Marietta Heights Post Acute

Inspectors wroteBased on observation, medical record review, infection control log review, review of local health department guidance, Center for Disease Control information review, review of text message communication, nursing staff schedule review, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program that included prevention, identification, investigation and reporting of communicable disease including Respiratory Syncytial Virus (RSV) infection. This resulted in Immediate Jeopardy and the likelihood of serious harm, complications and/or death for all 37 residents beginning on [DATE] when staff (Licensed Practical Nurse (LPN) #251) worked providing care to residents despite positive RSV test results and subsequently, a second staff (Certified Nursing Assistant (CNA) #237) was positive for RSV and worked (on [DATE]). [...]

Inspectors wroteBased on observation and interview, the facility failed to protect the privacy of personal records of all residents by storing medical records in an unlocked, open resident room in the facility which could be accessed at all times. This had the potential to affect all residents. The facility census was 37.

Inspectors wroteBased on record review, review of a Self-Reported Incident, policy review and interview, the facility failed to treat residents with dignity and respect. This affected one resident (Resident #2) of three residents reviewed for dignity. The facility census was 37.

Inspectors wroteBased on record review, review of a self-reported incident and interview, the facility failed to thoroughly investigation an allegation of staff to resident abuse. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 37.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a fall intervention was implemented immediately after a fall. This affected one resident (Resident #78) of three residents reviewed for accidents. The facility census was 37.

Inspectors wroteBased on record review, policy review, Employee Counseling Form review and interview, the facility failed to maintain complete and accurate medical records. This affected two (Resident #84 and Resident #78) of three residents reviewed for accurate medical records. The facility census was 37.

Inspectors wroteBased on observation and interview, the facility failed to post, in a place readily accessible to residents and family members and legal representatives of residents, the results of the most recent survey of the facility, which included any surveys, certifications, and complaint investigations made during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. This affected all residents of the facility. The facility census was 37.

Inspectors wroteBased on record review, review of the facility's water management program, observation, interview, and policy review the facility failed to ensure enhanced barrier precautions were implemented per orders/care plan for three residents (Resident #11, #22 and #28) and the water management program was implemented per the facility's protocol. This affected three residents (Resident #11, #33 and #28) of three residents observed for enhanced barrier precautions but had the potential to affect all 38 residents residing in the facility related to the water management program.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to complete a comprehensive assessment for a resident who had an identified weight gain and diagnosis of congestive heart failure and failed to notify staff of a physician ordered fluid restriction. This affected one resident (Resident #31) of four residents reviewed for nutrition. The facility census was 38.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to implement a comprehensive, individualized and effective behavioral health plan to address Resident #22's mental health needs related to depression. This affected one resident (Resident #22) of three residents reviewed for behavioral/emotional needs. Actual psychosocial harm occurred beginning on 10/31/25 when Resident #22 was assessed to have a deterioration in mental health with increase in depression symptoms with request to speak to a therapist. The facility failed to obtain the requested services for the resident. The resident's mental health continued to decline. Interview on 02/23/26 with Resident #22 revealed he had still not been provided the necessary mental health therapy services; [...]

Inspectors wroteBased on observation, record review, interview, review of manufacturer guidelines, and facility policy review, the facility failed to ensure kitchen staff (Cooks #531 and #541) were competent with job responsibilities. This had the potential to affect all the residents in the facility. The facility census was 38.

Inspectors wroteBased on observation, record review, review of manufacturer guidelines, review of invoices, and interview, the facility failed to store and serve food under sanitary conditions. This had the potential to affect all residents residing in the facility. The facility census was 38.

Inspectors wroteBased on observation, record review, review of Quality Assurance and Performance Improvement program (QAPI) meeting minutes, and interview, the facility failed to maintain an ongoing, comprehensive, and effective Quality Assurance and Performance Improvement Program to address concerns with facility practices and operations, to ensure corrective action plans from prior survey activity addressed quality concerns, systemic gaps and outcomes and corrective interventions were evaluated for effectiveness to meet the total care needs of the residents in the facility. This affected all 37 residents residing in the facility.

Inspectors wroteBased on observation, invoices, and interviews, the facility failed to ensure all electrical equipment was maintained in safe operating condition. This had the potential to affect all residents residing in the facility. The facility census was 38.

Inspectors wroteBased on review of resident council minutes, review of concern forms, review of the facility's assessment and interview, the facility failed to maintain sufficient staffing to timely meet the total care needs of all residents. This affected ten residents (#1, #2, #4, #11, #14, #15, #22, #27, #28, and #47) of 38 residents residing in the facility. Review of Resident Council minutes dated 09/15/25 to 02/18/26 revealed old business resolved was resident had voiced concerns about how long it takes aides to find help using the Hoyer (mechanical lift). New concerns residents voiced included concerns about staff call offs and not having enough staff members available. An action plan was to provide education about call offs and scheduling. Additional staff provided to help residents' needs. During the meeting held on 11/17/25 and 12/15/25 resident's voiced concerns about food being served late. [...]

