Merkel Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 5 of 20 (Resident #1, Resident #2, Resident #3, Resident #5, and Resident #16) residents reviewed for neglect. 1. The facility failed to ensure 34 of 84 shifts were staffed with at least two nurse aides, per the facility assessment, between the dates of 1/1/26 and 2/11/26. 2. The facility failed to ensure effective training was provided to staff based on resident care requirements and needs. Staff employees designated as Nurse Aide (NA) were aides that had not completed the Nurse Aide Training and Competency Evaluation Program and passed the required written and skills test, required to be a certified nurse aide. 3. [...]

Inspectors wroteBased on observation, 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 of 11 residents 20 (Resident #1, Resident #2, and Resident #3) reviewed for falls. 1. The facility failed to ensure Resident #1 was transferred with a mechanical lift by 2 staff, required when using a mechanical lift, which resulted in a distal femur fracture requiring surgical intervention 01/26/2026. 2. The facility failed to ensure Resident #5 had appropriate interventions and adequate staffing to prevent falls which resulted in multiple rib fractures and hospitalization on 01/15/2026. 3. The facility failed to ensure Resident #3 had appropriate interventions and adequate staffing to prevent a fall on 01/31/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing sufficient numbers of licensed nurses and nurse aides for 34 of 84 shifts reviewed for nurse staffing and 4 of 28 (Resident #2, Resident #3, Resident # 5 and Resident #16) residents reviewed for sufficient staffing. The facility failed to ensure 34 of 84 shifts were staffed with at least two direct care staff, per the facility assessment, between the dates of 1/1/26 and 2/11/2026 (1/02/26 6:00PM -6:00AM; 1/06/26 6:00PM -6:00 AM; 1/08/26 6:00PM -6:00 AM; 1/10/26 6:00AM -6:00PM; 1/11/26 6:00AM -6:00 PM; 1/15/26 6:00AM -6:00 PM; 1/16/26 6:00PM -6:00 AM; 1/17/26 6:00PM -6:00AM; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 9 (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, NA-M, and NA- P) of 9 NA's reviewed for competency and training and 1 of 8 (Resident #1) residents reviewed for mechanical lift. The facility failed to ensure NA-A did not transfer Resident #1 with a mechanical lift without the assistance of a CNA or nurse, which resulted in Resident #1 receiving a distal femur fracture. The facility failed to ensure nurse aides were trained on how to use a mechanical lift for NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, NA-M, and NA- P. An Immediate Jeopardy (IJ) situation was identified on 02/13/2026. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for full-time DON.The facility failed to ensure there was a full-time (worked 40 or more hours a week) DON in 9 of 11 (week 12/14/2025 - 12/20/2025, week 12/21/2025 - 12/27/2025, week 12/28/2025 - 01/03/2026, week 01/04/2026 - 01/10/2026, week 01/11/2026 - 01/17/2026, week 01/18/2026 - 01/24/2026, week 01/25/2026 - 01/31/2026, week 02/01/2026 - 02/07/2026, and week 02/08/2026 - 02/14/2026) weeks reviewed. This failure could affect all residents in the facility by leaving residents and staff without supervisory coverage for nursing care and services.

Inspectors wroteBased on interview and record review the facility failed to not use any individual working in the facility as a nurse aide for more than 4 months on a full-time basis unless that individual is competent to provide nursing and nursing related services and that individual has completed a training and competency evaluation program, or a competency evaluation program approved by the state or had been deemed or determined competent as provided in S483.150(a) and (b) for 8 of 11 (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, and NA-P) Nurse Aides. The facility failed to ensure NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, and NA-L were certified within the required time frame. This failure could place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on interview and record reviews, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 3 months reviewed for antibiotic stewardship. The facility failed to maintain a system to monitor antibiotic use during the months of December 2025, January 2026 and February 2026. These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics.

