73's representative had been notified of the hospital transfer in writing. On 4/17/25, at 1:00 p.m., Surveyor asked Licensed Practical Nurse (LPN)-JJ who would notify a resident or their resident representative of a transfer to the hospital in writing. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect 2 of 6 units at the facility. *On 04/15/2025, staff member informed Surveyor that 4 residents, who required an assistance of 2 staff with a mechanical lift, remained in bed due to not having a second staff assistance available. *On 04/17/2025, Surveyor observed residents receiving meal trays 1.5 hours after breakfast was scheduled- due to staff being unavailable to help pass trays and/or assist residents with eating. *On 03/31/2025, The Facility's schedule documented residents were unable to be rounded on, due to staffing.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medication for 4 (R93, R514, R8 & R72) of 6 Residents reviewed. * R93 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R514 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R8 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 6 medication carts and 2 of 2 medication refrigerators located in the nurses station. Concerns include: * An expired Basaglar insulin pen for R22 with an open date of [DATE]. * Used Lantus Solostar insulin which was not labeled with a resident's name and an expired bottle of Humalog insulin for R42 with an open date of 11/23. * A bottle of Extra Strength Rapid Release Tylenol 500 mg (milligrams) with the expiration date of 8/2024. * A used Semglee insulin pen for R13 that was not dated when opened and a used bottle of Lispro insulin for R13 that was not dated when opened. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety for 95 of 108 residents that receive food from the kitchen. * In the facility's main kitchen, observations of partially used and undated food were made in the dry storage and walk-in freezers/coolers. Several food items were observed in the facility's dry storage uncovered open to air and undated. * Inadequate hand hygiene was observed by multiple kitchen staff working in the main kitchen area. * Contaminated utensils were placed back into food ready to be served to residents.

Inspectors wrote2.) R414 was admitted to the facility on [DATE]. Diagnoses includes pleural effusion (fluid accumulates between lungs & chest wall), acute respiratory distress, malignant neoplasm (cancer) of unspecified ovary, anxiety disorder, and depression. The hospital assessment/plan not dated under recommendations documents (1) Pleurx (drainage catheter) placed -Drain daily -Up to 1L drainage -Bedside nurse to complete self education for patient and patient's son -Interventional Pulm (pulmonary) f/u (follow up) as outpatient. (2) Neoadjuvant therapy (treatment given before the main treatment) for metastic ovarian cancer per Gyn/Onc (Gynecology/Oncology). R414's pre admit note dated 3/20/25, at 1:28 p.m., written by Director of Admissions/ Licensed Practical Nurse (LPN)-FF for admission diagnosis document R (right) pleural effusion. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R100) of 3 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Range of motion was not provided to R100 during two personal care observations per R100's plan of care.

Inspectors wroteBased on observation, record review and interviews the facility did not provide pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 1 of 22 residents (R10) investigated for proper medication administration. *R10 did not have the correct order for her B12 injection transcribed

Inspectors wroteBased on interview and record review, the facility did not ensure adequate monitoring for adverse reactions/side effects of psychotropic medications, or behavior monitoring required for use of psychotropic medications for 1 (R1) of 6 residents reviewed for psychotropic medications. R1 does not have any behavior monitoring in place related to their use of psychotropic medication (Buspar).

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 3 medication errors in 35 opportunities which resulted in a medication error rate of 8.57%. Medication errors were identified for R38 & R82. * R38's Sodium Chloride was crushed. * R82 received the incorrect dosage of Vitamin D and was administered multivitamin with minerals instead of adult multivitamin

Inspectors wroteBased on interview and record review, the facility did not ensure the Hospice communication process was followed for 1 (R41) of 2 residents reviewed for Hospice services. The facility did not ensure Hospice required documentation was maintained in R41's medical record. The facility did not have a communication process in place between the facility and Hospice.

