Momentous Health at Richfield

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation was recorded in the residents' medical record. This affected two residents (#14 and #57) of three residents reviewed for documentation. The facility census was 56.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #7, #13, #18, #25 and #34. This affected five (Residents #7, #13, #18, #25 and #34) of five residents reviewed PASRR. The facility census was 55. Findings Include:1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes and high cholesterol. Review of the PASRR level two evaluation from the state department of mental health dated 01/23/26 revealed Resident #7 had a level two mental illness. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure recommendations from the state Pre-admission Screening and Resident Review (PASRR) authority, the Ohio Department of Mental Health and Addiction Services, were incorporated into residents' comprehensive care plans as required. This affected four (Residents #7, #13, #18, #34) of five residents reviewed for PASRR requirements. The facility census was 55.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the environment remained clean, sanitary, hazard-free, and in a state of good repair. This affected 17 (Residents #1, #2, #8, #9, #10, #19, #21, #27, #33, #38, #42, #48, #52, #53, #58, #59, and #61) of 23 residents reviewed for physical environment and had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received proper liability notices that included required information on how to request an immediate appeal of the discontinuation of skilled services. This affected one (Resident #62) of three residents reviewed for beneficiary notices. The facility census was 55. Findings Include:Review of the medical record for Resident #62 revealed the resident received a Notice of Medicare Non-Coverage (NOMNC) dated 11/11/25. Further review of the NOMNC provided to Resident #62 revealed the notice failed to include the name of the Quality Improvement Organization (QIO) and the QIO's telephone number, which are required elements to allow the resident or responsible party to request an immediate appeal. Specifically, under the subsection titled How to ask for an immediate appeal, the notice stated: [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTED AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of facility investigations, staff interviews, and review of facility-initiated corrective actions, the facility failed to ensure adequate supervision and interventions were implemented to prevent resident elopement and exit-seeking behaviors. This deficient practice affected three (Residents #4, #47, and #75) of three residents reviewed for elopement risk. The facility census was 55.

Inspectors wroteBased on record review, observations, resident and staff interviews, and facility policy review, the facility failed to identify and incorporate known post-traumatic stress disorder (PTSD) triggers into the care plan to prevent re traumatization for one (Resident #40) of one resident reviewed for trauma-informed care. The facility census was 55.

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring general cleanliness was maintained, water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, and door frames were without the need for repair. This affected all residents residing in the facility. The facility census was 51.

Inspectors wroteBased on observation, interview, and review of the facility menus, the facility failed to serve palatable meals at appetizing temperatures for residents' meals. This had the potential to affect all 51 residents residing in the facility. The facility indicated all residents received meals from the kitchen. The facility census was 51.

Inspectors wroteBased on review of personnel files, interviews, and review of the nursing job description, the facility failed to ensure nurses providing direct care to residents maintained current cardiopulmonary resuscitation (CPR) certification. This had the potential to affect all 37 residents whose advanced directives were listed as full code (term used to signify all measures which should be taken to resuscitate, including CPR). The facility census was 51.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure the power of attorney (POA) was notified of a change in condition. This affected one resident (#32) of four residents reviewed for notification of change in condition. The facility census was 51.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure weights were obtained upon readmission from the hospital and refusals were consistently documented. This affected one resident (Resident #32) of four residents reviewed for weights. The facility census was 51.

Inspectors wroteBased on observation, medical record review, facility policy review, Centers for Disease Control (CDC) guidance on COVID-19 and interview the facility failed to provide timely and necessary intervention following changes in resident condition. Actual Harm occurred on [DATE] when Resident #18 had unwitnessed fall resulting in increased pain, decreased functional ability and inability to participate in therapy services due to pain. On [DATE] (15 days following the fall) Resident #18 was transferred to the hospital and assessed to have an acute fracture of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Actual Harm occurred on [DATE] when Resident #55 was admitted to the hospital for treatment of pneumonia and was experiencing dark, tarry stools. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #49, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel and bladder, received timely and necessary pressure ulcer prevent and treatment. Additionally, the facility failed to ensure accurate and comprehensive weekly skin assessments for Resident #11's in-house acquired pressure ulcer. This affected two residents (#49 and #11) of two residents reviewed for pressure ulcers. The facility census was 54. [...]

Inspectors wroteBased on observations, staff and resident interviews, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, door frames, and hand rails were without the need for repair. This affected all residents residing in the facility. The facility census was 54.