Inspectors wroteBased on interviews and record reviews, the facility failed to have a designated Infection Preventionist who worked at least part-time at the facility and had completed specialized training in infection prevention and control for 1 of 1 facility reviewed for infection control. The facility failed to have a designated Infection Preventionist (IP) who worked at least part-time in the months of December 2025, January 2026 and February 2026. This failure could affect residents by placing them at risk of infection spread by the facility not appropriately recognizing and responding to communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility's QAPI committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility. The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction, dated 8/29/2024, for deficient practice F695, F909, F941, F944, F949. This failure could place residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety, respiratory treatment, and employee training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care consistent with professional standards of practice for 4 of 14 residents (Resident #2, Resident #3, Resident #7 and Resident #11) reviewed for oxygen therapy. The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #2, Resident #3, Resident #7 and Resident #11. This failure could place residents who use oxygen at risk of injury from fire.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #3, Resident #10, and Resident #24) of 3 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #3, Resident #10, and Resident #24 received adequate end-of-life care. The facility failed to have hospice care plans for Resident #3, Resident #10 and Resident #24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, to identify areas of potential entrapment hazards for 4 (Resident #2, Resident #3, Resident #7, and Resident #9) of 14 residents reviewed for physical environment. The facility failed to conduct regular inspections of resident side rails, bed frames and mattresses to identify entrapment risks for Resident #2, Resident #3, Resident #7, and Resident #9. This failure could place residents at risk of injury resulting from equipment malfunction, entrapment, or falls.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 16 (ADMN, DON, DM, Maint. D, and NA G) staff reviewed training requirements. The facility failed to implement and maintain a training program that ensured the DON, DM, Maint. D, and NA G received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured the ADMN received required HIV annual training. These failures could place residents at risk of being cared for by staff insufficiently trained on the mode of HIV transmission, HIV prevention, behaviors related to substance abuse, precautions, rights of an infected individual and behaviors associated with HIV transmission.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 6 of 16 (the DON, the DM, RN C, LVN E, NA G, and NA H) staff reviewed for training on effective communication. The facility failed to ensure communication training was provided to DON, DM, RN C, LVN E, NA G, and NA H upon hire. This failure could place residents at risk of not understanding their total health status and not effectively being provided notice of rights and services both orally and in writing in a manner that the resident understands.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 4 of 16 (the DM, LVN E, NA G, and NA H) staff reviewed for training on resident's rights. The facility failed to ensure that the DM, LVN E, NA G, and NA H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire. This failure could place residents at risk of their rights not being honored by uninformed staff.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 3 of 16 (the DM, RN C, and NA G) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure that NA G was educated on abuse, neglect and exploitation & dementia management upon hireThe facility failed to ensure that the DM and RN C were educated on dementia management upon hire. These failures could place residents at risk of being abused, neglected, or exploited by uniformed staff and could delay the facility's investigation of abuse, neglect, or exploitation.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 16 (the DON, the DM, RN C, LVN E, and NA G) staff reviewed for training on QAPI. The facility failed to ensure that the DON, the DM, RN C, LVN E, and NA G were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 4 of 16 (the DON, the DM, LVN E, and NA G) staff reviewed for training on infection control. The facility failed to ensure that the DON, the DM, LVN E, and NA G were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 3 of 16 (the DON, the DM, and NA G) staff reviewed for training on behavioral health. The facility failed to ensure that the DON, the DM, and NA G were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #7) of 12 residents reviewed for resident records. The facility failed to ensure Resident #7's physician order and face sheet matched Resident #7's care plan for DNR.This failure could place residents at risk of having CPR when they or their representatives have requested no CPR 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 diseases and infections for 1 of 3 (NA G) staff reviewed for infection control. The facility failed to ensure NA G performed proper peri-care (incontinent care) for Resident #22. This failure could place residents at risk of infections from incontinent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 24 residents (Resident #1 and Resident #2) whose records were reviewed for quality of care. 1. The facility failed to ensure Resident #1 was supervised to prevent the ingesting of chemical. 2. The facility failed to ensure Resident #2 received adequate supervision to prevent the resident from leaving the facility. An Intermediate Jeopardy (IJ) was identified on 08/14/2025. The IJ template was provided to the facility on [DATE] at 5:00 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 Dietary Manager (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility had a certified DM from July 21, 2025, until August 20, 2025. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, Resident #3) of 24 residents. 1. Resident #1 ingested harmful chemicals and was hospitalized on [DATE].2. Resident #2 left the facility unaccompanied and without facility knowledge on 07/04/2025.3. Resident #3 reported an allegation of abuse and the facility administration failed to follow internal policies.4. The facility's administrative personnel did not ensure the facility was administered by a full-time licensed administrator who was knowledgeable of regulations, facility policies, and procedures.5. [...]