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R614, and R83) of 3 residents observed. * R614 was not placed in Enhanced Barrier precautions with a foley catheter and a Physician's order for R614 to be in Enhanced Barrier precautions until Surveyor brought it to the facility's attention. *R83 has been placed in Enhanced Barrier Precautions (EBP) and staff did not put a gown on when assisting with cares. Finding Include: The Facilities Policy titled, Infection Control policy and procedure. Subject: enhanced barrier precautions. Effective 6-20. Revised Reviewed 11-24. Documents: Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 95 out of 108 residents service by the facility kitchen. *The Lead Cook-VV did not follow a recipe for preparing texture and modified consistency of pureed food to ensure nutritive value and consistency. **Food on Surveyor's test tray was cold and lacked flavor. ***Resident council complained to Surveyor that food was consistently cold and lacked flavor. Findings Include: The Facility's Policy titled, Food services policy and procedure, subject: Standardized recipes effective 7/92, revised 9/21, reviewed 10/21, documents: Policy: Standardized recipes are used for the preparation of all food items to ensure consistent quality and quantity of the food. Procedure: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the necessary Respiratory Therapy services to provide respiratory care consistent with professional standards of practice to 2 (R7 and R1) of 3 residents reviewed for respiratory cares/ services. The facility did not ensure staff were trained, knowledgeable and competent to provide respiratory care to 9 residents who are ventilator dependent and 7 residents who are not ventilator dependent but have tracheostomies (trach). *On 01/25/2025, R7 was not put on R7's ventilator at night due to the Facility not having a Respiratory Therapist at the Facility. R7 did not have Respiratory orders relating to R7's ventilator. R7 did not have a documented Respiratory Assessment for every shift, between 01/06/2025 through 02/04/2025. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to include individual assessment and reporting when experiencing a medical change of condition, per standards of practice for respiratory therapists. This was discovered with 1 (R2) of 1 resident reviewed that had a medical change of condition while on a ventilator. On [DATE], at 11:12 PM, there was a progress note written by the Respiratory Therapist (RT)-T that indicated shortness of breath was present for R2 and that this was new, not chronic. RT-T raised R2's oxygen flow rate from 5 lpm (liters per minute) to 8 lpm. There is no evidence that any further assessment was completed indicating why to increase the flow rate or to help determine why R2 was newly short of breath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide written notice to residents and offer them a choice in a change of room for 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change. R7, R8, R9, and R10 were moved from one unit to another without having taken resident preference into account or offering to show the possible rooms to the resident/resident representative prior to the move.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the right to refuse transfer to another room in the facility when the purpose of the move is solely for the convenience of staff for 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change. R7, R8, R9, and R10 were moved from one unit to another without having the opportunity to refuse the transfer.

Inspectors wroteBased on observation, interview, and record review, the facility did not allow 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change the right to make a choice regarding moving within the facility. R7, R8, R9, and R10 were moved from one unit to another without taking resident preference into account or offering to show the possible rooms to the resident/resident representative prior to the move.

Inspectors wroteBased on record review and interviews, the facility did not ensure a through investigation was completed for 1(R1) of 3 facility self-reports reviewed. * The facility did not thoroughly investigate an allegation of neglect reported for R1 on 2/4/2025.

Inspectors wroteBased on interview and record review the facility did not revise care plans for 1 (R1) of 7 residents care plans that were reviewed. * R1's family was observed by facility staff suctioning R1. R1's care plan was not revised, or interventions implemented to indicate to staff what to do if family is observed suctioning R1 again unassisted. * R1 was care planned to have an Alexa device/camera in room to communicate with family. Facility policy was changed, and video cameras not allowed- R1's care plan was not revised to indicate this change.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure staff followed infection control procedures for 1 (R4) of 2 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R4.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R3) of 3 Resident's representative was notified when there was change in condition and a need to alter treatment. On 11/11/24 R3 vomited in the morning and a KUB (kidney, ureter, bladder) was ordered. R3's resident representative was not notified.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R1 and R5) of 5 Residents who filed grievances with the facility had investigations into their grievances which included details on the steps taken to resolve the grievance, a summary of pertinent findings regarding the concern, a statement as to whether the grievance was confirmed or not, corrective action to be taken as a result of the grievance, and prompt attempts to resolve the grievance.

