Medical Suites at Oak Creek (the)

Inspectors wroteBased on interview and record review, the facility did not develop an Activities of Daily Living (ADL) comprehensive plan of care for 1 (R1) of 3 residents reviewed for plans of care.

Inspectors wroteBased on interview and record review the facility did not provide the necessary Activities of Daily Living (ADL) services for 1 (R1) of 2 residents who were dependent on staff to provide ADL care. R1 is dependent on staff for showering and was admitted to the facility on [DATE]. On 5/18/26, R1 informed Surveyor that R1 has not received a shower since admission. Facility staff have not documented that R1 has received a shower since admission. R1 has not been bathed weekly according to the facility policy.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R1) of 3 residents received the necessary services for acceptable nutrition.*R1 did not have a comprehensive nutritional assessment on admission that included how R1 chews food. Facility staff did not identify that R1 is missing all R1's upper teeth and multiple lower teeth. R1's nutrition care plan did not document interventions related to R1's difficulty in chewing certain foods. R1 had an MD order for weekly weights. Facility staff did not weigh R1 weekly as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 (R14, R5, R31, R12, and R8) of 5 sampled residents received care and treatment in accordance with assessments and professional standards of practice (including N6, Nurse Practice Act) to ensure their highest practicable physical, mental, and psychosocial well-being. Facility staff did not assess changes in condition, did not ensure orders for labs and treatments were promptly implemented, and did not communicate condition changes to appropriate personnel as necessary to ensure consistency and continuity of care across all disciplines. * R14's Annual Minimum Data Set, dated [DATE] assessed R14 as having declines in her incontinence and mobility during the look back time frame. These declines were not further assessed or addressed in R14's plan of care. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 3 (R14, R15 and R32) of 3 sampled residents with pressure injuries received care and treatment based upon standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. * R14 was assessed to be at risk for pressure injuries and was noted to have a pressure injury that was healed on 12/1/25. 12/3/25 was the assessment reference date for R14's annual minimum data set (MDS). This MDS assessed R14 as requiring greater assistance for turning and repositioning and decline in incontinence of bladder for R14. This MDS also identified R14 to be at risk for pressure injuries but did not assess additional interventions such as pressure relieving devices for R14's wheelchair and bed and a repositioning program for R14 as her mobility had declined. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 residents (R) of 4 residents reviewed were provided with adequate supervision and assistance to prevent accidents (R11, R5, and R13.) *R11 had an unwitnessed fall, without injury, on 2/13/2026. The facility did not implement immediate fall interventions, complete a fall investigation, determine a root cause, or review/revise the fall care plan to prevent further falls. R11 experienced another fall on 2/14/2026, which resulted in a laceration to R11's right eye and a Traumatic Brain Injury (TBI) requiring admission to a Neurology Intensive Care Unit. *R5 is documented as being dependent on staff for all cares. On 4/5/26, Certified Nursing Assistant (CNA)-X was performing cares alone with R5 in bed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.*The facility did not ensure sufficient Certified Nursing Assistant (CNA) and nurse staffing was provided based on the facility's staffing plan and staffing patterns. This deficient practice has the potential to affect 98 of 98 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not implement an effective infection control program, including surveillance of infections in the facility, and sanitizing equipment. This had the potential to affect all 105 residents in the facility. The facility did not have documentation of facility infection surveillance for January, February and March of 2026. * R20 received blood glucose sampling through an un-sanitized glucometer machine.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed received the required communication training. CNA (Certified Nursing Assistant) TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed, received the required resident rights training. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed, received the required training regarding abuse, neglect and exploitation. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review the facility did not ensure that 5 out of 5 direct care staff reviewed received the required QAPI (Quality Assurance and Performance Improvement) training. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review the facility did not ensure that 5 out of 5 direct care staff reviewed received the required training regarding infection control practices. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review the facility did not ensure that 5 of 5 direct care staff reviewed received the required training regarding compliance and ethics. CNA (Certified Nursing Assistant) TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review the facility did not ensure that 5 out of 5 Certified Nursing Assistants completed 12 hours of required training annually. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than one year and have not completed the required annual 12 hours of training. This has the potential to affect all 112 residents as the 5 staff members work on various units throughout the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed received the required behavioral health training.*CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required behavioral training. This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 1 (R5) of 3 residents reviewed for allegations of abuse. On 4/5/26, Certified Nursing Assistant (CNA)-X performed cares independently with R5, and R5 rolled out of bed. R5 was evaluated in the emergency room (ER) on 4/9/26 with findings that did not correlate to the fall on 4/5/26 and with the bruising identified as potential abuse in the ER.

Inspectors wroteBased on interview and record review, the facility did not ensure 13 (R13, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, & R27) of 13 sampled residents with scheduled medication administrations on 3/6/2026 from 7:00pm to 7:00am were free from significant medication errors.

Inspectors wroteBased on interview and record review, the facility did not ensure residents' physician and/or residents' representative were notified of changes including accidents resulting in injury, need to alter treatment for 3 (R1, R5, and R14) of 30 residents reviewed. R1's physician was not made aware of/ consulted with regarding a 20 lb. weight loss between 3/25/2026 - 4/8/2026. R5's case manager was not notified of a fall with injury that occurred on 4/5/2026. R14's power of attorney (POAHC) was not notified on abnormal lab results or changes to R14's wounds.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident's grievance was thoroughly investigated, pertinent findings or conclusions were documented and communicated to the resident. This was observed with 1 (R12) of 16 record reviews.* R12 voiced a grievance to the facility on 1/7/2026 related to R12 requesting referrals to 2 other Skilled Nursing Facility (SNF). There is no documentation the referrals were completed, or that the grievance findings or conclusion was communicated to R12.

