Memorial Medical Nursing and Rehabilitation

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 3 of 6 residents (Residents #3, #4, and #5) reviewed for care plans. 1. The facility failed to update Resident #3's care plan to reflect Resident #3 had a behavior of refusing showers.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 2 of 6 Residents (Residents #4 and #5) reviewed for abuse. 1. The facility failed to report an allegation of resident-to-resident abuse of Resident #5, when Resident #4 slapped Resident #5 in the face on 2/12/2026. 2. The facility failed to report an allegation of suicidal ideation symptoms for Resident #5 on 1/9/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Residents #4 and #5) reviewed for assessments. 1. The facility failed to accurately reflect physical and verbal behavioral symptoms directed toward others on Resident #4's admission MDS, dated [DATE]. 2. The facility failed to accurately reflect physical and verbal behavioral symptoms directed toward others on Resident #5's significant change MDS, dated [DATE].3. The facility failed to accurately reflect Section D - Mood on Resident #5's quarterly MDS, dated [DATE], following her suicidal ideation symptoms on 1/9/2026 that implemented psych medications. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 6 residents (Residents #1 and #2) reviewed for medical records. 1. The facility failed to ensure MA A documented she administered medication Methocarbamol Oral Tablet 750 MG to Resident #1 on 03/03/2026 at 9:00 PM.2. The facility failed to ensure LVN C document Y instead of N on Resident #2's January 2026 Medication Administration Record on 01/14/2026 during the day and 01/15/2026 during the day. These failures could place residents at risk for inaccurate medical records.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care/treatment. Resident #1 was not given wound care three times in [DATE] and one time in [DATE] for a back tailbone surgical wound. This failure could result in residents needing wound care undergoing a decline in health, non-healing of pressure ulcers or wounds, exposure to infections, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 3 resident rooms (Resident #1 and Resident #2) and 1 of 2 patio door entries observed for housekeeping and maintenance services. 1. The facility failed to provide a functional accessible bathroom door and bedroom door to Resident #1.2. The facility failed to ensure Resident #2's room had broken/torn rubber baseboards, holes in the wall, and broken/missing tiles in the shower.3. The facility failed to ensure the entry/exit door to the patio which led to the smoking area functioned properly and there was no gap between the ramp and the threshold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 4 of 7 Residents (Resident #4, #6, #1 and #7) reviewed for labeling and medication storage:1. The facility failed to ensure Resident #4 did not have an ampule of Ipratropium-Albuterol Solution (prescribed for use with a nebulizer for breathing treatments for shortness of breath) at the bedside.2. The facility failed to ensure Resident #6 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold), a bottle of eye drops, and a medication cup with antacids at the bedside. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #5) reviewed for accuracy of records:The facility failed to ensure nursing staff documented Resident #5's admission nursing assessment. This failure could affect residents whose records were maintained by the facility and could place the residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #4) reviewed for infection control:The facility failed to ensure Resident #4's oxygen mask and tubing were stored properly when not in use. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 3 of 20 residents (Residents #52, #75 and #80) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan to address Resident #52's admission MDS assessment triggered care area. 2. The facility failed to develop a comprehensive, person-centered care plan to address Resident #75's use of smokeless tobacco. 3. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store clean cups properly to allow for air-drying. 2. The facility failed to store a mop and a broom in a sanitary manner in the utility closet. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Resident #10 and 71) reviewed for infection control, in that: 1. While providing colostomy care for Resident #10, LVN C did not change his gloves or sanitize his hands after touching the privacy curtain and before starting the care. 2. a. While providing wound care for Resident #71, LVN A did not change her gloves or sanitize her hands after touching the privacy curtain and before starting the care. 2.b. While providing incontinent care for Resident #71, CNA D did not change his gloves or sanitize his hands during care. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #71) reviewed for privacy, in that: LVN A did not close Resident #71's privacy curtain while providing wound care on 06/10/2025. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 20 residents (Resident #75) whose assessments were reviewed. The facility failed to indicate Resident #75's current tobacco use on his significant change MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for 1 (Resident #75) of 20 residents reviewed for resident assessments. The facility failed to refer Resident #75 for a level II resident review following a new diagnosis of schizoaffective disorder-bipolar type, added on 12/17/2024. This failure could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #11) reviewed for care plans. The facility failed to revise Resident #11's comprehensive care plan to reflect the resident's refusal to have her weight taken. This deficient practice could cause confusion for staff members responsible for providing direct care for residents and result in staff not respecting residents' wishes regarding care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed tracheostomy care were provided such care, consistent with professional standards of practice, for 1 of 1 residents (Resident #76) reviewed for tracheostomy care. The facility failed to provide tracheal care and suctioning according to professional standards for Resident #76. These deficient practices could result in the resident's not receiving the care and services ordered by the physician and a decline in health status and respiratory infection.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 6 residents (Resident #76 ) by 1 of 3 nurses (RN B) reviewed for competent staff, in that: The facility failed to provide tracheal care and suctioning according to professional standards for Resident #76. The failure could place residents at risk for not receiving nursing services by adequately trained and licenses nurses and could result in a decline in health and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 of 1 residents (Resident #5) reviewed, in that: The facility failed to ensure food items stored in Resident #5's personal refrigerator was labeled and dated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 4 halls (West hall) reviewed for pest control. The facility did not have an effective pest control program to eradicate the gnats in the facility. The facility failure placed residents at risk for infections and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 had a drain plug. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interview and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's medication reconciliation log for the Schedule II medication (substances with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) Hydromorphone accurately reflected the number of doses administered. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain resident medical records that were complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical records. Resident #1 was administered supplemental oxygen via nasal cannula, Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) without a physician's order. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate communication system to allow residents to call for staff assistance for 1 of 6 rooms (Room # 1's room) on the PCC hallway reviewed for an operating call light system. The facility failed to ensure Resident #1's room had an operating call light system. This deficient practice could place residents at-risk of not being able to call for staff assistance to meet care needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 (West Hall Downstairs) of 4 resident hallways reviewed for environmental concerns. On [NAME] Hallway Downstairs- the facility failed to repair the overhead 5x2 ft light in the unmarked resident shower room on the right side of the resident hallway between resident rooms [ROOM NUMBERS] which was not operable and the overhead 1 ft circular ceiling heater in the unmarked resident shower room on the left side of the resident hallway between rooms [ROOM NUMBERS] was not operable. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one (1) of four (4) residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure a cognitively impaired resident (Resident #1) had adequate supervision on 09/01/2024 which allowed him to elope from the facility from an unknown door after lunch on 09/01/2024 and was not located until 02:40 a.m. on 09/02/2024 at a local hospital. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 09/05/2024 at 04:24 p.m. The IJ template was provided to the facility on [DATE] at 05:17 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 1 of 4 days (09/04/2024), observed for postings. The facility failed to ensure the survey results were available and accessible to residents and visitors without having to ask for them on 09/04/2024. This failure resulted in residents, family members, and legal representatives of residents being unable to access prior survey results without having to ask to see them.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food safety in the facility kitchen. 