Inspectors wrote2.) R3 is a [AGE] year old male with diagnoses which includes acute & chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, obesity, and epileptic seizures. R3 has a tracheostomy, gastrostomy & jejunostomy tube, and is non verbal. The significant change MDS (minimum data set) with an assessment reference date of 10/22/24 assesses R3 as having short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R3 is dependent for toileting hygiene, roll left and right, chair/bed to chair transfer and is always incontinent of urine & bowel. On 11/11/24, at 9:53 a.m., Surveyor called R3's resident representative to discuss R3. R3's representative informed Surveyor she is coming to the facility. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure a thorough investigation was completed for allegations of abuse/neglect for 2 (R1 & R2) of 2 residents reviewed for alleged abuse investigations. *The Facility did not ensure a thorough investigation was completed for an allegation of verbal abuse of R2 on 09/22/2024 and 10/10/2024 by R2's family member. *R1 reported to the night nursing supervisor (RN)- C that on the night shift of 11/3-11/4/24, R1 overheard Certified Nursing Assistant (CNA)-Z be verbally abusive to R8. The allegation of verbal abuse was not investigated thoroughly including obtaining staff statements and conducting Resident interviews.

Inspectors wroteBased on comprehensive assessment the facility did not ensure 1 (R3) of 7 residents received treatment and care in accordance with professional standards of practice. On 11/11/24 R3 was observed with a foam dressing on R3's mid back which was dated 11/3/24. There is no physician order for the foam dressing.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 1 resident (R4)'s environment remains free of accident hazards. * R4 was admitted to the facility ventilator wing on 5/29/24 with a diagnosis of Chronic Respiratory Failure. The facility did not ensure R4's room remained free of accident hazards after a heating and air conditioning condensation valance, located on the wall near the ceiling, fell open on 07/10/24 splashing condensate on R4's bed. The condensation valance fell open again on 08/08/24 splashing condensate and debris on R4.

Inspectors wroteBased on interview, and record review the facility did not provide pharmaceutical services to assure accurate dispensing and administering medications to meet the needs of each resident and did not ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 (R2 & R3) of 2 residents reviewed. *The Facility did not have records to account for R2's controlled medication administration. *R3 did not receive Mexiletine 150 mg on 11/10/24 at 12:00 p.m., 6:00 p.m., 11/11/24 at 12:01 a.m., 6:00 a.m., 6:00 p.m., 11/12/24 12:01 a.m., & 6:00 a.m. as the medication was not available.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 4 medication errors in 25 opportunities which resulted in a medication error rate of 16%. Medication errors were identified for R9, R10, & R11. * On 11/12/24 R9 was not administered Sennosides 8.6 mg (milligram)-docusate sodium 50 mg and only 20 cc (cubic centimeters) was added to Polyethylene Glycol 3350 17 grams. * On 11/12/24 Licensed Practical Nurse (LPN)-W added only 30 cc (one ounce) to R10's Polyethylene Glycol 3350 17 grams. * R11 did not receive Aspirin 81 mg tablet delayed release on 11/12/24.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R3 & R10) of 4 Residents. * Staff did not wear appropriate PPE (personal protective equipment) when providing incontinence cares and changing a dressing for R3. R3 is on EBP (enhanced barrier precautions). * Staff did not wear appropriate PPE when administering R10's medication via the feeding tube. R10 is on EBP.

Inspectors wroteBased on observation, interview, and record review the facility did not establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections for 1 (R3) of 1 residents reviewed. * Incorrect transmission-based precaution sign observed on R3's door. * Staff was observed interacting with R3 while not wearing a mask and when R3 was coughing. * R3 was observed in hall unattended, without a mask coughing and grabbing a hand railing. * Staff was observed assisting R3 in a wheelchair, then assisting another resident, without performing hand hygiene in between tasks. * Staff were unaware of R3's proper transmission-based precaution status. This has the potential to affect 31 residents residing on the affected unit in the facility at the time of the survey.