Inspectors wroteBased upon interview and record review, the facility did not ensure a comprehensive assessment, including an analysis of findings to develop a plan care, was completed for 1 (R14) of 30 sampled residents. R14 had an Annual (comprehensive) Minimum Data Set (MDS) completed with an assessment reference date of 12/3/25. The MDS indicated R14 had changes in bladder continence and mobility. The MDS Care Area Assessments (CAAs) had areas that were not comprehensively reviewed to include a rationale of the R14's individual needs and summary analysis to develop a comprehensive plan of care for R14.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R11 and R14) of 16 sampled residents had their care plan reviewed and revised by the interdisciplinary team. *R11 experienced falls on 2/13/2026 and 2/14/2026. The facility did not review, revise or update R11's care plan with person centered interventions to prevent additional falls. *R14's Annual Minimum Data Set, dated [DATE] assessed R14 as having a decline in mobility and bladder incontinence. R14's plan of care was not updated to address the change in assistance needed by R14. Additionally, R14's care plan for skin integrity and Activities of daily living were not updated to reflect an individualized plan to reposition R14 despite nursing notes referencing repositioning R14 every 2 hours per protocol. R14 had an unstageable pressure injury with osteomyelitis.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 1 (R32) of 4 sampled residents reviewed for ADL ( activities of daily living) dependent care received the necessary services to maintain good hand hygiene. R32 is dependent on staff for all activities of daily living. R32 also has significant hand contractures to both the right and left hand. The facility did not ensure that R32 was receiving proper hand hygiene by making sure the length of R32's fingernails would not compromise the skin integrity of the palm of her hand. R32 developed a Stage 3 pressure injury to R32's palm due to her finger nail becoming imbedded into the palm of her left hand.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1(R12) of 2 sample residents with a foley catheter had indications for use, along with care and services.*R12 was observed with a foley catheter and did not have a physician order to indicate use, along with care and services.

Inspectors wroteBased on interview and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R1) of 1 residents reviewed for weight loss.* R1 was admitted to the facility on [DATE] and the facility did not obtain an admission weight. On 4/8/2026, the facility weighed R1 and documented a weight loss of 19.9 pounds (lbs.) from R1's hospital discharge weight. R1's weight loss was not prescribed, no new interventions were implemented to prevent further weight loss, and facility did not obtain an additional weight for R1, per Registered Dietician (RD)-G's recommendation.

Inspectors wroteBased on record review and interview, the facility did not provide medically related social services to a resident to maintain their highest physical, mental, and psychosocial well-being. This was observed with 1 (R14) of 16 residents reviewed for social services.*R14 had an activated Power of Attorney for Healthcare (POAHC) (CCC). In December 2025, R14 developed pressure injuries, a wound infection, a change in nutritional needs, and an order for Hospice services. There is no documentation of Social Service involvement with R14's clinical changes leading to suggestion of hospice services and coordination of the referral to hospice.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R28) of 3 reviewed. R28's Amlodipine Besylate 5mg (milligrams) medication for hypertension was unavailable and facility staff did not check contingency for the medication or notify R28's physician.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 2 (R24 and R29 ) of 6 residents observed receiving medications. The facility medication error rate was 12%. *R29 received one 81mg enteric coated Aspirin. R29's physician order documents Aspirin 81 oral tablet chewable (aspirin). Give 81mg by mouth in the morning for NSTEMI.*R24 received one 81mg chewable Aspirin. R24's physician order documents Aspirin EC (enteric coated) tablet delayed release 81MG (aspirin). Give 1 tablet by mouth in the morning for heart disease. *R24 received Senna 8.6mg. R24's physician order documents Senna-Docusate Sodium oral tablet 8.6-50 mg (sennosides-docusate sodium). Give 1 tablet by mouth two times a day for constipation.

Inspectors wroteBased on observation, interview, and record review, drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles, and include the resident name, opened on or expiration date when applicable for 1 of 1 medication carts reviewed. The medication cart on front Sparkle unit contained insulin pens that were not labeled with a resident name or dated of when the pens were opened.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident's change in diet consistency was comprehensively assessed, including obtaining supporting physician or Registered Dietician documentation, after a change in condition for 1 (R14) of 6 residents reviewed for nutrition.*R14's diet was downgraded from a mechanical soft ground diet with thin liquids to a pureed diet with nectar thick liquids without evidence of a comprehensive assessment related to the change in condition. There was no physician order or Registered Dietitian order regarding the diet downgrade.

Inspectors wroteBased on record review and interview, the facility did not offer the influenza immunization to 1 (R4) of 1 residents reviewed for immunizations.*R4 requested the influenza vaccine in [DATE], and has not received a influenza vaccine as of April of 2026. Findings Include:The facility's policy titled, Influenza Vaccination dated as last revised on [DATE] documents: Influenza vaccinations will be routinely offered annually from [DATE]st to [DATE]st unless such immunizations is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 3 (R159, R2, R170) of 14 residents reviewed received necessary care and treatment. * R159 did not have weekly skin assessments completed for three weeks, there was not a comprehensive assessment completed, treatment initiated, or care plan revision when R159 developed a gluteal fissure on 12/8/2025. * R2 did not have consistent monitoring of daily weights or fluid intakes to monitor for fluid overload. * R170's urinalysis was not processed for one week and required antibiotics for a urinary tract infection.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident's skin was comprehensively assessed, to identify, and prevent, pressure injuries from developing. This was observed with 1 (R169) of 3 residents reviewed with pressure injuries. * R169 had a current pressure injury (PI) and experienced a decline in their health status. Their skin was not comprehensively assessed with the onset of additional risk factors. R169 was admitted to the hospital on [DATE] with 4 pressure injuries. The facility's policy and procedures titled Pressure Injury Prevention and Management dated 4/17/2025, documents, The Guideline: [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility did not ensure medication administration was timely for 1 of 1 resident (Resident (R)) 2, reviewed for late medications out of 14 sampled residents. This failure had the potential to interfere with the medication effectiveness.*R2 did not receive 9 doses of an ordered medication due to the medication being unavailable.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure two of seven residents (Residents (R) 48 and R158) out of a total sample of 30 received prescribed medications to manage pain. This failure resulted in harm for both residents.