Inspectors wroteBased on interview, and record review the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility. The facility failed in conducting the facility assessment to ensure involvement from nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 2 of 5 employees (Administrator Q and ADON E) reviewed for employability. The facility failed to follow written policy of completion of criminal history check and an initial EMR/NAR check for ADON E prior to offering employment. The facility failed to follow written policy of annual EMR verification was completed for Administrator Q. These findings placed residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in 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 (Resident #1, Resident #2) of 24 residents reviewed for allegations of neglect. 1. The facility failed to report when Resident #1 ingested harmful chemicals and was hospitalized on [DATE] to the State Survey Agency. 2. The facility failed to report when Resident #2 left the facility unaccompanied on 07/04/25 to the State Survey Agency and to the police. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to administrator and to other officials in accordance to State law, including to the State Survey agency, within 5 working days after the incident, and if the alleged violation is verified appropriate corrective action must be taken for 3 of 3 incidents reviewed. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not submitting the results of all investigations to the State Survey agency, within five (5) working days after the incident was reported, for: 1. The self-reported incident that involved Resident #9 when she suffered a mildly displaced fracture of the ankle on 07/23/2025.2. The self-reported incident that involved Resident #8 when she suffered a fall that required stitches to her left forehead on 07/08/2025. 3. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility. The facility failed to notify the State Agency of a change in AdministrationThis failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control practices. CNA A and Nursing Aid B failed to perform proper hand hygiene and change gloves while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #10) of 3 residents reviewed for change of condition. The facility failed to notify Resident #10's physician after Resident #10's change in condition did not improve after she returned from the hospital. This failure could place residents at risk of not having their change of condition communicated to their physician, delay of treatment, and a decline in the residents' health and well-being.

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #6, Resident #7, and Resident #10) of 7 residents reviewed for care plan accuracy, in that: Resident #6 and Resident #7 did not have a care plan that addressed smoking, and for Resident #10, the facility failed to develop a comprehensive care plan as required. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or cause injury or harm.

Inspectors wroteBased on interviews and records reviews, the facility failed to maintain medical records on each resident that are complete and accurately documented, in accordance with accepted professional standards and practices for 3 (Resident #5, Resident #6, and Resident #7) of 3 residents reviewed for smoking assessments. The facility failed to completely and accurately document quarterly smoking assessments for Resident #5, Resident #6, and Resident #7 per facility smoking policy. This failure could place residents at risk of having incomplete and inaccurate records, which could lead to miscommunication and interruption of services.

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to implement and follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 10/09/2024 when a red, labeled, self-enclosed, covered smoking receptacle in the designated smoking area was observed to contain plastic trash items and was lined with a clear, plastic trashcan liner. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #10) of 3 residents reviewed for baseline care plans. The facility failed to ensure Resident #10 had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. This failure could place newly admitted residents at risk of not receiving the care and services needed to promote good health and continuity of services.

Inspectors wroteBased on observations, interviews, and records reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #3) of 3 residents reviewed for care plan revision. Resident #3's comprehensive care plan was not reviewed or revised after Resident #3 fell and sustained a lower, left leg fracture. This failure could place residents at risk for inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 7 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in August 2023, October 2023, November 2023, December 2023, April 2024, May 2024, and June 2024. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 15 residents (Resident # 6 and Resident #18) reviewed for dignity. The facility failed to ensure staff treated Resident #6 and # 18 with dignity while assisting residents with their lunch meal. This failure could place residents at risk of a diminished quality of life and lead to loss of self-esteem, isolation, and weight loss.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a comprehensive person- centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 15 residents (Resident #16, #17, #19, #24) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #16's Care plan incorporated Code status and PASRR status. The facility failed to ensure Resident #17's Care Plan incorporated measurable objectives or interventions for Tracheostomy Care or Feeding Tube. The facility failed to ensure Resident #19's Care plan incorporated interventions for falls. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment that was as free from accident hazards as was possible for 2 of 3 (Back Hall and Front Hall) halls reviewed for accident hazards . The facility failed to ensure shampoo, wound cleanser, nail polish remover, shaving cream, disinfectant spray, and perineal and skin cleanser were locked in the Back Hall Shower room and not accessible to residents. The facility failed to ensure perineal and skin cleanser were locked in the Back Hall bathroom room and not accessible to residents. The facility failed to ensure bottle of shampoo was locked in the front hall bathroom and not accessible to the residents. These failures could place residents at risk of injury due to hazardous chemicals.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 3 of 14 resident (Resident #2, Resident #14, and Resident #235's) reviewed for oxygen administration. The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #2, Resident #14, and Resident #235's door. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection.