Inspectors wroteBased on review of the personnel files, review of the facility assessment and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) #305 and #329 received annual performance reviews. This affected two of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to follow the menu spreadsheets as written to ensure proper portion sizes were served to the residents. This affected 53 residents receiving food from the kitchen as Resident #10 was ordered nothing by mouth (NPO). Facility census was 54.

Inspectors wroteBased on observation, interview and review of the menu, the facility failed to serve palatable meals at appetizing temperatures. This had potential to affect all 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth. The facility census was 54.

Inspectors wroteBased on observation, interview, review of the facility policy and record review the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth (NPO). The facility census was 54.

Inspectors wroteBased on record review, review of facility job descriptions and interview the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental and psychosocial well being of all 54 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment was accurately completed. The facility also did not implement their facility assessment in regard to staff training and education. This had the potential to affect all 54 residents residing at the facility.

Inspectors wroteBased on record review, contract review, review of the facility policy and staff interview, the facility failed to ensure the medical director fulfilled his responsibilities related to the coordination of medical care, the implementation of facility policies and procedures and evidence of participation in Quality Assurance and Performance Improvement to ensure quality care is provided to residents. This affected all 54 residents who reside in the facility.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified concerns timely and effectively. This had the potential to affect all 54 residents in the facility.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure all required members of the quality assurance performance improvement (QAPI) committee met quarterly as required. This affected all 54 residents residing in the facility.

Inspectors wroteBased on record review, observations, interviews, review of hospital discharge summaries, review of the Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS), review of the Summit County Public Health (SCPH) Public Health Nurse (PHN) communications, and facility policy review, the facility failed to develop, maintain, and implement an effective infection control program. This had the potential to affect all 54 residents residing in the facility. The failed to follow the local health department's directives for Resident #24 with a MDRO. This affected one resident (#24) of one resident reviewed for a MDRO and had the potential to affect all residents. The facility failed to ensure infection control tracking was not complete or accurate. This had the potential to affect all residents. [...]

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) meetings, staff interview, review of staff certificates and personnel files, the facility failed to ensure there was a qualified infection preventionist (IP) working on at least a part time basis. This had the potential to affect all residents residing in the facility. The facility census was 54.

Inspectors wroteBased on record review, review of a facility immunization report, facility policy review, review of facility census, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to ensure residents were offered, screened, educated and received influenza and pneumococcal vaccinations as required. This affected nine residents (#23, #24, #25, #26, #31, #38, #43, #55 and #204) reviewed/interviewed as part of the survey and the lack of an effective system to manage vaccinations and prevent incidents of influenza/pneumonia had the potential to affect all 54 residents residing in the facility. The facility census was 54.

Inspectors wroteBased on medical record review, review of a facility immunization report, review of staff vaccination reports, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed ensure residents and staff were educated, screened, and offered COVID-19 vaccinations as required. This affected seven residents (#23, #24, #25, #31, #38, #55 and #204) of seven reviewed for immunizations and the lack of an effective program to manage vaccinations affected all residents in the facility. The facility census was 54.

Inspectors wroteBased on review of the personnel files, review of the facility assessment and interviews, the facility failed to ensure Certified Nursing Assistants (CNA) #305 and #329 received annual performance reviews. This affected two CNAs of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected five residents (#7, #15, #20, #25 and #34) out of 24 resident records reviewed. The facility census was 54.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments for residents were complete and accurate. This affected four (Residents #22, #24, #37 and #43) of 28 residents reviewed for the accuracy and completion of assessments. The facility census was 54.

Inspectors wrote4. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety and depression. Review of Resident #25's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). No care plan was available addressing Resident #25's advance directives. Interview on 03/12/25 at 9:11 A.M. with Social Service Designee (SSD) #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #25 did not have a care plan developed addressing his advance directive and should have. 5. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure showers were provided as scheduled and per the resident preference for dependent residents. This affected four (Residents #23, #37, #43 and #48) of four dependent residents reviewed for activities of daily living. The facility census was 54.

Inspectors wroteBased on observation, medical record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #18 and Resident #204 to prevent falls. The facility also failed to ensure cigarette butts were properly disposed of after smoking. This affected two residents (#18 and #204) of three residents reviewed for falls/accidents and 19 residents (Residents #1, #2, #3, #9, #11, #12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203) identified by the facility as residents who smoke. The facility census was 54.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to act upon pharmacy reviews in a timely manner. This affected five (Residents #5, #7, #18, #24 and #37) of five residents reviewed for unnecessary medications. Facility census was 54.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure medical records were complete and accurate. This affected four (Residents #11, #18, #22 and #43) of 28 records reviewed. The facility census was 54.

