Mulder Health Care Facility

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R61) reviewed for fall concerns. CNA G (Certified Nursing Assistant) did not utilize a gait belt while transferring R61 in the shower room. R61 fell sustaining a right hip fracture and other injuries. R61 is a 1 person assist with transfers and requires a gait belt. The facility failed to identify that CNA G did not utilize a gait belt for the transfer. As evidenced by:Per OSHA (Occupational Safety and Health Administration) Gait belts, also called transfer belts, are designed to provide caregivers with a secure grip to stabilize patients during transfers, ambulation, or repositioning. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 4 residents (R68) reviewed for medication errors out of a sample of 24. R68 had an order to stop oral chemotherapy medication. R68 was given chemotherapy medications and experienced nausea, weakness, worsening dysphagia, and dizziness. R68 was sent to the emergency room and was found to be significantly more anemic than the week prior. R68 required intervention in the ER when he was given a unit of blood and hospitalized for several days. Evidenced by:This The facility policy entitled, Med Pass, dated 4/2020, states, in part: . III. Medication Error Types: . B. Unauthorized Drug Error: Administration to the patient a dose of medication not authorized for the patient at the time. V. Medication Administration Procedures: . E. General Information: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the implementation of an effective antibiotic stewardship program, including adherence to evidence-based criteria and accurate tracking of antibiotic use, for 3 of 10 residents (R3, R13, R97) reviewed for antibiotic therapy. R97 was prescribed an antibiotic the identified organism was resistant to in April 2026. R97 then developed 3 more UTIs over the following weeks and developed resistance to two additional antibiotics. R97 eventually required treatment with IV (intravenous) antibiotics to treat their urinary tract infection. Antibiotic stewardship education was not given to the provider over this time period. R13 was prescribed Cefdinir, an antibiotic, however no sensitivity test was conducted to determine if the antibiotic was effective against the identified organism. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 70 residents who reside in the facility. Surveyor observed staff turning wet dishware upside down on a tray creating a seal and not allowing the dishware to air dry completely. Surveyor observed food to be in circulation past the use by date. Surveyor observed an unclean mixer stored under a plastic covering. Evidenced by:Example 1Facility policy, titled Handling of Leftover Food, revised 1/2025, includes: .Leftovers should be covered, labeled, dated, and refrigerated as soon as the tray line is finished. Refrigerated leftovers should be used within 3 - 7 days after opening. [...]