Inspectors wroteBased on resident/representative interview, staff interview, policy review, record review, and review of binding arbitration agreements, the facility failed to ensure binding arbitration agreements were explained to residents/representatives in a manner that they understood and included an explanation that they were giving up the right to litigation in a court proceeding and could withdraw/terminate the agreement within 30 days after signing. This affected five residents (#2, #7, #10, #17, and #19) of six residents reviewed for arbitration agreements. The facility census was 38. Findings Include:The facility Administrator identified, with a list, that all 38 residents in the facility had signed a binding arbitration agreement. 1. Review of the record for Resident #7 revealed a readmission date of 11/25/25. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure a resident was provided a dignified dining experience. This affected one resident (#6) of five residents observed for dining. The facility census was 38.

Inspectors wroteBased on record review, interviews, policy review, and facility CQI/QA Assessment Tool review, the facility failed to ensure an allegation of neglect/mistreatment was reported to the State Survey Agency as required. This affected one resident (#15) of three residents reviewed for abuse/neglect/mistreatment. The facility census was 38.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded related to dental and vision. This affected two residents (#6 and #38) of 13 residents reviewed for accuracy of assessments.

Inspectors wroteBased on medical record review, interview and policy review the facility failed to ensure care plans were revised to reflect current activities and discharge planning. This affected two (Resident #18 and #22) of 13 records reviewed. The facility census was 38.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a dependent resident was provided adequate and appropriate denture care. This affected one (Resident #6) of five residents reviewed for dental care. The facility census was 38.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to provide a comprehensive, resident centered activity program to meet resident needs. This affected one (Resident #22) of two residents reviewed for activities. The facility census was 38.

Inspectors wroteBased on record review and interview, the facility failed to provide ophthalmology services as ordered and assist the resident with the application of their glasses. This affected one (Resident #38) of four residents reviewed for vision. The facility census was 38.

Inspectors wroteBased on record review, observation, and interview, the facility failed to have pressure relieving devices (Prevalon boots) in place as ordered. This affected one resident (#38) of three residents reviewed for pressure ulcers. Findings Include: Review of Resident #38's record revealed an admission date of 11/15/23 with diagnoses including sensorineural hearing loss bilaterally, visual hallucinations, acute pyelonephritis, abnormalities of gait and mobility, diabetes mellitus, altered mental status, neuromuscular disfunction, need for assistance with personal care, chronic pain, presence of artificial hip joint, osteoarthritis, neuropathy, dementia, mood disturbance, anxiety, hypothyroidism, Alzheimer's disease, cognitive communication deficit and muscle weakness. [...]

Inspectors wroteBased on medical record review, interviews, employee file review, review of a facility investigation report and policy review the facility failed to provide adequate assistance and interventions to prevent injury during a transfer. The facility also failed to ensure fall prevention interventions were in place for a resident at risk for falls. This affected two residents (#15 and #31) of five residents reviewed for accidents. The facility census was 38.

Inspectors wroteBased on medical record review, interview, observation, and policy review, the facility failed to ensure oxygen use was documented and humidification was provided per the resident's plan of care. This affected two (Resident #3 and #37) of two reviewed of respiratory care. Findings Include: 1. Review of Resident #37's medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including abnormal findings of lung fields, nicotine dependence, edema, chronic obstructive pulmonary disease, anxiety, chronic respiratory failure, and palliative care. Review of Resident #37's oxygen plan of care dated 10/15/25 revealed to administer oxygen per order and change humidification and oxygen tubing as indicated. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] reflected oxygen use. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure dialysis residents fluid restrictions were accurate and implemented timely. This affected two (Resident #2 and #11) of two reviewed for dialysis. Findings Include: 1. Medical record review revealed Resident #2 was admitted to the facility 04/28/25 with diagnoses including dependence of renal dialysis, end stage renal disease, and heart disease. Review of Resident #2's nutritional recommendation dated 02/26/26 revealed a 1500 milliliter (ml) fluid restriction with instructions for nursing to administer 780 ml and dietary to administer 720 ml (240 ml with breakfast, lunch, and dinner). [...]

Inspectors wroteBased on medical record review, observation, facility assessment review and interview the facility failed to ensure a comprehensive, trauma-informed approach to care was implemented for a resident with post-traumatic stress disorder (PTSD). This affected one resident (Resident #22) of three residents reviewed for behaviors.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents were reviewed monthly by the pharmacist. This affected three (Resident #2, #3, and #22) of five reviewed for unnecessary medication review.