Inspectors wroteBased on interview, record review, review of infection control logs, and review of facility policy, the facility failed to ensure implementation of appropriate antibiotic stewardship measures. This affected one Resident (#9) of three reviewed for urinary tract infections and 15 residents (#2, #9, #19, #23, #24, #25, #29, #32, #33, #35, #37, #42, #43, #50, and #55) of 15 residents reviewed in the infection control log. The facility census was 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident authorized the facility to manage their personal funds and the authorization was witnessed by a third party. This affected two (Residents #30 and #207) of six residents reviewed for personal funds. The facility census was 54.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resident personal funds were disbursed to the resident's estate within 30 days. This affected two (Residents #30 and #207) of two residents reviewed for personal funds after death. The facility census was 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were able to use the phone when requested and in private. This affected one (Resident #206) of one resident reviewed for facility phone usage. The facility census was 54.

Inspectors wroteBased on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to prevent resident-to-resident physical abuse. This affected one resident (#23) out of five residents reviewed for abuse. Facility census was 54.

Inspectors wroteBased on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to timely report allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse. Facility census was 54.

Inspectors wroteBased on review of a self-reported incident, review of the facility policy, record review and interview, the facility failed to thoroughly investigate allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse Facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing assessments were completed on admission for residents. This affected one (Resident #48) of 28 residents reviewed for nursing assessments.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan for Resident #48. This affected one (Resident #48) out of 19 residents reviewed for baseline care plans. The facility census was 54.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to timely update care plans to address changes in residents' advance directives. This affected three residents (#7, #15 and #20) out of 26 residents reviewed for care planning. Facility census was 54.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure showers were completed for independent residents. This affected three (Residents #15, #22 and #203) of three residents reviewed who were independent with activities of daily living (ADL). The facility census was 54.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure an anchoring device for Resident #204's indwelling urinary catheter was implemented to prevent catheter-related complications. This affected one resident (Resident #204) of one resident reviewed for indwelling urinary catheters. The facility census was 54.

Inspectors wroteBased on record review, review of the facility contract, review of the facility policy and interview, the facility failed to complete pre and post dialysis assessments as required and to collaborate care with the outside dialysis center. Also, the facility failed to ensure there was a valid contract between the facility and the outside dialysis center to ensure coordination of all care and services pertaining to dialysis treatment for Resident #25. This affected one resident (#25) of one resident reviewed for dialysis. The facility identified no other residents as receiving dialysis. The facility census was 54.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure staff were providing necessary behavioral health care for residents to attain and maintain their highest physical, mental and psychosocial well-being. This affected one (Resident #204) of six residents reviewed for behaviors. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and administered as ordered. This affected one (Resident #23) of 28 residents reviewed for medication administration. The facility census was 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were monitored for the use of psychotropic medications. This affected three residents (#5, #18, and #37) of five residents reviewed for unnecessary medications. The facility census was 54.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one resident (#18) of 28 residents reviewed for medications. The facility census was 54.

Inspectors wroteBased on record review, review of the facility's self-reported incidents (SRI) #250112 and #250126, staff interview, and review of the facility's abuse policy, the facility failed to submit their SRI investigation findings within five working days. This affected three residents (#5, #21, and #37) of five reviewed for abuse. The facility census was 44.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure a safe environment, and equipment was functioning and available for preparation of resident food. This had the potential to affect all residents served food from the kitchen. The facility census was 40.

Inspectors wroteBased on observation of camera footage, interview, record review and review of facility policy the facility failed to ensure Resident #21 was treated with dignity and respect. This affected one resident (Resident #21) out of three residents reviewed for dignity. The facility census was 40.

Inspectors wroteBased on observation, interview, record review, facility self-reported incident (SRI) review, and review of facility policy the facility failed to ensure Resident #21's Injury of Unknown Origin was reported to the State Agency. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure a thorough investigation of Resident #21's Injury of Unknown Origin on her bilateral arms. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure Resident #18 and #21's incontinence care was completed timely, and followed appropriate standards of care. This affected two residents (Resident's #18 and #21) out of three residents reviewed for incontinence care. The facility census was 40.

Inspectors wroteBased on observation, interview, record review the facility failed to complete Resident #20's Speech Therapy evaluation was ordered to ensure safe eating and adequate nutrition. This affected one resident (Resident #20) out of three residents reviewed for nutrition. The facility census was 40.

Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to ensure Resident #21 was free from significant medication error and medications were administered per physician orders. This affected one resident (Resident #21) out of three residents reviewed for medications administered per physician orders. The facility census was 40.