Inspectors wroteBased on interview and record review, the facility did not ensure that the PASRR (Pre-admission Screen and Resident Review) for 1 (R2) of 1 residents were conducted accurately and did not ensure the completion of Level II Screen after the level one PASRR screen identified R2 as having a mental illness or developmental disability. * R2's Level 1 PASRR Screen dated 12/8/20 documents R2 has a serious mental illness with psychotropic medication(s) and 30 day exemption was checked. A new PASRR Level I Screen was initiated after the 30 days which would have generated a Level II Screen.

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R2) of 1 residents reviewed received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. *R2's hospital discharge paperwork dated 1/7/24 has instructions for R2 to follow-up for a gastrointestinal(GI) consult scheduled on 3/6/24 at 1:20 PM. R2 did not have the GI consult until 5/15/24. Findings Include: 1.) R2 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Adjustment Disorder, Anxiety Disorder, Depression, Chronic Pulmonary Disease, Chronic Kidney Disease, Stage 3, Fibromyalgia, Chronic Fatigue, and Morbid Obesity. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status(BIMS) score of 15, indicating R2 is cognitively intact for daily decision making. [...]

Inspectors wroteBased on observation, record review and interview, the facility was unaware that the dish machine was not working, and the facility did not have a process in place to ensure the high temperature dish machine was properly working for 1 of 1 kitchen which has the potential to affect all 95 residents within the facility. *During an observation of the high temperature dish machine, the temperature gauges outside of the dish machine were not indicating that the dish machine was reaching an appropriate temperature. *The facility did not have a process in place to verify the temperature of the high temperature dish machine.

Inspectors wroteBased on observations, interview, and record review the facility does not have a comprehensive water management plan, transmission based precautions for COVID were not followed, and the N95's in use were not fit tested for staff. This deficient practice has the potential to affect all 95 residents residing in the facility at the time of the survey. * The facility does not have a current water management team that meets on a regular basis, there were no flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R18 tested positive for COVID-19. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents were protected from potential abuse while an investigation of an allegation of abuse was being conducted for 1 of 2 Facility Reported Incidents reviewed. R34 made the allegation on 2/29/2024 at 7:00 PM that R100 entered R34's room and hit R34 in the head and twisted R34's left arm. R100 was moved to another unit/floor after the incident without increased supervision during the investigation into the allegation potentially putting the eight residents on the unit at risk for abuse.

Inspectors wroteBased on record review and interview, the facility did not ensure all alleged violations involving abuse were reported to the State Survey Agency within the 2-hour time frame for 1 of 2 Facility Reported Incidents reviewed. R34 made the allegation on 2/29/2024 at 7:00 PM that R100 entered R34's room and hit R34 in the head and twisted R34's left arm. The alleged abuse was not reported to the State Agency until 3/1/2024 at 2:05 PM.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents admitted to the facility with an indwelling catheter are assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and an indwelling catheter is not used unless there is valid medical justification for catheterization. In addition, the facility did not ensure residents with fecal incontinence and constipation received appropriate treatment and services to restore as much normal bowel function as possible for 1 of 1 (R87) residents reviewed for bowel and bladder. R87 admitted to the facility with a Foley catheter. There was no diagnosis or medical justification for the catheter, no size indicated, and no assessment or plan for removal of the catheter. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure medications were administered timely for 1 (R34) of 6 residents reviewed for medication administration. R34 did not receive 8 PM or bedtime medications until 11:00 PM.