1) CNA A failed to put on a hair net before entering the facility kitchen. This failure could place residents receiving food from the facility kitchen at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to post daily information that included the actual hours worked by registered nurses, licensed practical or licensed vocational nurses, and certified nurse aides directly responsible for resident care per shift and readily accessible in a prominent place. The facility failed to ensure the daily staffing information was posted per shift and in a prominent place on two (07/15/2024 and 07/16/2024) of three days observed. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation was made to the State agency for 1 of 7 staff (Resident #1) reviewed for failure to report. in that: 1. CNA B did not report an allegation of abuse at the time of the suspected abuse for Resident #1 on 05/31/2024. 2. CNA C did not report an allegation of abuse at the time of the suspected abuse for Resident #1 on 05/31/2024. This failure could place residents at risk of abuse or neglect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There were 10 slices of bread in the refrigerator that were not labeled or dated. 2. There was a box of 400 coffee creamers in the refrigerator that were not labeled or dated. 3. An ice cream freezer had an internal temperature of 70 degrees with 20 4 -ounce packets of melted ice cream. 4. A bag of 12 waffles in an outside freezer was not labeled or dated. 5. Three boxes of 3-gallon containers of apple juice concentrates in the storeroom were not labeled or dated. 6. The ceiling vent across from the dish machine had dirt and grease on the vent slats. 7. A Dietary Aide, DA D was observed in the kitchen not wearing a hair restraint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 (Main Dining Room) of 2 dining rooms reviewed and 1 (Hall 100) of 5 hallways reviewed for pests, in that: 1. Numerous flies were observed in a resident room on Hall 100. 2. Numerous flies were observed near a trash can and on Resident #53's food and drink in the Main Dining Room. This deficient practice could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 4 of 8 residents (Residents #20, #8, #3, and #29 ) reviewed for care plans. The facility failed to invite and include the input of the resident (Resident #20, #8, #3, and #29 ) and/or residents' representatives as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or residents' representatives in Care Plan Conference meetings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 30 residents (Residents #46, #53, and #85) reviewed for comprehensive person-centered care plans, in that: 1. Resident #46's care plan did not address the resident's broken and missing teeth. 2. Resident #53's care plan did not address the resident's diet, need for assistance with activities of daily living, or discharge plans, and contained incomplete sentences/incomplete care information. 3. Resident #85's care plan did not address the resident's diet, advance directive, wounds, medication, need for assistance with activities of daily living, specialized medical equipment, or discharge plans. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 (Resident #20) reviewed for quality of care in that: Resident #20 did not receive ordered weekly skin assessments between 2/23/2024 and 4/22/2024. This failure could place residents at risk of not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 (Residents #68 and #87) of 30 residents, and in 1 of 5 hallways (Hall 100) reviewed for accident hazards, in that: 1. Resident #68 was observed with a package of cigarettes and a cigarette lighter in the facility dining room. 2. Resident #87 was observed with a package of cigarettes and utilizing a cigarette lighter and pair of scissors in the facility courtyard. 3. A storage room on Hall 100 was marked, Clean Linen was open and unlocked and contained bathing supplies including razors. 4. Shower room [ROOM NUMBER] on Hall 100 was open and unlocked and container bathing supplies including razors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 4 of 4 residents (Residents #3, #12, #42, and #63) reviewed for oxygen, in that: 1. The facility failed to ensure orders were in place to manage Resident #3's supplemental oxygen support devices. 2. The facility failed to ensure oxygen humidifier bottles were changed for Residents #12, #42, and #63 when empty. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 residents' refrigerators (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed in that: The personal refrigerators in residents' rooms [ROOM NUMBERS] contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that: The Sharps container in Resident # 2's room was overfilled. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and enforce policies regarding smoking for 1 of 1 facility reviewed for smoking, in that: Residents #43, #198, and #199 were observed smoking in the facility courtyard and all stated that they kept their own cigarettes and lighters in their rooms. This failure could place residents at risk of dwelling within an unsafe smoking environment.