Inspectors wroteBased on interview and record review the facility did not 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, this has the potential to affect the census of 70. The facility did not monitor residents with potentially infectious symptoms. The facility policies do not indicate what data should be collected for the residents with potentially infectious symptoms. CNA R (Certified Nursing Assistant) did not complete hand hygiene per standards of practice while providing perineal care for resident (R21). This is evidenced by: Facility policy entitled, Monitoring Infection Control Practices, last reviewed 2/13/26, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review the facility did not ensure the required contents of the Notice of bed-hold policy and return was provided with the bed hold notice for 4 of 4 residents (R39, R53, R68, R9) reviewed for hospitalizations out of a sample of 24 Residents. R39 had an incomplete bed hold notice for 3/8/26 and 5/26/26. R53 had an incomplete bed hold notice for 6/15/26. R68 had an incomplete bed hold notice for 6/30/26. R9 was sent to the hospital on 2/5/26. The bed hold provided to R9 did not include the reason for transfer or include resources available for the resident. R9 was sent to the hospital on 4/8/26. The bed hold provided did not include resources available to resident. This is evidenced by: Per the State Operations Manual, The written notice must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not always serve food that was palatable and served at the right temperature. This has the potential to affect 1 of 1 sampled Residents (R33) and 2 of 2 supplemental residents (R17 and R79), and 1 of 1 test trays. This has the ability to affect more than a minimal number of Residents. Surveyor performed a test tray, and the results were not palatable. R79, R33, and R17 voiced concerns of their hot meals being served to them at cold and undesirable temperatures. During the Resident Council Group, residents voiced the coffee is always cold and residents do not get menus. Evidenced by: Facility policy, titled Food Temperature Records/Control, revised 1/25, includes: The temperature of all foods on serving line will be measured prior to resident service. Cold foods should be 41 degrees F (Fahrenheit) or less. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the PASARR (Preadmission Screening and Resident Review) process for 3 of 5 residents (R8, R9 and R72) reviewed for PASARR screening out of 24 sampled Residents. R8 had a Level 1 PASARR screening completed with a 30-day exemption request. The facility did not have a level II PASARR screening completed at the end of the 30-day exemption. R9 had a Level 1 PASARR screening completed with a 30-day exemption request. The facility did not have a level II PASARR screening completed at the end of the 30-day exemption. R72 did not have a level two PASRR (Preadmission Screening and Resident Review) completed. Evidenced by: The facility policy, entitled Pre-admission admission Process, dated 1/25, states, in part: Standard: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 2 of 5 residents (R8 & R44) reviewed for unnecessary medications. R8 is receiving Melatonin for insomnia and did not have a sleep assessment completed. R44 did not have any kind of assessment completed prior to or on a regular basis after beginning a sleep aid. Evidenced by: The facility policy entitled, Psychotropic Medication Use, dated 1/2026, states, in part: . Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. Policy Explanation and Compliance Guidelines: 1. Psychotropic medications include, but are not limited to: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for 2 of 4 residents (R33 & R3) out of 24 sampled Residents. R33 had a scheduled colonoscopy with instructions to hold Eliquis prior to procedure. The facility administered R33's Eliquis and the colonoscopy had to be cancelled due to the Eliquis given. The facility did not follow physician orders resulting in a medication error. R3 received new orders to increase his losartan, and this medication was not provided per physician orders. Evidenced by: The facility policy entitled, Med Pass, dated 4/2020, states, in part: . III. Medication Error Types: . B. Unauthorized Drug Error: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications (R8). R8 is receiving Trazodone for Insomnia. The facility failed to complete a sleep assessment prior to starting the medication. Evidenced by:The facility policy entitled, Psychotropic Medication Use, dated 1/2026, states, in part: . Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. Policy Explanation and Compliance Guidelines:1. Psychotropic medications include, but are not limited to: antipsychotics, antidepressants, anti-anxiety, and hypnotics.2. The indications for use of any psychotropic drug will be documented in the medical record.a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 1 sampled resident's (R33). R33 voiced concerns he does not receive his preferences as specified on meal tickets unless he asks for them. Evidenced by:The facility policy entitled, Nutritional Assessment, dated 1/25, states, in part: . Policy: A nutritional assessment will be completed on all residents within 5-14 days of admission. Procedure:1. Collect Data: A. Complete Nutritional Assessment Form in EMR (electronic medical record). 1. Assessment form includes: . f. Collecting likes/dislikes. Communicate Data: 1. Document nutrition related problems and approaches. 2. [...]

Inspectors wroteBased on interview and record review the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 26 sampled residents (R53) for change of condition. The facility did not maintain a complete medical record for R53. Evidenced by:Facility policy, titled Clinical Record policies, reviewed 1/2026, includes: . The clinical record shall contain information to identify the resident clearly, a record of the resident's assessments, the plan of care and services, the results of pre-admission screening, and progress notes which indicate changes towards achieving care plan objectives. In addition, the resident's clinical record shall be readily accessible and systematically organized to facilitate retrieving and compiling information. [...]

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to ensure four Residents (R)2, R3, R4 and R5) of a total of 16 residents reviewed for abuse/neglect/misappropriation were free from misappropriation of funds when money was stolen from each of the residents by a staff member (Certified Nursing Assistant (CNA1)). The facility's failure to ensure residents were free from misappropriation of property/funds created the potential for these and other residents to experience psychosocial harm related to the misappropriation and/or continued misappropriation of property/funds. A total of 16 residents were reviewed in the sample.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure menus were followed. This failure placed 78 of the 79 residents in the facility at risk for nutritional problems and dissatisfaction with their meals.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the kitchen staff prevented contamination of food containers while taking food temperatures and also when the kitchen staff was placing lids on the bowls that contained food the residents would eat. This failure had the potential to increase the risk of foodborne illness for 78 of the facility's 78 residents. During an observation on 01/21/26 at 11:20 AM, Cook1 was observed taking food temperatures of the Chili with Beans, Mashed Potatoes, and pureed Mixed Vegetables. Cook1 was observed to touch the inside of each of these food containers with her bare hand while taking the food temperatures. [...]