Inspectors wroteBased on observations, document review, interviews, and facility policy review, the facility failed to ensure milk gallons were held at the proper temperature in the 300-hall dining room; failed to ensure the pantry refrigerator and the entire main kitchen were clean for one of two observed pantries and one of one kitchen; failed to ensure food was labeled, dated, and disposed of after expiration for one of two observed pantries; and failed to ensure holding temperatures for the tray line were monitored for proper temperatures for one of one kitchen. The failures had the potential to affect potential food borne illnesses and the potential of contamination for 115 of 116 census residents that take food by their mouth.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the exterior trash area was free from debris and the doors were closed on two of two trash bins with the ability to affect all 116 census residents. This failure had the potential to contribute to pest infestation.

Inspectors wroteBase on QAPI record reviews, interviews, and facility policy review, the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) process to address identified deficient practices resulting in continued noncompliance. Lack of developing and implementing improvement plans for identified problems through the QAPI process could lead to prolonged periods of non-compliance affecting residents, staff, and families accordingly thus affecting all 116 residents.

Inspectors wroteBased on record review, observations, interview, and review of call light data, the facility failed to ensure that five out of 46 residents (Resident (R) 156, R162, R65, R7, R109) call lights were answered timely. This failure increased the risk of residents not having their needs met.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure food was palatable and served at a safe and appetizing temperature for five of 30 sampled residents (Resident (R) 7, R22, R48, R90, and R124) reviewed for palatability. This failure had the potential to lead to decreased oral intake and weight loss.

Inspectors wroteBased on observation, record review, interview, and document review, the facility failed to determine one of 30 sampled residents (Resident (R) 132) was safe in the self-administration of physician ordered medications. This failure had the potential for R132 to not take her medication and experience adverse effects of not taking the physician ordered medications.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure code status was accurately reflected in the electronic medical record (EMR) for one of 30 residents (Resident (R) 83) reviewed in the Initial Pool out of a census of 116. This failure had the potential for R83 to receive cardiopulmonary resuscitation (CPR) when the wishes of the resident were to die a natural death, which could contribute to physical injury or emotional anguish.

Inspectors wroteBased on record review, interview, and document review, the facility failed to notify the ombudsman of discharges and failed to provide a transfer notice and bed hold policy to the resident and/or Resident Representative (RP) for one of three residents (Resident (R)12) reviewed for discharges out of a total of 30 sampled residents. This failure had the potential for the residents and RP to be misinformed of the transfer out of the facility.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the Care Plan for one of two residents reviewed for behaviors (Resident (R) 2) out of a total sample of 30 reflected their behavioral health needs. This failure created potential for lack of behavioral intervention for R2.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure baths or showers were provided according to the schedule for three of three residents (Resident (R) 109, R7, and R48) reviewed for bathing out of 30 sample residents. This failure had the potential to result in the residents not maintaining adequate hygiene to prevent odor and skin infections.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to address a significant weight loss of 19% in one month for one of five residents reviewed for nutrition (Resident (R) 3) out of a total sample of 30 residents. This failure had the potential to contribute to further weight loss, malnutrition, muscle wasting, weakness, and death.

Inspectors wroteBased on observation, record review, interview, and review of policy and procedures, the facility failed to follow infection control guidelines for the storage of a nebulizer mask for one (Resident (R)132) of three residents reviewed for respiratory care out of 30 sampled residents. This failure had the potential to increase infections in vulnerable residents receiving respiratory care in the nursing facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments were completed to ensure communication with the dialysis facility for one (Resident (R) 111) of one resident reviewed for dialysis out of a total sample of 30 residents. This failure had the potential to lead to uncommunicated and unassessed changes or complications for R111 and other residents receiving dialysis.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure medication administration was timely for one of one resident (Resident (R) 109) reviewed for late medications out of 30 sampled residents. This failure had the potential to interfere with the medication effectiveness.

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician order prior to obtaining laboratory tests for one of one resident (Resident (R)98) out of a total sample of 30 residents. This failure had the potential of obtaining unnecessary laboratory testing from residents.

Inspectors wroteBased on interview and record review, the facility failed to collaborate care with the hospice agency for one of one resident (Resident (R)127) reviewed for hospice services out of a total sample of 30 residents. This failure had the potential to increase the risk of resident needs not being addressed.

Inspectors wroteBased on observation, record review, interview, and review of policies and procedures , the facility failed to wear Personal Protective Equipment (PPE) when entering into a contact isolation room for one of two residents (Resident (R)56) and failed to follow infection control guidelines when administering medications to one of three residents (Resident (R)132) observed during the Medication Administration Observation out one of 30 total sampled residents. The facility also failed to review and/or revise the infection control policies in the facility annually. These failures had the potential for residents to be exposed to infections unnecessarily.

Inspectors wroteBased on record review, interview, document review, policy review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for three of three residents (Resident (R)5, R62, and R96) reviewed for antibiotic stewardship out of total sample of 30 residents. This failure had the potential for residents to be prescribed unnecessary antibiotics.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents who were self-administering medications had a self-administration of medications assessment, a physician's order, and a care plan completed for two (Resident (R) 1 and R2) of two residents reviewed for self-administration of medication.