Inspectors wroteBased on observations, record review, interviews and policy review, the facility failed to ensure residents were provided with dental services to meet their needs. This affected two of five residents reviewed for dental (Residents #2 and #16). The facility census was 38.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were available for inspection. This affected two residents (#4 and #22) of 15 resident records reviewed. The facility census was 38. Findings Include: 1. Review of the record for Resident #4 revealed an admission date of 11/05/25 with diagnoses including malignant neoplasm of the lung, adult failure to thrive, acute kidney failure, and esophageal obstruction. The resident had a physician's order dated 11/10/25 for hospice services with diagnosis of malignant neoplasm of the lung. A notebook containing the hospice plan of care was noted at the nursing station. Review of the notebook indicated the resident would have visits from hospice staff including nurse, chaplain, and nursing assistant. However, there were no visit notes in the notebook since December 2025. [...]

Inspectors wroteBased on closed record review, review of fall investigations, review of Quality Assurance (QA) documentation, Mayo Clinic Diabetic Ketoacidosis information review, review of hospital notes, and interviews, the facility failed to comprehensively assess and timely identify an acute change in Resident #22's condition resulting in hospitalization and failed to ensure effective and necessary care and treatment was provided to manage the resident's diabetes mellitus. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 53. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all residents were provided with a dignified dining experience. This affected one (#50) of five residents reviewed for meals. The facility census was 53.

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to notify the resident and the resident's primary care physician of a medication error. This affected one resident (#50) of three residents reviewed for medication errors. The facility census was 53. Findings Include:Review of the medical record for Resident #50 revealed an initial admission date of 08/27/25 with the diagnoses including but not limited to diabetes mellitus (DM), chronic obstructive pulmonary disease, asthma, hypertension, chronic kidney disease, polyneuropathy, intervertebral disc degeneration, lumbar region, severe morbid obesity, osteoarthritis and obstructive sleep apnea. [...]

Inspectors wroteBased on record review, interview, review of staff schedules, review of the facility assessment, and policy review, the facility failed to maintain safe staffing levels to prevent harm to residents. This affected one (#22) of three residents reviewed and had the potential to affect 19 additional residents residing on the 400 unit. The facility census was 53.

Inspectors wroteBased on medical record review, facility incident report review, interview and facility policy review, the facility failed to ensure residents were free from unnecessary medication. This affected two residents (#54 and #87) of five residents reviewed for medication administration errors. The facility census was 53.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when the facility failed to timely ensure outside facility appointments were maintained. This affected one resident (#3) of 15 residents reviewed. The census was 48.

Inspectors wroteBased on staff schedule review, facility assessment review, resident council meeting minute review, resident interview and staff interview, the facility failed to provide sufficient staffing to meet the needs of residents in a timely manner. This had the potential to affect all 48 residents residing within the facility. The facility census was 48. Findings Include: Review of the Facility assessment dated [DATE] revealed the assessment will inform the facility's staffing decisions to ensure there are a sufficient number of staff with appropriate competencies necessary to care for residents' needs as identified through resident assessments and plans of care. The facility will consider staffing needs for each resident unit in the facility for each shift and adjust a necessary based on resident population. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain the kitchen in a sanitary manner. This affected 47 of 48 residents who receive meals from the kitchen The facility identified one resident who did not receive nutrition from the kitchen. The facility census was 48.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and effective infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed during care, failed to ensure the infection control log was complete and accurate and failed to follow the water management plan for Legionella per facility policy. This affected two (#1 and #3) residents reviewed for wound care, six residents (#19, #17, #4, #11, #21 and #36) reviewed on the facility infection control log and had the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents or representatives were notified of bed hold days remaining and transfer to hospital as well as notification to the ombudsman. Additionally, the facility failed to ensure residents had a completed recapitulation of stay upon discharge. This affected six residents (#2, #3, #4, #19, #29, and #51) of six residents reviewed for transfer and discharge. The facility census was 48.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents received nutritional interventions after weight loss was identified and failed to ensure residents were weighed as ordered. This affected four residents (#2, #6, #9 and #29) of four residents reviewed for nutrition. The census was 48. Findings Include:1. Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including dysphagia (oropharyngeal phase), schizophrenia, diabetes mellitus and bipolar disorder. Review of the Individual Nutrition Recommendations/Response dated 05/15/25 revealed the physician agreed with a dietitian recommendation to add weekly weights for four weeks. Review of the record revealed no evidence weekly weights were obtained as ordered. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents were aware of the risks versus benefits of the use of psychotropic medications. This affected one resident (#2) of five residents reviewed for unnecessary medication. Findings Include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder. Review of a care plan dated 06/26/25 and revised on 05/07/25 revealed Resident #2 required the used of psychotropic medications with potential for adverse reactions related to anxiety. Review of a minimum data set (MDS) dated [DATE] revealed Resident #2 had moderately impaired cognition and no behaviors. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to maintain a safe and comfortable living environment. This affected one resident (#12) of 16 sampled residents. The census was 48.