Inspectors wroteBased on interview and record review, the facility did not keep 2 (R401 and R33) of 5 residents reviewed free from unnecessary drugs. 1. On 3/26/24 R401 was prescribed Memantine 5 mg by mouth every day for depression. Depression was not included on R401's diagnoses. 2. On 5/6/23 R33 was prescribed Phenytoin 100 mg by mouth three times a day for seizures. Seizures was not included on R33's diagnoses.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled to include the expiration date when applicable, drugs were not expired, and drugs were stored under proper temperature controls for 2 of 4 medication carts and 1 of 2 medications rooms observed. The facility policy titled Medication Administration revised 4/24 documents (in part) . .Policy: The facility following current professional standards of practice, regulations and published drug administration guidelines will maintain a medication administration system that will safely prepare, administer, and store resident medication. 4. Safety j. Expiration dates on all medication packaging/vials/bottles/patches must be checked prior to administration. k. All medication must be labeled and dated when opened. 8. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement interventions when 1 of 6 residents (R5) reviewed for elopement out of a total sample of 11 was assessed as being at risk for elopement. R5, who was described as extremely confused, was assessed as being high risk for elopement on 12/14/23 and should have had a departure alert bracelet in place at that time. R5 was last seen on 12/16/23 between 4:00 PM and 4:15 PM. Staff identified that R5 was not in the building at 4:30 PM. R5 crossed a heavily traveled 4 lane street and was found by a neighbor in their yard at 4:50 PM. The resident was outside unsupervised and without the staff's knowledge of the resident's whereabouts for approximately 20 minutes. R5 did not have a wanderguard placed until after the elopement. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to timely report an injury of unknown origin to the Administrator and the State Survey Agency for 1 (R4) of 2 sampled residents investigated for injuries of unknown origin.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to prevent further potential abuse of residents following a report of injury for 1 of 2 sampled residents (R4) investigated for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure nursing staff documented the administration of medication for 1 (R3) of 3 residents sampled for medication review.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R5 and R12) of 5 residents reviewed for pressure injuries. * R5 did not have a comprehensive assessment with measurements or treatment in place when a new open area was observed on [DATE] until [DATE] which allowed the open area to worsen to an unstageable, facility acquired pressure injury. * R12 did not have a comprehensive assessment of an open area when returned from the hospital. On [DATE] R12's open area healed; the facility continued to do R12's treatment on the healed open area.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (R15) residents reviewed for choking. R15's Minimum Data Set (MDS) indicated she was to receive 1 person physical assist with meals, which was not care planned. R15 was served pieces of solid meat for lunch instead of the sliced roast beef that was on the menu, the pieces of the solid meat were the approximate size of 2 inches. There was no evidence the meat was cut when served to the resident as indicated on her meal ticket. R15 sustained a witnessed choking episode during the meal. 911 was not immediately called resulting in a delay of emergency medical services (EMS) arrival to provide medical assistance.

Inspectors wroteBased on interview, observation of video footage, and record review the facility did not ensure residents the right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 of 1 (R15) residents' advanced directives reviewed. R15 did not have an advanced directive signed by her Activated Health Care Power of Attorney (AHCPOA) at the time R15 sustained a choking episode which required medical intervention, including Cardiopulmonary Resuscitation.

Inspectors wroteBased on interview and record review the Facility did not self report to the State agency allegations of abuse for 1 (R16) of 4 Residents. R16's allegation of being treated roughly as her shoulder was yanked was not investigated.

Inspectors wroteBased on interview and record review the Facility did not have evidence allegations of abuse were thoroughly investigated for 1 (R16) of 4 Residents reviewed for abuse. R16's allegation of R16's being treated roughly as her shoulder was yanked was not investigated.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure quality of care was provided for 2 (R7 & R11) of 16 Residents. * R7's bowel movements were not being monitored. * There was not an order or comprehensive assessment for R11's urinary culture originally obtained on 8/2/23 and 8/4/23.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 (R8) residents reviewed for splints. R8 did not have splints applied on bilateral arms and hands as care planned.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R32) of 12 residents at high risk for elopement were not provided with safety measures, interventions and assessments to prevent elopement; 1 (R329) of 5 residents with falls followed Care Plan to prevent falls; 12 (R80 and R11) of 24 residents reviewed for environment were provided with a safe environment; and 1 (R40) of 1 resident who smoked was assessed to be a safe smoker. 1. R32 was assessed as a high elopement risk and demonstrated active wandering behavior and desire to leave facility starting on 10/2/22. Facility placed a Wanderguard on and initiated a Care Plan. Facility stated they initiated 1:1 monitoring but that was not put in place until 11/6/22. R32 continued to have wandering behaviors. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R12) of 1 residents with a change in condition following a fall was thoroughly assessed, so appropriate treatment could be provided based off the assessment. * R12 was readmitted to the facility on [DATE] following hospitalization from 3/21/22 thru 3/25/22. Upon arrival to the facility R12 informed staff of the need to use the bathroom. R12 was assisted to the toilet, provided the call light, and instructed to call for assistance when finished. Staff left R12 unattended in the bathroom. R12 was then found on the floor with her head at base of toilet and wall. From 3/26/22 through 3/31/22, R12 was documented to be experiencing a change in condition with increased weakness, increased confusion, difficulty expressing needs, only able to answer yes/no questions and incontinent. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 (R11) of 7 Residents reviewed for pressure injuries. R11 had a right buttock pressure injury that increased in size and slough percentage. The wound doctor assessed the pressure injury and wrote orders for a new treatment. The facility failed to transcribe the order, R11 continued to receive the previous treatment for two weeks and the pressure injury continued to increase in size and slough percentage.