Inspectors wroteBased on interviews and record review, the facility did not complete neurological checks in accordance with policy and procedure for 2 (R3 and R4) of 2 residents reviewed for unwitnessed falls. *R3 sustained an unwitnessed fall on 6/27/25. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure. *R4 sustained an unwitnessed fall on 6/9/25 and 6/23/25. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R4) of 2 residents reviewed for falls. On 6/9/25, R4 was found by facility staff on the floor between R4's bed and wall. The facility did not thoroughly investigate the fall.

Inspectors wroteBased on interviews, clinical record review, and policy review, it was determined the facility failed to ensure one of three residents (Resident(R)1) reviewed for abuse, neglect, and misappropriation was free from physical abuse. This does not ensure the protection of additional residents from abuse.

Inspectors wroteBased on interviews and facility document review, it was determined that the facility failed to report the allegation of neglect for one of three residents (Resident(R)3) sampled for abuse, neglect, and misappropriation. This failure places all residents in danger of abuse, neglect, and misappropriation.

Inspectors wroteBased on observation, interview, medication audit review, and policy review, the facility failed to ensure a medication administration error rate was less than 5 percent (%). There were eight errors out of 28 opportunities observed resulting in a medication error rate of 28.57% for two residents (Residents (R) 30 and R31) of three residents observed out of a total sample of 31. This had the potential for the residents to have unmet health needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure trash was contained in the dumpsters and the yard was maintained in a sanitary condition with views from resident windows. This failure created a potential sanitation issue for residents, staff, and visitors that may go outside the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents and or their representatives (Resident (R) 1, R7, and R17) reviewed for facility initiated emergent hospital transfer out of a total sample of 31 were provided with a written transfer notice that contained all required information; or notify the Ombudsman's office of resident transfers. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure three of three residents (Resident (R) 1, R7, and R17) reviewed for hospitalization, from a sample of 31 residents, received a written bed hold policy upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on record review, interview, and review of the Infection Prevention and Control Program (IPCP), review of the McGreer's Infection Symptom Tracking criteria, and facility policy review, the facility failed to ensure one of two residents (Resident (R)8) reviewed for antibiotic use out of a sample of 31 residents received an antibiotic with justification for its use. This had the potential for the resident to receive an antibiotic unnecessarily and could potentially contribute to the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered laboratory testing for one of two residents (Resident (R) 8) reviewed for antibiotic use from a sample of 31. This failure had the potential to affect the appropriate diagnosis and treatment of residents by practitioners.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide three of three residents (Resident (R) 5, R15, and R17) written notification of room change as indicated in their facility policy of 17 sample residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a physician order for one of one resident (Resident (R) 1) of 17 sample residents, to be Nothing by Mouth (NPO) prior to a scheduled surgery. Specifically, R1 consumed his breakfast meal prior to being transferred to the hospital, which caused the surgery to be canceled. This deficient practice caused the resident to experience emotional stress and delay in having hip surgery.

Inspectors wroteBased on interview and record review, the facility did not develop, implement, and maintain an effective training program for contracted staff, consistent with contracted staff's expected roles and types of training necessary for 6 of 6 agency staff interviewed. This deficient practice has the potential to affect all 112 residents residing in the facility. * The facility does not have an effective training program consistent with expected roles and did not determine the amount or types of training necessary for agency staff.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R402 and R404) of 4 residents reviewed for showers and who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene. * R402 and R404 did not receive showers according to their shower schedule.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary care and services to prevent and/or promote healing of pressure injuries for 1 (R405) of 5 residents reviewed for pressure injury prevention and treatment. *R405 did not have off-loading boots in place per R405's care plan.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R35) of 23 residents experiencing a change of condition received treatment and care in accordance with professional standards of practice. *R35 went to the emergency room on 9/12/2023. R35 was prescribed Prednisone for neck inflammation with no end date. R35 received a high dose of Prednisone from 9/12/23 through 9/29/2023 when the Provider ordered a Prednisone taper. R35 was hospitalized on [DATE]. Hospital documentation indicated R35 might have an element of adrenal insufficiency considering [R35] was on high dose of Prednisone for 2 to 3 weeks. R35 had a history of recurrent Urinary Tract Infections (UTI) and sepsis. On 10/1/2023 and 10/2/2023, R35 experienced low blood pressure readings. No provider was notified of R35's low blood pressures. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that 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 3 (R11) of 8 residents reviewed for pressure injuries. * R11 developed a stage 4 pressure injury to the sacrum and a stage 3 to the left buttock. The left buttock was deemed heeled [DATE]. The Facility knew the risk for pressure ulcers was present due to R11 having a femur fracture and other related comorbidities. The Facility failed to take immediate action by creating a plan of care to include comprehensive interventions for prevention of pressure ulcers. The resident did not receive an air mattress until 12 days after admission and 7 days after development of pressure ulcer. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 5 (R167, R83, R35, R11, and R99) of 5 residents reviewed were provided adequate supervision and interventions to prevent accidents. R167 was admitted to the facility on [DATE] and discharged from the facility on [DATE] after an unwitnessed fall occurred on [DATE], at 10:50 PM. R167 had a Fall Risk Assessment completed on [DATE], which put R167 at high risk for falls. There were no further fall risk assessments completed after [DATE]. Despite being at high risk for falls and despite staff indicating R167 would scoot at times to the edge of the bed, there were no individualized care plan interventions addressing the high risk for falling (e.g., bed in lowest position, floor mat next to bed). On [DATE], at 10:50 PM, R167 had an unwitnessed fall from bed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of neglect and verbal abuse for 1 (R83) of 1 residents reviewed, included steps that were taken by the facility to ensure safety of the facility residents. * R83 was transferred without a mechanical lift and fell, fracturing her right ankle. The Certified Nursing Assistants (CNAs) knew they should use a mechanical lift and decided to transfer R83 with an assist of 2 and a gait belt. When R83 fell during the transfer, the CNAs got her off the floor and into her wheelchair. The fall was not reported to the nurse on duty until several hours later. During the transfer, the CNA was heard telling R83, I'm not your bitch, causing R83 to experience anxiety. Neither CNA-JJ nor CNA-KK were suspended pending an investigation and both were allowed to finish their shifts on 6/9/24, the day of R83's fall. [...]