Inspectors wroteBased on medical record review, preadmission screening and resident review (PASRR) review and interview, the facility failed to ensure PASRR level II screenings were completed as determined by resident needs and determinations by the state level II program were available for review. This affected one resident (#9) reviewed for PASSR. The census was 48. Findings Include:Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia and depression. Review of the significant change in condition PASRR dated 07/28/23 revealed Resident #9 had a decline. Diagnoses included paranoid schizophrenia, bipolar disorder, insomnia and other psychotic disorder. The resident had no functional limitations due to the mental disorder and had not been prescribed psychotropic medications in the previous six months. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive care plans were developed as required. This affected three residents (Residents #2, #4 and #7) of 15 residents reviewed for care plans. The census was 48. Findings Include:1. Medical record review revealed Resident #4 was admitted on [DATE] with diagnoses including metabolic encephalopathy, hypertension, gastroesophageal reflux, benign prostatic hyperplasia, insomnia, osteoarthritis, history of fractures and constipation. Review of the electronic Physician Orders dated August and September 2025 revealed Resident #4 received the following medications: [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident, who was dependent on staff for personal care, was provided the assistance needed to complete bathing activities of her choice when scheduled, and nail care was provided when needed. This affected one (Resident #7) of four residents reviewed for activities of daily living (ADL's). The facility census was 48.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care planned interventions for turning and repositioning were completed to promote timely and adequate healing of a pressure ulcer for Resident #1 and failed to ensure newly identified skin breakdown was timely identified and treated. This affected one resident (#1) of two residents reviewed for wound care. The facility census was 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure smoking aprons were worn during smoking time. This affected one resident (#49) of five residents observed during their smoking time. The census was 48.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure systems were in place to restore normal bladder function for Resident #9 and to prevent additional decline in urinary continence. This affected one resident (#9) of one sampled resident for bladder incontinence. The facility identified 22 residents with bladder incontinence. The census was 48. Findings Include: Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including bipolar disorder, schizophrenia and depression. Review of the quarterly Minimum Data Set 3.0 (MDS) assessments dated 01/04/25 and 04/05/25 revealed Resident #9 was moderately impaired for daily decision-making. The resident was independent in both toileting hygiene and toilet transfers during both assessments and was occasionally incontinent of urine without a retraining/toileting program. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner and contained a rationale for decision. This affected two (#2 and #49) of five residents reviewed for unnecessary medications. The facility census was 48.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to ensure opioid pain medications had adequate monitoring including indications of when to administer. This affected one resident (#4) of five residents reviewed for unnecessary medications. The census was 48. Findings Include: Medical record review revealed Resident #411/14/22 was admitted on [DATE] with diagnoses including metabolic encephalopathy, hypertension, gastroesophageal reflux, benign prostatic hyperplasia, insomnia, osteoarthritis, history of fractures and constipation. The resident was admitted to hospice services on 07/19/25. Review of the care plan: Risk for Pain/Discomfort related to arthritis, depression, hip fracture and neuralgia initiated 04/03/24 and revised on 03/10/25 included the following interventions: administer pain medications as ordered by the physician. [...]

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to prevent a significant medication error involving Resident #4 when the resident was not administered an antibiotic as ordered to treat aspiration pneumonia. This affected one resident (#4) of five residents sampled for unnecessary medications. The census was 48. Findings Include:Medical record review revealed Resident #4 was admitted on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, pharyngeal phase, Barrett's esophagus without dysplasia and diaphragmatic hernia without obstruction or gangrene. Review of the Significant Change in Status assessment/5-day MDS assessment dated [DATE] revealed Resident #4 was severely impaired for daily decision-making and was receiving an antibiotic. [...]

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure medications were stored and labeled properly. This had the potential to affect two residents (#2, #23) of three residents observed for medication pass and four medication carts with one medication room observed for medication storage and labeling.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory tests were obtained as ordered by the physician. This affected one (Resident #29) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, medical record review, dietary card review, policy review and interview, the facility failed to serve food to meet the resident needs. This affected one resident (#9) of four residents sampled for nutrition. The census was 48. Findings Include: Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including dysphagia, oropharyngeal phase. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #9 was moderately impaired for daily decision-making, received a therapeutic and mechanically altered diet, and was edentulous. Review of the care plan: At Potential Risk of Nutritional Decline related to the resident's need for a mechanically altered diet revised 07/17/25 revealed interventions included to provide her diet and supplement per dietitian recommendation and physician order. [...]

Inspectors wroteBased on record review, review of the facility's cycle and special diet menus, observation, and interview, the facility failed to ensure a resident received the appropriate therapeutic diet as ordered by the physician for management of end stage renal disease with dependence on hemodialysis. This affected one (Resident #6) of one resident reviewed for dialysis and nutrition.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's medical record was complete to include completion dates of consents for immunizations. This affected one resident (#3) of five residents reviewed for infection control. The facility census was 48.