Inspectors wroteBased on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety to ensure dishes and utensils were properly sanitized by the facility's dishwashing machine. This had the potential to affect 103 of 119 Residents who receive nutrition orally from food prepared in the kitchen. The wash temperature did not meet manufacturer's minimum recommendations for proper washing. Staff were observed to put away dishware and utensils that were washed below the minimum recommended temperature of 160 degrees for the wash cycle. Findings Include: On 12/19/22 at 10:33 AM dishwashing was observed in the kitchen via the dishwasher. The dishwasher had instructions on it that read: wash minimum 160 degrees, rinse minimum 180 degrees. [...]

Inspectors wroteBased on observations, record review and interviews with staff and residents, the facility did not always ensure that they made prompt efforts to resolve grievances regarding cold food being served to residents and the appearance of the front entrance to the facility. This was expressed during the Resident Council meeting where 5 residents were in attendance and during 3 individual interviews out of a sample size of 24 residents. Resident Council members expressed concerns to Administration staff during Resident Council Meetings in August, September, October and December, 2022 regarding being served cold food and concerns with cigarette butts not being disposed of properly near the front entrance to the facility. Individual interviews were conducted with residents during the survey and statements were made that residents are still being served cold food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure all drugs and biologicals were in locked compartments for 2 of 6 units potentially affecting 31 of 119 residents. The medication carts on Park View-1 and Terrace View-1 units were observed to be unlocked and not under direct observation of authorized staff in an area where residents, other facility staff, and family members could have access to it.

Inspectors wroteBased on observation and interview the Facility did not ensure that each resident received food that was palatable, attractive and served at an appetizing temperature. This had the potential to affect 103 out of 119 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure that Residents with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for 1 (R11) of 2 Residents reviewed with limited range of motion. R11 was observed not wearing bilateral soft hand splints as recommended by therapy on 12/19/22, 12/20/22, and 12/21/22.

Inspectors wroteBased on interview and record review, the Facility did not provide dialysis services consistent with professional standards of practice for 1 (R70) of 3 Residents reviewed for dialysis. * R70 receives dialysis three times per week. R70's dialysis center communication records are not consistently completed by Facility nurses.

Inspectors wroteBased on observation, interview and record review the Facility did not assess the risk of entrapment and review the risk & benefits for 1 (R80) of 1 Residents observed having bed rails. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. R80 was observed to have bilateral grab bars to upper bed without an assessment.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R52) of 5 residents reviewed for unnecessary medications had adequate behavior monitoring while receiving psychotropic medications. *R52 received psychotropic medications without adequate behavior monitoring.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents were free of significant medication errors for 1 (R484) of 1 residents reviewed for insulin administration. On 12/20/2022 at 8:27 AM, R484 was administered 6 units of Levemir insulin (long-acting insulin) instead of the physician ordered, 6 units of Lispro (short acting insulin).

Inspectors wroteBased on record review and interview, the facility did not ensure all staff were fully vaccinated for COVID-19. The facility's current staff vaccination rate is 97.2%