Inspectors wroteBased on observations and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 115 residents residing at the facility during the onsite visit.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 115 residents residing in the facility. * DON (Director of Nursing)-B not complete specialized training for infection prevention and control.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 (CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG) of 5 sampled CNAs (Certified Nursing Assistant), who had been employed at the facility for over a year, had documented performance reviews. This deficient practice has the potential to affect all 115 residents residing in the facility whom can receive care from the 5 CNAs. Findings Include: The facility's policy titled Annual Employee Evaluations and dated 5/2/23 was reviewed and documented: To comply with federal regulations, all employees will receive an annual evaluation of their work performance. On 7/15/24, CNA-CC, CNA-DD, CNA-EE CNA-FF, and CNA-GG's annual performance evaluations were requested from the facility. On 7/15/24, the list of CNAs that had worked for the facility for longer than a year was reviewed. The employment list documented: [...]

Inspectors wrote3.) R31 admitted to the facility on [DATE] and has diagnoses that include Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Diseases, End Stage Renal Disease, Malignant Neoplasm of Colon, Major Depressive Disorder, Dementia, Anxiety, Colostomy status, Obstructive and Reflux Uropathy, Nephrostomy Catheter, Peripheral Vascular Disease, Hypertension, Acute Pyelonephritis and Sepsis. R31's E-interact dated 3/16/24 documented: Situation: The Change In Condition/s (CIC) reported on this CIC Evaluation are/were: Bleeding (other than GI) Tired, Weak, Confused, or Drowsy. Nursing observations, evaluation, and recommendations are: resident c/o (complained of) increased lethargic, weakness and poor appetite. C/O abdominal pain. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: [...]

Inspectors wroteBased on record review and interview, at the time of transfer of a resident for hospitalization or therapeutic leave, the facility did not provide to the resident or the resident representative written notice which specifies the duration of the bed-hold policy for 4 of 7 (R31, R40, R35 and R59) reviewed for bed hold.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were labeled and stored in accordance with facility policy and procedures for 2 of 4 medication carts reviewed for medication storage. * Observations of medications stored in medication carts with no dates listed as to when medication had been opened, including ophthalmic and liquid medications. Four ophthalmic medications and one liquid medication were noted by Surveyor with no names or open dates on the first floor medication cart. One expired stock medication was noted on the first floor medication cart. Two ophthalmic medications were noted by Surveyor with no names or open dates on the second floor medication cart. Two expired stock medications were noted on the second floor medication cart. Six expired medications were found in the first floor medication room.

Inspectors wroteBased on observations, interviews and record review, the facility did not 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 of 2 residents (R8 and R229) observed for infections and for 2 of 2 units observed in the facility. * R229 was positive for Covid (Coronavirus disease 2019). Staff did not utilize appropriate PPE (personal protective equipment) while in R229's room and staff was observed not wearing masks on the unit. * R8 was suspected for Clostridium Difficile and contact precautions were not implemented. * Uncovered linen was observed on the 300 unit.

Inspectors wroteBased on interview and record review the facility did not ensure residents the right to voice grievances to the facility. The facility did not make prompt efforts to resolve grievances that were voiced for 1 of 23 (R217) resident reviewed for grievances. * R217 informed the APNP (Advanced Practice Nurse Practitioner) of a concern and requested to file a grievance. The APNP did not follow up on R217's request to file a grievance.

Inspectors wroteBased on interview and record review, the facility did not protect 1 (R83) of 3 residents reviewed for abuse/neglect from being verbally abused and neglected. R83 was transferred without a mechanical lift and fractured her right ankle. The Certified Nursing Assistants (CNAs) were aware that they should use a mechanical lift and decided to transfer R83 with an assist of 2 and a gait belt. When R83 fell during the transfer, the CNAs got her off the floor and into her wheelchair. These events were not reported to the nurse on duty until several hours later. During the transfer, a CNA was heard telling R83 I'm not your bitch causing R83 to experience anxiety and resulting in actual harm to R84.

Inspectors wroteBased on record review and interview, the facility did not ensure that 2 (R83 & R23) of 2 reviewed allegations of abuse were immediately reported to the Administrator and that the completed investigation was sent to the state agency within 5 business days. * R83 was transferred without a mechanical lift and fractured her right ankle. During the transfer the Certified Nursing Assistant (CNA) was heard to say to R83 I'm not your bitch causing anxiety to R83. This was not immediately reported to the NHA (Nursing Home Administrator) or the LPN (Licensed Practical Nurse) on duty at the time. * R34's results of an abuse investigation were not reported to the State Survey Agency within 5 working days.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 23 (R15, R64 and R229) residents reviewed for Activity of Daily Living (ADL's). * R229 was not set up for meals and was not toileted, checked or changed for a period of 4 hours. * R15 did not receive scheduled showers. * R64 was observed to have long nails during survey.