Inspectors wroteBased on closed medical record review and interview, the facility failed to complete an accurate comprehensive assessment. This affected one resident (#3) of three residents sampled. The census was 49. Closed medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including Alzheimer's disease, schizoaffective disorder and intermittent explosive disorder. Review of the Physician Progress Note dated 04/15/25 revealed Resident #3 was being evaluated for his dementia. The facility gave the patient and family a 30-day notice that the secured unit was closing. The resident was not suitable for the main floor and was at high-risk for elopement, had a history of aggressive behaviors and agitation. He had a brief time out on the main floor and things did not go well. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Resident #13 was free verbal and emotional abuse. This affected one resident (#13) of one resident reviewed for abuse. The facility census was 51.

Inspectors wroteBased on medical record review, policy review, and interview, and policy the facility failed to ensure an allegation of resident sexual abuse was reported to the state survey agency and the facility administrator within the required timeframes. This affected one resident (#43) of three residents reviewed for abuse.

Inspectors wroteBased on medical record review, interviews, and policy review the facility failed to ensure resident representatives received complete discharge notices timely and failed to notify the state health department of resident discharge. This affected five residents (#58, #59, #60, #61, and #62) of five residents reviewed for discharge from the facility's secured unit.

Inspectors wroteBased on personnel file review, interview and policy review, the facility failed ensure staff hired to work at the facility did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This had the potential to affect all residents. The census was 57.

Inspectors wroteBased on observation, policy review and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 57 residents who were served meals from the kitchen.

Inspectors wroteBased on review of personnel files, interview and policy review, the facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of in-services annually. This had the potential to affect all 57 residents residing in the facility.

Inspectors wrote3. Review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus, unspecified dementia, age related cognitive decline, muscle weakness, and need for assistance with personal care. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. His cognition was severely impaired. He was not known to display any behaviors or reject care during the seven days of the assessment period. He was dependent on staff for bathing/ showers and a substantial/ maximum assist was needed with personal hygiene. Review of Resident #27's active care plans revealed the resident had a care plan in place for an activities of daily living (ADL) performance deficit related to dementia, impaired balance, and the use of psychotropic medications. [...]

Inspectors wroteBased on observation, dietary meal card review, medical record review, policy review and interview, the facility failed to serve double portions when indicated. This affected one resident (#50) who required double portions during observation of trayline. The facility identified two residents that required double portions. The census was 57.

Inspectors wroteBased on observation, diet guide sheet review, medical record review, policy review and interview, the facility failed to ensure pureed food was the correct consistency. This affected two residents (#35 and #45) of six residents receiving pureed diets. The census was 57.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to develop and implement a comprehensive and effective infection control program to decrease the risk of infection. The facility failed to ensure staff applied (donned) appropriate personal protective equipment (PPE) when entering the room of a resident in transmission based precautions (TBP's), failed to ensure staff performed proper hand hygiene during wound care and during meal delivery processes, and failed to ensure nephrostomy bags were maintained off the floor to help prevent infection. [...]

Inspectors wroteBased on medical record review, infection control log review, policy review and interview, the facility failed to monitor the use of antibiotics and ensure infection criteria was met. This affected three residents (#7, #19 and #46) of three residents reviewed for antibiotic use.

Inspectors wroteBased on observations, review of email correspondence between the facility and an outside heating, cooling, plumbing, and refrigeration company, review of resident council meeting minutes, resident interview, and staff staff interview, the facility failed to ensure the building was free of any offensive odors. This had the potential to affect all 19 residents (#1, #5, #9, #11, #12, #13, #14, #17, #19, #21, #23, #27, #28, #34, #35, #38, #51, #206, and #260) that resided on the 400 hall.

Inspectors wroteBased on observation, review of camera footage, medical record review, interview and policy review, the facility failed to ensure residents were treated with respect and dignity. This affected two residents (#18 and #42) of 31 sampled residents. The census was 57.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident's desired code status was consistent between what was identified in the electronic medical record (EMR) and what was identified in the hard chart of the medical record. This affected one (Resident #51) of one residents reviewed for advanced directives.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to maintain resident privacy during the administration of insulin. This affected one resident (#7) of nine residents seated in the dining room during a meal observation. The census was 57.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected two residents (#7 and #16) of 31 residents reviewed. The census was 57.

Inspectors wroteBased on medical record review and interview, the facility failed to complete baseline care plans within 48 hours of admission to the facility. This affected two residents (#16 and #256) of 31 residents reviewed for care plans. The census was 57.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure Residents #42 and #45 and/or their representatives provided input during review and revision of care plans by participating in care conferences. The facility also failed to ensure care plans for Resident #7 were accurate. This affected three residents (#7, #42 and #45) of 31 residents reviewed for care planning. The facility census was 57.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure (non-pressure ulcer related) dressings were changed per physician orders and the bowel protocol was followed. This affected one (#46) of three residents reviewed for bowel and bladder continence and two residents (#7 and #8) of four residents reviewed for general skin conditions. The facility census was 57.