Inspectors wroteBased on interview and record review the facility failed to ensure 3 (NA B, NA C, and NA D) of 10 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA B, NA C, and NA D were certified within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 (Residents #235) residents who received a pureed meal reviewed during 2 of 2 lunch meals. The facility failed to ensure Resident #235, who received a pureed diet, was provided the food according to the menu, including a role on 07/29/2024 and mashed potatoes on 07/30/2024. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that resident food was discarded when past expiration date. The facility failed to ensure ice scoops were stored covered. The facility failed to ensure items in refrigerator where food was stored were cleaned. The facility failed to ensure dinnerware was in good condition, without chips. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for infection control procedures for 1 of 1 ice scoop reviewed for infection control. The facility failed to follow their Infection Control policy regarding CDC guidelines of performing hand hygiene when assisting residents with meals and one ice scoop laying on a counter in the kitchen not covered and one ice scoop laying on a cart uncovered at the nurses' station. This failure could place residents at risk of the spread of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 of 4 (Residents #2, #20, #30 and #235) residents reviewed for bed rails. The facility failed to assess bed rails for risk of entrapment for Residents #2, #20, #30 and #235's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 (Resident #19) of 15 residents reviewed for resident call system. The facility failed to provide a working communication system on 07/29/2024 that was easily at reach and that would allow Resident #19 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 1 staff (NA B) reviewed for Resident Abuse . The facility failed to suspend staff named as AP or remove staff named as AP from direct care position during resident abuse investigation . This deficient practice could place residents at risk for abuse and neglect.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and prevent new ulcers from developing for 1 of 13 (Resident #20) residents reviewed for pressure ulcers. The facility failed to perform weekly skin assessments for Resident #20 who was assessed as being at risk for skin breakdown. These failures could place residents at risk of developing pressure ulcers, infections and worsening of wounds from delay in treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure had the had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through the means other than a postal service for 11 of 11 confidential resident group meeting reviewed for resident rights. The facility failed to ensure residents received mail on the weekend. This failure could affect residents by placing them at risk of not receiving mail in a timely manner that could result in residents experiencing diminished psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review the facility failed to have a provide an activities program directed by a qualified professional for 1 of 1 activity directors (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 3 of 7 days reviewed for nursing services and postings (7/29/24, 7/30/24, and 7/31/24) The facility failed to ensure daily staffing information was posted in a prominent place on 07/29/2024, 07/30/2024, and 07/31/2024 This failure could place residents, their families, and visitors at risk of not having access to information regarding staffing and facility census.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective communications training program for all new and existing staff for 3 of 9 (DON, NA B, NA D) direct care staff personnel files reviewed for training. The facility failed to train for Communications for the DON, NA B, and NA D during new hire orientation. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 3 of 16 (DON, NA B, NA D) reviewed for Quality Assurance and Performance Improvement (QAPI) training. The facility failed to ensure the DON, NA B, and NA D were trained for QAPI upon hire. This failure placed residents at risk of at receiving care from incompetent/untrained staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 16 (DON, and NA D) reviewed for behavioral health training. The facility failed to ensure the DON, and NA D upon hire were trained for Behavioral Health or an assessment tool to behavioral health. This failure could place residents at risk at receiving care from of incompetent/untrained staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain mechanical and electrical equipment in a safe operating condition for 7 (Resident #1, #2, #3, #4, #5, #6, and #7) of 7 rooms affected by mechanical failure. 1. The facility failed to repair heating to resident's room to properly maintain safe and comfortable temperature for residents in their rooms. This failure could place residents at risk of cold room temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate residents needs and preferences and accommodation of needs, for 2 (Resident #2, Resident #5) of 5 residents reviewed for dignity. The facility failed to ensure Resident #2 and Resident #5 call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on interview, and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 2 (Residents #16 and Resident #29) of 12 residents reviewed with trust funds. The facility failed to ensure Residents #16 and Resident #29 had ready access to their personal funds on the weekends or if the BOM was not available. This failure could place residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician signed and dated all orders for 3 of 12 residents (Residents #14, #24, and #88) reviewed for complete and accurate medical records. The facility failed to obtain orders for bed rails for Residents #14, #24, and #88. This failure placed resident at risk for not receiving the appropriate physician ordered care. Findings Included: Record Review of the Resident #14's Face Sheet dated 06/08/2023, revealed she was a 91 yr. old Female, admitted to the facility on [DATE], with a diagnoses of Congestive heart Failure, open wounds, and skin conditions. Record Review of Resident #14's MDS, dated [DATE], Section C revealed a BIMS score of 09 (moderately impaired). Record Review of Resident #14's undated Care Plan, revealed, SIDE RAILS: (half rails) up for safety during care provision, to assist with bed mobility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 7 days of the FY 1 Quarter out of 4 Quarters. (11/05/2022, 11/06/2022, 11/12/2022, 11/13/2022, 12/03/2022, 12/04/2022, and 12/17/202) This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage. The facility failed to keep medication cart 1 secured when not in use, leaving resident medication in a locked compartment when not being immediately used. The failure placed residents at risk of adverse actions caused by inadvertent medication consumption as well as drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 8 of 8 meetings (May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023) reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023. The facility did not ensure the DON, or a representative attended QAPI meetings in July 2022, August 2022, and February 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

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 3 (RN-Q) staff observed during medication administration. RN-Q placed her fingers inside the medication cup and the crushed the medication sleeve while preparing medication and without performing hand hygiene while administering medication. RN-Q did not sanitize the glucometer before or after use on a resident. RN-Q did not place lancet in the sharps box after use it on a resident. These failures placed residents of the facility at risk of infections from medication administration.