Inspectors wroteBased on interview and record review, the facility did not provide an ongoing, individualized, and meaningful activities program designed to meet the residents interest and support their physical, mental and psychosocial well-being for 1 (R11) of 23 residents reviewed for activities. * The facility failed to complete an assessment of activity goals for R11 and no plan of care related to activities was developed. R11 reported that they are bored, nothing to do but watch TV in room, R11 is bed bound and legally blind.

Inspectors wroteBased on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs of each resident for 1 (R35) of 23 residents reviewed. *R35 went to the emergency room (ER) on 9/12/2023. R35 was prescribed Prednisone for neck inflammation with no end date or tapered dosing. The facility process of reviewing admission orders was not followed after R35 was readmitted to the facility on [DATE]. R35 received a high dose of Prednisone from 9/12/23 through 9/29/2023 when the provider ordered a Prednisone taper. R35 was hospitalized on [DATE] for a change in condition. Hospital documentation indicated R35 might have an element of adrenal insufficiency considering [R35] was on a high dose of Prednisone for 2 to 3 weeks.

Inspectors wroteBased on record review and interview, the facility did not have evidence that the pharmacist's medication record review of any irregularities were reported to the attending Physician, Medical Director and Director of Nursing and that these reports are acted upon for 2 of 5 residents (R57 & R99) whose drug regimens were reviewed.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R57 & R40) of 5 residents reviewed who was receiving a psychotropic medication, was free from unnecessary drugs. * R57 had a PRN (as needed) order for an anti-anxiety medication that did not have a documented rationale in R57's medical record that indicated the duration for the PRN order beyond 14 days. * R40 had a PRN order for an anti-anxiety medication that did not have a documented rationale in R57's medical record that indicated the duration for the PRN order beyond 14 days.

Inspectors wroteBased on observation, interview, and record review the facility did not always provide food that is palatable for 1 (R59) of 23 residents reviewed for food. On 7/8/2024, R59 requested cold cereal and did not receive the cereal. On 7/9/2024, R59 requested oatmeal and did not receive the oatmeal.

Inspectors wroteBased upon interview and record review, the facility did not ensure the rights of 8 (R1, R15, R16, R17, R18, R19, R20, and R21) of 15 residents to formulate their advanced directive preferences to receive cardiopulmonary resuscitation (CPR) (full code) or do not resuscitate (DNR) if found pulseless and not breathing. *R1 was admitted to the facility on [DATE]. During the admission process, R1 was given a facility Code Status Election form to complete. This document has both Resuscitation and Do Not Resuscitate checked. On the form, the box next to Resuscitation has an X in it and is circled and the box next to No Resuscitation has an X in it and the words are boxed off (bracketed). The document is signed by R1 but does not clearly indicate R1's wishes at the time of signature. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (R1) of 1 resident reviewed who became unresponsive and pulseless received basic life support and emergency care based upon physician orders and the resident's advanced directives; including their code status. On [DATE], R1 was found unresponsive by staff. R1 had a Code Status Election document on file which had both Resuscitation and Do Not Resuscitate marked. The only signature on the form was that of R1 and the form did not clearly indicate R1's wishes nor have the correct signatures. Facility staff did not initiate CPR or other lifesaving measures for R1 upon discovery of her being unresponsive although a code was called as was 911. After an RN checked R1's electronic medical record (EMR), she informed staff responding to the facility's code system that resident was a DNR. 911 responded. [...]

Inspectors wroteBased on observation and interview the Facility did not ensure insulin was dated and/or labeled with a Residents name when opened in 1 of 3 medications carts. This has the potential to affect R12, R13, and any diabetic Resident on the [NAME] unit who have been prescribed Aspart or Levemir insulin.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were assessed for self-administration of medications prior to staff leaving medications at bedside for 1 (R7) of 1 residents reviewed for medication self-administration. R7 reported medications were left on the overbed table on 3/8/2024 and R7 was not assessed for the ability to self-administer medications.

Inspectors wroteBased on interview, and record review, the facility did not ensure 2 (R2 and R7) of 4 Facility Reported Incidents reviewed were reported to the State Agency as required. * On 3/22/24 at 8:00 pm, R2 alleged a staff member hit her on the left forearm. The facility did not report the allegations of abuse to the State Agency within 2 hours as required and did not call law enforcement. * R7's family reported to the facility an allegation R7 received the wrong medications on 3/16/2024. The facility did not submit the allegation to the State Agency until 3/18/2024.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R9) of 3 Residents reviewed for discharge received a complete discharge summary including post discharge plans, follow up care necessary and medications provided to the Resident in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. *R9 was discharged home on 1/22/24 without a completed discharge summary and list of medications to allow for coordination of care and to effectively transition R9 to post-facility care. Findings Include: Surveyor reviewed the facility's Discharge policy and procedure last revised/reviewed 4/23 and notes the following: .Discharge to Home: 4. A discharge form is completed by all involved members of the interdisciplinary team (IDT) that explain the Resident care needs at home. 5. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice when outside appointments are needed for 1 (R5) of 3 residents reviewed for appointments. R5 had discharge instructions from the hospital on 2/15/2024 to schedule a follow up appointment with the nephrologist within one to two weeks. The scheduler for appointments was not given the information to schedule the appointment until 3/4/2024, eighteen days after admission, and R5 did not see the nephrologist until 3/13/2024, one month after admission.

Inspectors wroteBased on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 2 (R3 & R9) of 4 Residents reviewed. * R3 was not transferred according to R3's plan of care which resulted in a fall. * On [DATE] R9 had an outside physician appointment at 9:00 a.m. The Facility did not follow up to determine where R9 was and transportation did not pick R9 up until approximately 4:00 p.m.