Inspectors wroteBased on interviews and record reviews the facility failed to develop, implement, and revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 33 residents (Residents #43 and #55) reviewed for care plans, in that: 1. The facility failed to include insulin administration on Resident #43's Care Plan. 2. The facility failed to revise a care plan to address Resident #55's insulin administration on the care plan dated 3/29/24. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. Resident #1 was moved rooms within the facility. Nursing staff failed to ensure the bed in the new room had side rails for bed mobility and positioning. Resident #1 rolled out of bed during care and fell to the floor hitting her head. Resident #1 was hospitalized for evaluation and treatment and diagnosed with thoracic spine compression fractures, multiple rib fractures, and subsequently expired. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that: 1. There was no signage on the front door of the facility to let visitors know the facility was in outbreak mode due to COVID. 2. Staff of multiple disciplines (the SW, Agency LPN Z, LPN B, RN X) were not utilizing appropriate PPE while the facility was experiencing a COVID outbreak. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided with the necessary care and services to maintain good personal hygiene for 2 of 5 Residents (Residents #7 and #10) whose records were reviewed for ADL care. 1. Nursing staff failed to ensure Resident #7 received incontinent care for over 2 hours after she urinated and had an episode of diarrhea. 2. Nursing staff failed to ensure Resident #10 received incontinent care as needed for at least 6 hours during the morning shift. These deficient practices could affect residents who required assistance with toileting and could contribute to feelings of discomfort and skin break down.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 19 of 49 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #11, #21) reviewed for pharmacy services, in that: The facility failed to ensure residents received medications as ordered by the physician for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #11, and #21. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medication, resulting in worsening or exacerbation of chronic medical conditions, hospitalization, and/or death.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (Residents #1 and #2) reviewed for comprehensive care plans in that: 1. The facility failed to develop a plan of care to address Resident #1's multiple wounds. 2. The facility failed to develop a plan of care to address Resident #2's wounds. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: 1. The facility failed to ensure Resident #1's wound care was documented on the TAR for multiple dates in January. 2. The facility failed to ensure Resident #2's wound care was documented on the TAR for multiple dates in January. This deficient practice could affect residents whose records are maintained by the facility and could place improper identification of staff and role in the resident medical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 6 staff (Agency LVN A) reviewed for background screenings, in that: The facility had failed to ensure an Employee Misconduct Registry search was completed for Agency LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for monitoring and implementing the facility policy and procedures for 1 of 1 facility reviewed for Administration. The facility failed to develop and implement a written policy for nursing student. The facility failed to supervise and provide oversight to nursing students and their instructor. These deficient practices could place residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control, in that: The facility failed to ensure Resident #1 received wound care to her left heel DTI using appropriate hand hygiene and infection control principles. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health.

Inspectors wroteBased on interview and record review the facility failed to refer all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 5 Residents (Resident #9) reviewed for PASSAR services. The MDS Coordinator failed to refer Resident #9 for a resident review after being diagnosed with bipolar disorder current episode manic severe with psychotic features and Manic depressive disorder. The onset of both diagnoses was during 2021. This deficient practice could place residents at risk of not receiving the needed PASSAR services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs for 5 of 17 residents (Residents #6, #8, #34, #44 & # 65) reviewed for care plans. 1. Resident #6's comprehensive care plan did not address the resident's use of scheduled pain medication. 2. Resident #8's comprehensive care plan did not address the resident's multiple missing teeth. 3. Resident #34's comprehensive care plan did not address the resident receiving rehabilitation services. 4. Resident #44's comprehensive care plan did not address the resident's behavior of leaving the facility independently in his electric wheelchair. 5. [...]

Inspectors wroteBased on observation, interview and record review based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident choices for 3 of 3 residents (Resident #59, #64 and #80) reviewed for quality of care. The facility failed to accurately assess and develop care plans for Residents #59, #64, and #80 for the residents' use of pacemakers, and did not complete daily checks for the residents' pacemakers. These deficient practices could place residents at risk of cardiac complications or pacemaker malfunctioning due lack of treatment and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #14) reviewed for oxygen care. Nursing staff did not ensure Resident #14 received 3 liters of oxygen per physician orders for at least 3 days. This deficient practice could place residents at risk for experiencing breathing complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 Residents (Resident #8) reviewed for assessments. MDS Coordinator did not code that Resident #8 had missing teeth on her admission assessment. This deficient practice could place residents at risk of not receiving needed services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 6 Residents (Resident #8) reviewed for adl care. Nursing staff failed to ensure Resident #8 was assisted with feeding during a lunch meal. This deficient practice could place residents at risk of experiencing a decline in their physical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 8 of 12 resident rooms (Rooms 107, 109, 110, 111, 112, 113, 114 & 115) on 1 of 4 units (South hall) reviewed for environment. The facility failed to ensure eight of twelve (8 of 12) semiprivate resident rooms on the South hall had at least 80 square feet per resident (Rooms 107, 109, 110, 111, 112, 113, 114 and 115). This deficient practice could place residents at risk of being crowded and could compromise resident privacy.