Inspectors wroteBased on medical record review, interview, observation, and policy review the facility failed to ensure a pressure ulcer dressing was in place per physician order. This affected one resident (#22) of three residents reviewed for skin alteration.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure a resident with contractures had orthotics applied daily for contracture management, as per their plan of care. This affected one (Resident #35) of four residents reviewed for limited range of motion (ROM).

Inspectors wroteBased on record review, observation, review of a facility investigation, review of an employee personnel file, staff interview, and policy review, the facility failed to ensure a resident's fall prevention interventions were implemented as per plan of care. They also failed to ensure another resident's medication that was mixed and attempted to be administered in a snack was taken by the resident it was intended for and not left unattended, which resulted in the medication being partially ingested by the resident's visiting family member. This affected two (Resident #23 and #42) of seven residents reviewed for accidents.

Inspectors wroteBased on observation, medical record review, national institute of health review and interview, the facility failed to provide ordered care and services for an indwelling urinary catheter. This affected one resident (#7) of four reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The facility identified seven residents with the use of an urinary catheter. The census was 57.

Inspectors wroteBased on record review, staff interview, observation, and policy review the facility failed to provide care and services to maintain acceptable parameters of nutritional status by monitoring resident meal intakes and failed to ensure residents who experienced weight loss were properly monitored and changes were reported to the physician. This affected two (Resident #45 and Residents #25) of five residents reviewed for nutritional status. The census was 57.

Inspectors wroteBased on interview, observation, policy review, and record review the facility failed to timely identify, treat, monitor, and manage Resident #6 pain, and provide appropriate pain interventions during care to Resident #7. This affected two (Resident #6 and Resident #7) of four residents reviewed for pain management. The census was 57.

Inspectors wroteBased on observation, medical record review, diet guide review, education/in-service review and interview, the facility failed to ensure certified nurse aides (CNAs) had the knowledge to identify mechanically altered food. This affected one resident (#45) of three reviewed for accidents. The census was 57.

Inspectors wroteBased on record review and interview the facility failed ensure assess/monitor Resident #40 for side effects and behaviors to prevent unnecessary use of psychotropic medications. The facility also failed to ensure Resident #48 did not receive psychotropic medications without an appropriate diagnosis and documentation of necessity. This affected two residents (#40 and #48) of six sampled for unnecessary psychotropic medications. The facility census was 57.

Inspectors wroteBased on observation, medical record review, menu review and interview, the facility failed to provide meals that were palatable and attractive. This affected one resident (#7) of three residents reviewed for food. The census was 57.

Inspectors wroteBased on observation, dietary snack summary review, medical record review and interview, the facility failed to ensure residents received evening snacks. This affected two residents (#3 and #28) of 13 residents ordered an evening/bedtime snack from the dietary department. The census was 57.

Inspectors wroteBased on observation, medical record review, meal ticket review and interview, the facility failed to provide assistive eating equipment as needed. This affected one resident (#2) of eight residents who ate meals in the dining room. The census was 57.

Inspectors wroteBased on medical record review and interview, the facility failed to maintain comprehensive and accurate medical record. This affected one resident (#26) of 31 residents sampled. The census was 57.

Inspectors wroteBased on review of facility billing/financial ledger and interviews, the facility administration failed to operate in a manner to ensure bills were being paid in a timely manner to prevent potential interruption in service and failed to ensure adequate transfer of services following a change in ownership to provide continuity of care. This had the potential to affect all 53 residents residing in the building.

Inspectors wroteBased on observation, medical record review, review of a sheriff report, and interview the facility failed to ensure effective measures/interventions were in place to prevent Resident #1 from exiting the facility unsupervised. This affected one (#1) of three residents reviewed for elopement.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain a clean and safe environment for the residents residing in the facility. This affected 25 of 53 residents (#1, #2, #3, #4, #5, #6, #7, #8 #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52 and #53) residing in the facility and two of three shower rooms (100 and 400 hall). The census in the facility was 53.

Inspectors wroteBased on observation, staff interviews and medical record review, the facility failed to implement interventions to prevent falls as per the plan of care. This affected two of three residents (#29 and #35) reviewed for falls. The facility census was 53.

Inspectors wroteBased on review of facility billing/financial information, review of the Facility Assessment, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 61 residents residing in the facility. Findings Include: Although there was no evidence of any current shut-off notices for services at the time of the investigation, the risk for notice or interruption of services was identified. The facility failed to provide evidence of fund availability and systems in place to ensure bills/invoices were paid timely and as due. On 06/05/24 at 3:50 P.M., an interview with the facility Administrator revealed that currently all bills were paid by the accounts payable department at the corporate level. [...]