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to ensure consistent and comprehensive management of nutritional services for one Resident (R ) R14) out of three residents reviewed for nutrition. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits. A total of 50 residents were reviewed in the sample.

Inspectors wroteBased on interview and record review, the facility failed to put measures in place to prevent further abuse, following an allegation of abuse, for 1 of 1 allegation reviewed. This has the potential to affect a pattern of the facility's 75 residents. On 09/09/25, allegations of potential abuse were reported against Certified Nursing Assistant (CNA) G. CNA G was allowed to continue working with residents for the rest of that shift and worked again on 09/11/25 and 09/12/25 during the facility's investigation. This is evidenced by:The facility policy, titled Abuse Prevention Program, dated last reviewed 01/2025, states in part: Upon recognizing signs/symptoms of stressed staff, the observer will take action which may include but is not limited to. relieve the staff member of direct care duties. The investigation must include but not limited to: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident remained free from abuse for 1 of 8 sampled residents (R4). R4 was spoken to in a manner that is described by the resident as abusive; the resident also states that staff did not release her wrist as requested. The facility policy, titled Abuse Prevention Program, dated last reviewed 01/2025, states, Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. R4 was admitted to the facility in 2024, with diagnoses including, gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. R4 is alert and oriented and able to make her needs known. [...]

Inspectors wroteBased on interview and record review the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 resident incidents reviewed. (R4)R4 was spoken to in a manner that is described by the resident as abusive; [...]