Inspectors wroteBased on observation, record review, and interview, residents did not receive medications in a timely manner for 3 (R5, R3, and R12) of 3 residents reviewed for medication administration. R5, R3, and R12 were administered medications outside of the time range when medications were to be administered.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R3) of 3 Residents reviewed. R3 receives Metformin twice a day for HTN (hypertension). Hypertension is not an appropriate diagnosis for Metformin.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 5 medication errors in 33 opportunities which resulted in a medication error rate of 15.15%. Medication errors were identified for R12 & R3.

Inspectors wroteBased on record review and staff and family interview, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (R7) of 3 sampled residents. R7 had a history of falls, spastic movements and contractures of bilateral upper extremities. R7 was left alone seated on a mechanical lift sling on a shower chair in his room. The Certified Nursing Assistant (CNA) left R1 unattended and left the room to retrieve a bath blanket. Upon the CNA's return to R7's room, R7 was observed on the floor with bleeding from the head. R7 was transferred to the hospital and diagnosed with a laceration to the head that required 15 sutures and a fractured neck at the 1st cervical vertebrae. The failure to supervise R7 while seated on a shower chair which resulted in a fall created a finding of immediate jeopardy that began on 8/27/23. [...]

Inspectors wroteBased on record review and staff and family interview, the facility did not ensure 1 (R5) of 3 sampled residents received sufficient fluids to maintain fluid status. R5 was admitted to the facility with a diagnosis of sepsis, acute urinary tract infection (UTI) and urinary retention with a Foley catheter. The facility did not monitor R5's fluid intake. R5 developed a low blood pressure (BP), and was not feeling well. R5 was transferred to the hospital by the request from a family member. R5 was diagnosed with severe dehydration, lactic acidosis (lactic acid build up in the bloodstream which can be caused by severe dehydration) and hypovolemia (low fluid volume) and hyponatremia (low sodium level).

Inspectors wroteBased on observation and interviews, the facility did not ensure timely assistance with Activities of Daily Living (ADL) care for 2 residents (R10 and R9) of 10 sampled residents. On 8/29/23, R10 waited 44 minutes for assistance with perineal care following urine incontinence. R9 reported long wait times for assistance to the bathroom which included need for assistance with perineal care when R9 had urine incontinence related to long wait times. Findings Include: Example 1: R10 was admitted to the facility on [DATE] with diagnoses to include Osteoarthritis, and Chronic Obstructive Pulmonary Disease. R10's Minimum Data Set (MDS) assessment dated [DATE] stated R10's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R10 had moderate cognitive impairment. R10's medical record indicated R10 was responsible for R10's own healthcare decisions. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate administration of medication for 3 residents (R8, R9 and R10) of 3 sampled residents reviewed for medication administration times. R8 did not consistently receive multiple medication doses timely as ordered by R8's physician. R9 did not consistently receive multiple medication doses timely as ordered by R9's physician. R10 did not consistently receive multiple medication doses timely as ordered by R10's physician. Findings Include: Facility provided policy titled Medication Pass Times with revision/reviewed date of 05/2023 stated, Medications are administered according to a standard schedule, resident needs and physician orders . The following is a list of scheduled medication times: .a. QD (every day) : 9am b. BID (twice daily) : 9am - 5pm c. TID (three times daily) : 9am - 1pm - 5pm .h. [...]

Inspectors wroteBased upon observation, interview & record review, the facility failed to ensure 1 (R36) of 1 Residents reviewed with a modified consistency for their diet and swallow precautions received supervision as assessed and received a food tray with a mechanical soft consistency to prevent choking. Additionally, the facility did not ensure 1 (R22) of 5 Residents reviewed for falls had fall safety interventions being implemented. * On 3/20/23 and 4/30/23 R36 experienced choking episodes that occurred when R36 was not under the supervision of staff at mealtimes, who were to ensure that R36 took. small bites/sips, had a slow rate of intake, alternated a drink every 2-3 bites, and was in an upright position. On 6/13/23, R36 was served another resident's food trayfrom a Certified Nursing Assistant (CNA) who did not look at R36's meal card. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failure to conduct complete background checks, including the Background Information Disclosure (BID) form for 6 of 8 facility staff reviewed for pre-employment screening. This had the potential to affect all 95 residents who resided at the facility. Certified Nursing Assistant (CNA)-P was hired by the facility on 05/10/2022 and did not have a BID form completed. Licensed Practical Nurse (LPN)-Q was hired by the facility on 10/18/2022 and did not have a BID form completed. Certified Medication Technician (CMT)-R was hired by the facility on 06/21/2022 and did not have a BID form completed. CNA-T was hired by the facility on 02/07/2023 and did not have a BID form completed. [...]

Inspectors wroteBased on interview and review of employee records, the facility did not ensure 2 out of 5 medication technicians were qualified to pass medications to residents residing in the Facility having the potential to affect an approximate average of 30 residents residing on the units where Med Tech (MT)-R and MT-S worked. MT-R was employed by the facility on 06/21/2022 as a med tech but lacked the proper qualifications to pass medications in a skilled nursing facility (SNF). MT-S was employed by the facility on 11/08/2022 as a med tech but lacked the proper qualifications to pass medications in a SNF.

Inspectors wroteBased on observation, interview and record review the facility did not 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. This deficient practice had the potential to affect 31 residents residing in the facility.

Inspectors wroteBased on interview and record review the Facility did not ensure 5 of 5 direct staff chosen at random received communication training. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ & RN (Registered Nurse)-CC did not receive communication training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned.