Inspectors wroteBased on record review, podiatry list review, contract review and interview, the facility failed to provide routine foot/podiatry care to maintain good foot health for residents. This affected two residents (#57 and #101) of 36 residents identified as needing podiatry services and had the potential to affect all 26 residents with diagnosis of diabetes who were at risk for foot complications related to their condition (#9, #11, #19, #21, #24, #25, #27, #31, #33, #35, #39, #41, #43, #49, #69, #73, #77, #85, #87, #97, #101, #111, #113, #115, #117 and #127) residing in the facility. The census was 61.

Inspectors wroteBased on medical record review, resident fund review and interview, the facility failed to provide medically related social services to ensure cognitively impaired residents were assisted in financial matters when needed. This affected one resident (#123) of three sampled residents. The census was 61.

Inspectors wroteBased on nursing staff posting review, employee timecard review and interview, the facility failed to ensure the nursing staff posting was complete and accurate as required. This had the potential to affect all 61 residents.

Inspectors wroteBased on observation, record review, review of facility billing/financial information, review of the facility assessment, review of the Administrator and Director of Nursing Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident resulting in Immediate Jeopardy and actual harm or the potential for serious harm, injury and/or death to all facility residents. The facility administration failed to take appropriate action resulting in substandard quality of care deficiencies identified under Freedom from Abuse, Neglect, and Exploitation and Quality of Care. [...]

Inspectors wroteBased on medical record review, staff, certified nurse practitioner and physician interviews, hospital record review, review of literature from Centers for Disease Control (CDC), National Health Institute, and American Heart Association, and facility policy review, the facility failed to ensure Resident #80's blood pressure was adequately monitored to prevent incidents of hypotension (low blood pressure) and failed to notify the physician of the resident's hypotension resulting in a delay in care and treatment. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide Resident #67 a safe discharge and failed to provide the resident or resident representative with required documentation upon discharge. This affected one resident (#67) of one resident reviewed for discharge. The facility census was 65 residents. Actual Harm occurred on 03/16/24 (four days after admission), when Resident #67, who was admitted with primary diagnosis of post-surgical hip repair, was immediately discharged without a safe place to be discharged to, after being observed in the facility parking lot on one occasion smoking and taking sips of alcohol. [...]

Inspectors wroteBased on observations, record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure timely, accurate and thorough pressure ulcer assessments were completed and to ensure adequate interventions and treatment was in place to promote healing and prevent new ulcers from developing. This affected three residents (#29, #30, and #41) of three residents reviewed for pressure ulcers. The facility census was 65. Actual Harm occurred on 04/03/24 when Resident #29, who exhibited severe cognitive impairment, had current pressure ulcers present and required substantial/maximal assistance for bed mobility and total dependence for toileting was assessed to have new in-house developed pressure ulcers. [...]

Inspectors wroteBased on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure a resident received services and assistance to maintain bladder continence and failed to ensure a resident received appropriate treatment and services to treat urinary tract infections. This affected two of 36 residents reviewed for quality of care (#25 and #29). The facility census was 66. Actual Harm occurred on 05/03/23 when Resident #25, who had been always continent of bladder as assessed to be frequently incontinent of bladder. The resident reported the increased incontinence was a result of having to wait on staff to assist him to use the urinal resulting in accidents/incidents of urinary incontinence. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to implement an effective and timely pain management program. This affected two residents (#44 and #67) of four reviewed for pain. Actual Harm occurred on 03/12/24 at 2:30 P.M. when Resident #67, who was admitted for orthopedic aftercare, experienced pain rated a 10 out of 10 (on a 1-10 pain scale with 10 being the most severe) to the right hip. Staff failed to notify the provider the ordered narcotic analgesic pain medication, Oxycodone was not available, resulting in the resident continuing to experience pain as evidenced by the resident's crying and moaning in pain requiring the resident being transferred to the emergency room for uncontrolled pain where the resident was treated with intravenous administration of narcotic pain medication. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's drug regimen was free from unnecessary medication when the facility failed to receive ordered clarification of anticoagulation medication therapy resulting in a resident receiving an unnecessary anticoagulation medication for ten days, and failed to complete adequate blood sugar monitoring to ensure the correct amount of insulin was administered for a resident. This affected two residents (#16, #44) of 36 residents reviewed for quality of care. Actual Harm occurred on 03/21/24 to Resident #16 when Certified Nurse Practitioner (CNP) #104 and Medical Director/Physician #105 wrote the first order to call Resident #16's cardiologist to clarify the Heparin (anticoagulant medication) order. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to develop policies and procedures regarding advance directives and failed to ensure a procedure was in place to effectively implement a resident's advance directives. This affected one (Resident #80) of 50 residents records reviewed but had the potential to affect all 65 residents.

Inspectors wroteBased on observation, review of facility billing/financial information, review of the Facility Assessment, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 65 residents residing in the facility. Findings Include: On 03/27/24 at 1:57 PM an interview with Medical Records #157 revealed she was also responsible for paying vendors. During the interview, Medical Records #157 revealed the facility was behind on bills, however historically when they would receive a shut off notice the company would pay the bill to avoid disruption of services. No bills were paid in January 2024 due to two upper management staff having quit leaving no one to approve the bills. [...]