Inspectors wroteBased on interview and record review, 1 of 8 sampled residents (R1) was not provided with supervision to prevent accidents. R1 was being transferred to the bathroom via EZ stand when her shoulder was bumped into the door frame; the CNA staff who were assisting the resident at the time did not report this incident to the charge nurse. This is evidenced by: The facility policy, titled Resident Incident/Accident Reporting Protocol, dated reviewed 01/2025, states, All incidents and accidents (regardless of how minor they may present) must be reported to the Charge Nurse immediately upon discovery with a completed applicable event report and communicated to the oncoming shift. R1 was admitted to the facility with diagnoses including, right sided hemiplegia, impaired mobility, hypertensive intracerebral hemorrhage, chronic pain, and osteoarthritis. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all residents residing within the facility at the time of an outbreak on 1/2/25. This outbreak involved 49 out of 83 residents and 37 staff. As of 1/2/25, the facility was in a GI (gastrointestinal) outbreak with 2 staff and 1 resident with noted signs and symptoms of GI outbreak. - Facility staff line listings were not completed contemporaneously. - Temporary Care plans were not started for residents with GI signs and symptoms. - Residents with orders for Laxatives and Diuretics continued to take their prescribed medication without any monitoring for dehydration or bowel movement consistency and frequency. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and behavioral health related services to assure resident safety for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents reviewed (R55). R11 had expressed suicidal ideations related to his chronic pain (phantom limb pain) multiple times in the two months preceding R11 stabbing himself in the chest with scissors due to unrelieved pain. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate fluid intake to maintain acceptable parameters of hydration for 1 of 4 Residents (R19) reviewed for nutrition. On 3/7 - 3/13/25 R19 was hospitalized with aspiration pneumonia and received intravenous fluids during his hospitalization. On 3/17-3/19/25 R19 was hospitalized with dehydration requiring intravenous fluids. R19 was consistently not meeting his daily recommended fluid intake of greater than 1,400 ml (milliliters). R19 had a significant weight loss of 10.9% from 3/7/25 - 3/26/25. The facility failed to ensure R19 received adequate fluid intakes to maintain acceptable parameters of hydration by failing to total and assess daily fluid intake; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 76 residents residing in the facility. The facility assessment does not indicate: - How many residents the facility can safely care for with suicidal ideation - How many residents the facility can safely care for with PTSD or a history of trauma - How many staff members are required to safely care for residents with suicidal ideation - How many staff members are required to safely care for residents with PTSD or a history of trauma - Staff training required to care for residents with suicidal ideation and/or PTSD or a history of trauma This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies. This is evidenced by the number and seriousness of citations during this recertification survey, which has the potential to affect all 76 residents who reside in the facility. During this recertification survey from 4/7/25 through 4/14/25, the facility had multiple citations including F880 L, F741 J with 2 examples, F692 G, and F838 F. The facility Quality Assurance Committee has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices. 1. Sufficient/competent Staff-Behavioral Health Needs 2. Infection Control 3. Nutrition/hydration Status Maintenance 4. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure the environment remained free of hazards for 4 of 4 supplemental residents (R12, R66, R68 and R70) who smoke. R12 was observed outside smoking, on the sidewalk in the front of the facility, with no receptacle to dispose of her cigarette butts in the area. R66 was observed outside smoking, on the patio in the smoking area, with a small receptacle to dispose his cigarette butts. In the same area was a plastic garbage can with a large amount of cigarette butts in it. R68 and R70 are indicated as being smokers and the facility does not have an appropriate receptacle for smoking material to be disposed into. Evidenced by: The facility Smoking Policy, reviewed 01/2024, includes, in part, the following: Purpose: To offer a safe environment to all residents in the facility. 15.2 Procedure. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to assess for risk of entrapment between the mattress and side rail and failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 3 of 3 sampled residents (R73, R46 and R25) and 2 of 2 supplemental Residents (R49 and R54) reviewed for bed rails. R73, R46, R54, R25 and R49 all have an air mattress with enabler bars/bedrails. The facility did not complete all requirements as listed in F700 of the State Operations Manual prior to installing bed rails/enabler bars. The facility failed to complete a safety/gap test with the air mattress and provide written documentation of ongoing monitoring of bed rails.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect more than a minimal number of residents residing at the facility. Residents voiced concerns with hot foods being served cold. (R45, R25, R14, and R11) 3 of 3 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility Resident Council Minutes included, in part, the following: 3/3/25: Dietary: resident specific requests. Note there was no further explanation what the requests were. 12/2/24: Cold food, has improved. 11/4/24: Food coming cold. Example 1 R45 was admitted to the facility 11/8/24. R45's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/14/25 indicates R45 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not conduct thorough background checks on 2 of 8 employees that were randomly selected.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 22 sampled residents (R45 & R18) reviewed for abuse. Facility did not report an incident of resident-to-resident altercation involving R45 and R18 to the State Agency (SA). Evidenced by: The facility Abuse Prevention Program Policy and Procedure reviewed 01/2025, includes, in part, the following: VII. Reporting/Response. All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required official, including to the State Survey Agency, . [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 22 sampled residents (R45 and R18) reviewed for abuse. Facility did not fully investigate an incident of resident-to-resident altercation involving R45 and R18 to the State Agency (SA). Evidenced by: The facility Abuse Prevention Program Policy and Procedure reviewed 01/2025, includes, in part, the following: V. Investigation. 1. The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days. Example 1 On 4/7/25 at 1:55 PM Surveyor interviewed R45. R45 indicated in early March he had altercation with his former roommate (R18). R45's Resident Progress Notes include, in part, the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility following a hospitalization for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed. R11 was not permitted to return to the facility following an emergency facility-initiated transfer to the hospital. The facility discharged R11 and stated they would not allow R11 to return. R55 was not permitted to return to the facility following an emergency facility-initiated transfer to the hospital. The facility discharged R55 and would not allow R55 to return. It should be noted R55's guardian wished for R55 to return to the facility and R55 was pending Medicaid approval at the time of discharge. Example 1 R11 was admitted to the facility on [DATE], with diagnoses that include: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge, failed to ensure the written notice contained all pertinent information for a discharge notice including the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge. The facility failed to notify R11 and R55 in writing prior to a facility-initiated discharge, did not give R11 or R55 a chance to appeal the facility-initiated discharge, and did not appropriately prepare R11 or R55 for the facility-initiated discharge. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge. The facility failed to notify R11 and R55 in writing prior to a facility-initiated discharge, and did not appropriately prepare R11 or R55 for the facility-initiated discharge. This is evidenced by: The facility policy titled, Resident Transfers and Discharge Notification, dated 1/2025, states in part: . Procedure: Facility-initiated transfer or discharge - Involuntary Discharge The facility will provide written notice in a language the resident or resident's representative can understand. The notice must also be provided to an immediate family member or legal representative. [...]