Inspectors wroteBased on observations and interview the facility failed to ensure food was stored in a manner to prevent food borne illness and failed to maintain a sanitary kitchen. This had the potential to affect all residents except Resident #34 who did not receive nutrition by mouth. Facility census was 38.

Inspectors wroteBased on observations and interview the facility failed to dispose of garbage and refuse appropriately. This had the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents were provided dignified dining experience when meals were not provided on non-disposable plates. This affected 13 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #37, #60, #90 and #92) who were served all meals on Styrofoam plates due to the facility not having a sufficient number of plates. The facility census was 40.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of the policy, the facility failed to provide a phone for residents to use that would be located in a private area to allow for private conversations. This affected one (#37) and had the potential to affect all residents except (Resident #34, #6, #10, #60, #25, #9, #23, and #11) who did not use the facility phones. The facility census was 40.

Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of the policy, the facility failed to provide a clean, comfortable homelike environment for residents. This affected four (#1, #2, #8, and #26) of 22 resident rooms observed. The facility census was 40.

Inspectors wroteBased on observation, medical record review, activity calendar review, resident interview and staff interview, the facility failed to prove structured meaningful group activities for residents residing in the Memory Care Unit. This affected three (#7, #17, and #92) and had the potential to affect all 11 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #90 and #92) residing in the Memory Care Unit. The facility census was 40.

Inspectors wroteBased on observation, staff interview, record review, and review of policy, the facility failed to ensure fall prevention interventions were in place and ensure a resident was provided a smoking apron intervention to prevent burns. This affected six (#3, #9, #14, #27, #32, and #34) of seven residents reviewed for incidents and accidents. The facility census was 40.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure medications were stored in a secure manner. This affected one (#7) and had the potential to affect 10 (#6, #13, #17, #18, #20, #24, #28, #34, #90 and #92) additional residents residing in the Memory Care Unit. The facility census was 40.

Inspectors wroteBased on observation, resident interview, staff interviews, record review and review of the policies, the facility failed to maintain infection control practices of hand washing and during oxygen therapy. This affected four (#2, #6, #16 and #17) of six residents reviewed for infection control. The facility census was 40.

Inspectors wroteBased on record review, staff interview, and review of the policy, the facility failed to timely notify a resident's Guardian, after a fall. This affected one (#1) of three residents reviewed for notification to the responsible party after a fall. The facility census was 20.

Inspectors wroteBased on medical record review, review of resident council minutes, review of staff schedules, review of Self-Reported Incidents (SRI), staff interview and review of the policy, the facility failed to report an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40.

Inspectors wroteBased on medical record review, review of resident council minutes, staff interview and review of the policy, the facility failed to investigate an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility did not provide or offer resident showers or baths as care planned. This affected one (#9) of three residents reviewed for showers/bathing. The facility census was 20.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to implement a physician order timely for treatment to a wound for a resident and complete wound treatments as ordered. This affected two (#9 and #16) of five residents reviewed for wound treatments. The facility census was 40.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide nutritional supplements per physician orders. This affected one (#9) of three residents reviewed for supplements. The facility census was 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from a significant medication error when medications were not administered per the physicians order. This affected one (#37) of three residents reviewed for medication administration. The facility census was 40.

Inspectors wroteBased on record review, staff interview, and review of the policy, the facility failed to notify the physician/Certified Nurse Practitioner (CNP) timely of a high potassium level (lab value) for one resident. This affected one (#37) of three residents reviewed for physician notification of lab results. The facility census was 40.

Inspectors wroteBased on record review, staff interview, and review of the policy, the facility failed to consistently document three residents controlled drug administration on their Medication Administration Record (MAR). This affected three (#1, #2 and #3) of four residents reviewed for accuracy of documentation on the medication administration record. The facility census was 40.

Inspectors wroteBased on closed record review, policy and procedure review and interview, the facility failed to timely identify, provide timely medical intervention and notify Resident #42's physician and power of attorney (POA) of an acute change in condition/altered mental status. This affected one resident (#42) of three residents reviewed for change of condition. The facility census was 39. Actual Harm occurred beginning on 08/27/23 at 1:46 A.M. when facility staff failed to timely identify and provide medical intervention for an acute change in condition (including lethargy, pain, decreased oxygen level) for Resident #42. The resident was noted to have a change in condition with no evidence, from 08/27/23 through 08/31/23 the resident's physician or power of attorney (POA) were notified. On 08/31/23 at 9:36 P.M. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected seven of twelve rooms on the locked unit, the residents who used the East hallway, and had the potential to affect all 39 residents currently residing in the facility.