Inspectors wroteBased on interview and record review the Facility did not ensure 6 of 6 staff chosen at random received QAPI (quality assurance performance improvement) training on the elements & goals of the Facility's QAPI program. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ, RN (Registered Nurse)-CC & Server-MM did not receive QAPI program training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Server-MM works in the kitchen.

Inspectors wroteBased on interview and record review the Facility did not ensure 6 of 6 staff chosen at random received annual training on the Facility's compliance and ethics program. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ, RN (Registered Nurse)-CC & Server-MM did not receive training on the Facility's compliance and ethics program. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Server-MM works in the kitchen.

Inspectors wroteBased on interview and record review the Facility did not ensure 5 of 5 direct staff chosen at random received behavioral health training. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ & RN (Registered Nurse)-CC did not receive behavioral health training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R38, R35) of 3 Resident's reviewed, signed and received copies of the Notice of Medicare Non Coverage (NOMNC) form and/or Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) form. The SNF-ABN and NOMNC forms inform Residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility) and standard claim appeal rights and instructions. * On 2/8/23, Care Transitions Assistant (CTA)-O informed R38's Legal Guardian of the facility's decision to end R38's Medicare Part A coverage at the facility. CTA-O documented the notification on R38's Notice of Medicare Non Coverage (NOMNC) form. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure allegations of mistreatment or abuse were reported to the State Agency for 1 (Resident R12) of 2 allegations reviewed for abuse, neglect, exploitation, or mistreatment. R12 reported to Surveyor an aide hurt her shoulder and night staff holler at her to go to sleep. R12 informed Surveyor these allegations had been reported previously to staff.

Inspectors wroteBased on interview and record review the Facility did not ensure allegations of mistreatment or abuse were investigated for 1 (R12) of 2 allegations reviewed for abuse, neglect, exploitation or mistreatment. R12 reported to Surveyor an aide hurt her shoulder and night staff holler at her to go to sleep. R12 informed Surveyor these allegations had been reported previously to staff. The Facility did not investigate these allegations until after Surveyor spoke with Administrator-A.

Inspectors wroteBased on interviews, clinical record documentation and EMR (electronic medical record review), the facility did not ensure that the PASARR (Pre-admission Screen and Resident Review) for 2 of 5 Residents (R) (R40 and R68) were completed as indicated by resident characteristics. * R40 had a Level 1 PASARR (Preadmission Screen and Resident Review) dated 4/22/21 indicating R40 has a serious mental illness with medications and a diagnosis which would trigger a Level 2 screen to be completed, in order to determine the need for specialized services. A hospital discharge exemption of 30 day maximum is documented, however there is no documentation provided by the facility that R40's PASARR Level 1 screen was completed after the 30 days and sent for further review. R40 has remained in the facility. * R68 admitted to the facility on [DATE], and did not have a PASARR completed at time of admission. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure there was evidence of physician orders for how often neuro checks were to be completed or if neuro checks were no longer required after the initial neuro check for 3 (R88, R22, & R36) of 3 Residents reviewed for falls.

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 (R88, R144 & R28) of 6 Residents reviewed for pressure injuries. * R88 was admitted with a Stage 3 pressure injury on the left heel which has healed. R88's skin integrity care plan does not include interventions to offload R88's heels, R88's heels were observed not being offloaded and there is no documentation in R88's medical record regarding refusals. * R144 was admitted with Stage 1 pressure injuries on her heels and Stage 2 pressure injuries on her left and right buttocks. R144's heels were observed not being offloaded. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R36) of 2 Residents reviewed 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. *R36 was observed during the survey process to not be wearing R36's palm protectors to prevent further decrease in range of motion. Findings Include: R36 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Hyperlipidemia, Essential Hypertension, Bipolar Disorder, and Major Depressive Disorder. R36 has a legal guardian. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility did not ensure residents who presented with a weight change were assessed promptly. This affected 2 (R9 and R28) out of 4 residents reviewed for nutritional concerns. *R28 presented with a steady weight loss from admission on [DATE] to 06/28/23. The facility assessed documented weight loss on 06/09/23 and implemented interventions. R28 continued to lose weight without reevaluation of interventions or new interventions implemented. *R9 presented with weight gain which the facility did not assess promptly.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure respiratory care was consistent with professional standards of practice for 2 (R13 & R49) of 2 Residents reviewed for oxygen administration and care. R13 & R49 were observed receiving oxygen throughout the survey with no labeling of the tubing or humidifier bottles as to when they were last changed.

Inspectors wroteBased on record review and interview, the facility did not have an attending physician review and document on an identified medication irregularity for 1 (R36) of 5 Residents identified in a pharmacy medication regime report. Findings Include: R36 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Hyperlipidemia, Essential Hypertension, Bipolar Disorder, and Major Depressive Disorder. R36 has a legal guardian. On 7/18/23 at 1:03 PM, Surveyor reviewed R36's pharmacy reviews. The pharmacy review on 1/26/23 documents that there is no documented medical diagnosis for R36's Seroquel and it is recommended that there should be a documented medical diagnosis to support continued use. [...]

Inspectors wroteBased upon interview and record review the facility did not ensure 1 (R343) of 5 residents reviewed for unnecessary medications had monitoring of behaviors and possible side effects. R343 had medication increases in Seroquel without clear monitoring of behaviors or side effects as ordered by the physician.

Inspectors wroteBased on observation, interview and record review the facility did not ensure its Medication error rates was not 5 percent or greater. The facility medication error rate was 6.25% affecting 2 of 2 (R61 and R67) residents.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R143) of 26 Resident's records were complete and accurately documented. R143 ambulated into the bathroom with staff, sat abruptly onto the toilet sustaining a skin tear on R143's coccyx. There is no evidence of this incident in R143's medical record.