Inspectors wroteBased on observations, medical record review, staff interview, resident interview, review of the facility assessment, and review of resident council meeting minutes, the facility failed to have sufficient nursing staff to meet the needs of residents in areas including bathing, incontinence care, toileting, interventions to prevent pressure ulcers such as turning/repositioning, answering call lights, dining service, and medication administration. This had the potential to affect all 65 residents in the facility.

Inspectors wroteBased on review of quality assurance/performance improvement (QAPI) minutes, review of the facility governing body information, review of list of previous and current Administrators and Director of Nursing, interviews, and policy review the facility failed to have an effective governing body to oversee the functions of the facility. This had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on review of the facility record of Administrators and Directors of Nursing (DON) and interview the facility failed to notify the state agency of changes in administration. This had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on review of quality assurance/performance improvement (QAPI) minutes, interviews, and policy review the facility failed to have an effective QAPI program. This had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on record review, review of infection control log, interview, and policy review the facility failed to ensure the infection control log was comprehensive. This affected one resident (#34) of 36 reviewed for quality of control, with the potential to affect all 65 residents residing in the building.

Inspectors wroteBased on review the facility's timeline for who was the infection preventionist (IP), interview, and policy review the facility failed to ensure the IP was qualified. This had the potential to affect all 65 residents residing in the building.

Inspectors wroteBased on staff interview and policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This affected 65 of 65 residents in the facility.

Inspectors wroteBased on resident interview, staff interview, and policy review, the facility failed to ensure residents were treated with respect and dignity. This affected four of 50 records reviewed (Residents #13, #25, #37, and #54). The facility census was 65.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure resident/responsibility parties were notified timely of changes in resident treatment and changes in condition. This affected four residents (Resident #4, #24, #31, and #44) of 36 records reviewed for quality of care.

Inspectors wroteBased on observations, record review, resident interview, staff interview, and review of resident council meeting minutes, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene in the areas of bathing and incontinence care. This affected five residents (#13, #41, #50, #54, and #79) of 36 residents reviewed for quality of care . The facility census was 65.

Inspectors wroteBased on observations, medical record review, staff interview, policy review, and resident interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected 11 residents (#4, #9, #15, #16, #24, #25, #26 #35, #41, #44, and #60) of 50 residents reviewed. The facility census was 65.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents were free of significant medication errors. This affected five residents (#16, #34, #60, #66 and #73) of 36 residents reviewed for quality of care.

Inspectors wroteBased on medical record reviews, interviews, and policy review the facility failed to ensure admission assessment were completed timely, skilled charting was documented daily, and appointments, wounds, and adverse reactions were documented accurately. This affected ten residents (#1, #18, #35, #41, #44, #66, #72, #77, #78, and #81) of 50 residents records reviewed.

Inspectors wroteBased on observation, resident interview, staff interview, policy review, and record review, the facility failed to ensure residents had the right to choose bathing schedules consistent with their interests. This affected two of 50 records reviewed (Residents #1 and #41). The facility census was 65.

Inspectors wroteBased on observations, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided with personal privacy. This affected one resident (#13) of 65 residents in the facility.

Inspectors wroteBased on family interview, staff interview, review of grievance forms, record review, and policy review, the facility failed to make prompt efforts to resolve resident grievances. This affected two residents (Residents #44 and #50) of 50 records reviewed. The facility census was 65.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure resident medications were not misappropriated. This affected two residents (#42, #44) of four reviewed for pain management.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure the resident received a copy of the baseline care plan. This affected one resident (#44) of 50 records reviewed.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to develop comprehensive care plans related to the prevention of and care for pressure ulcers. This affected three residents (#29, #30, and #41) of three residents reviewed for pressure ulcers. The facility census was 65.

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of the resident to effectively transition the resident to post-discharge care, and the reduction of factors leading to preventable readmissions. This affected one resident (#54) of 50 resident records reviewed. The facility census was 65.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure intravenous (IV) fluids were administered per orders. This affected one resident (#34) of 36 reviewed for quality of care.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure aerosol treatments and antibiotics were started timely for resident with a diagnosed respiratory infection. This affected one resident (#32) of 36 residents reviewed for quality of care.

Inspectors wroteBased on medical record review, review of grievance log, interview, and policy review the facility failed to provide medically related social services to ensure social services ensured a safe discharge and grievances/concerns were followed up with timely. This affected three residents (#50, #54, and #67) of 50 sampled residents. The facility census was 65.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure laboratory results were obtained per orders. This affected two residents (#32 and #73) of 50 records reviewed.

Inspectors wroteBased on record review, review of infection control log, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected one resident (#34) of 36 residents reviewed for quality of care.