Inspectors wroteBased on observation and staff interview the failed to maintain Resident #7's padded electric wheelchair in a clean and sanitary condition. This affected one resident (#7) of 39 residents reviewed for environment.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure proper mouth care was provided for Resident #43. This affected one resident (#43) out of three residents reviewed for assistance with activities of daily living. The facility census was 39.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure routine ongoing skin assessments were completed to timely identify and/or prevent pressure ulcer development. This affected three residents (#7, #20 and #43) of four residents reviewed for skin assessments/pressure ulcer care and treatment.

Inspectors wroteBased on record review, interview, and observation the facility failed to ensure documentation was accurate for two residents (#20, and #41) out of four resident records reviewed for accurate documentation. The facility census was 39.

Inspectors wroteBased on review of facility staffing schedules and staff interviews, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 44 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food in the proper portions to meet the nutritional needs of all residents in the facility ordered regular and therapeutic diets. This affected all 44 residents receiving meals from the kitchen, as no residents were identified by the facility as nothing by mouth (NPO). The facility census was 44.

Inspectors wroteBased on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures. This had the potential to affect 44 residents receiving meals from the kitchen. No residents were identified as nothing by mouth (NPO). The facility census was 44.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the food was prepared, stored and served in a clean and sanitary manner. This had the potential to affect all 44 residents in the facility receiving meals from the kitchen, as there were no residents identified by the facility as nothing by mouth (NPO). The facility census was 44.

Inspectors wroteBased on record review, observation and staff and resident interviews, the facility failed to act promptly upon grievances voiced during Resident Council meetings concerning issues of resident care and life in the facility. This affected four residents (Resident #3, #10, #11, and #29) of six residents who attended the resident council meeting and voiced concerns. The facility census was 44.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #299) of one resident reviewed for funds conveyance. The facility census was 44. Findings Include: Resident #299 was admitted to the facility on [DATE]. Resident #299 expired at the facility on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis right side, dysphagia, diabetes mellitus, depression, and cerebral infarction. Review of the business records for Resident #299 revealed $974.48 were dispersed to the State Recovery of the United States on [DATE]. Interview on [DATE] at 9:46 A.M. with Human Resource Manager/Business Office Manager (HR/BOM) #255 revealed the corporate office sends her the check and then she sends it out right away. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #39) of one resident reviewed for advanced directives. The facility census was 44. Findings Include: Resident #39 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, schizophrenia, bipolar and systemic lupus erythematosus. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderate cognitively impairment and was independent for activities of daily living. Review of the physicians' orders for Resident #39 revealed an order dated [DATE] for do not resuscitate comfort care (DNRCC) a code status signifying cardiopulmonary resuscitative measures (CPR) was not to be conducted in case of cardiac or respiratory arrest. [...]

Inspectors wroteBased on medical record review, staff and family representative interview, and review of the facility policy, the facility failed to ensure a resident's family was notified following a change in status. This affected one (Resident #33) of three residents reviewed for notification of change in condition. The facility census was 44.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received showers as scheduled and per their preference. This affected three (Residents #2, #3, and #19) of three residents reviewed for showers. The facility had a census of 44 residents.

Inspectors wroteBased on medical record review, resident and staff interviews, review of job description, review of facility activity calendars, and policy review the facility failed to ensure activities to meet resident preferences and interests were offered on Saturdays. This affected two residents (Residents #10 and #29) of six residents reviewed for activities. The facility census was 44.

Inspectors wroteBased on observation, medical record review, staff interview and policy review the facility failed to change an enteral tube feeding after 24 hours. This affected one resident (Resident #248) of two residents reviewed for tube feedings. The facility census was 44.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected two (Resident #2 and #4) of two residents reviewed for respiratory care. The facility had a census of 44 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #2's pain medication was administered as ordered. This affected one (Resident #2) of three residents reviewed for timely reordering of pain medications. The facility had a census of 44 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all narcotic medication accounting logs were maintained. This affected one (Resident #2) of three residents reviewed for documentation and accounting of narcotic medications. The facility had a census of 44 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #2) of one resident reviewed for improperly stored medications. The facility had a census of 44 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food at the proper consistency to Resident #35. This affected one resident (Resident #35) of 44 residents receiving meals from the kitchen. No residents were identified by the facility as nothing by mouth (NPO). The facility census was 44.

Inspectors wroteBased on resident and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected three residents (Residents #3, #10 and #29) of six reviewed who attended the resident council meeting and voiced concerns. The facility census was 44.