Inspectors wroteBased on interview and record review the facility did not provide written information to the resident or resident representative regarding the bed hold policy for 1 (R55) of 1 supplemental resident's reviewed for facility-initiated discharge R55 is not his own person and has two guardians. Neither guardian was provided with a written bed hold prior to R55 being transferred to the hospital on 4/10/24. This is evidenced by: The facility policy entitled, Bed Hold, dated, 1/2025, states, in part: . Policy: Our facility allows residents to hold or reserve a bed while absent from the facility due to hospitalization or therapeutic leave. This policy applies to all residents regardless of payment source and will be provided to the resident or resident's representative at the time of admission and again with any emergency transfer from the community . Procedure: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit 1 of 1 sampled resident (R11) and 1 of 1 supplemental residents (R55) reviewed for facility-initiated discharge to return to the facility after a hospitalization and the ability to return to the facility. R11 and R55 were not allowed to return to the facility following an emergency facility-initiated transfer to the emergency room. The facility stated they would be discharging R11 and R55 due to inability to provide the staffing level needed to care for R11 and R55. It should be noted R11 signed a bed hold and the facility had a bed hold for R55 that stated the family gave verbal consent to hold the bed and would pay the bed hold charges. Example 1 R11 was admitted to the facility on [DATE], with diagnoses that include: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 22 residents reviewed for ADLs (Activities of Daily Living) (R34). R34 requested to use the bathroom. CNA EEE (Certified Nursing Assistant) told R34 she is on a two (2) hour toileting schedule and will need to wait. R34 was waiting approximately 1 hour and 20 minutes before being assisted to the bathroom. Evidenced by: The facility's policy, Activities of Daily Living, dated 3/2023, includes, in part, as follows: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 2 residents reviewed for pressure injuries (R73). R73 had a pressure reducing air mattress for pressure injury healing and was observed laying on the mattress with multiple layers under R73.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 sampled resident (R11) and 1 of 1 supplemental resident (R55). R11 stabbed himself with a pair of scissors after experiencing uncontrolled phantom limb pain. Prior to this, R11 had expressed suicidal ideations related to his chronic pain multiple times in the two months prior to this event. R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. Following this incident, the resident returned to the facility and continued to express suicidal ideation and uncontrolled pain. [...]

Inspectors wroteBased on interview and record review the facility did not provide food prepared in a form designed to meet individual needs for 1 of 1 sampled resident (R48). The facility has not reassessed R48's swallowing ability after she was unable to wear her lower denture due to an abscess to ensure she receives food prepared in a form that meets her needs. As evidenced by The facility's policy, Diet Order, revised 1/2025, documents, in part, as follows: During the course of the resident's stay, any diet change as recommended by the Dietician, Diet Technician, Speech Language Pathologist, or Nurse should be communicated to the attending M.D. (Medical Doctor). for consideration. Nursing may downgrade a diet texture temporarily for example: oral problems, difficulty swallowing/chewing, mouth sores, etc. [...]

Inspectors wroteBased on record review and interview, the facility did not immediately consult with the resident's physician when 1 of 3 sampled residents (R1) experienced a significant change or required a change in treatment. R1's physician was not consulted when R1's oxygen saturation and pulse fell below the desired range. This is evidenced by the following: The facility policy and procedure Notification of Change, last reviewed 1/24, states, in part: Introduction: The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change of condition, potential discharge, room transfer for death. Notification Parameters: [Facility] has adopted the current INTERACT Tools Change of Condition: When to report to the MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for needing assistance or supervision with meals. On 10/13/24, R1 was in the dining room for her supper meal. R1 was attempting to eat soup and spilled the soup onto herself causing 2nd degree burns to her right arm and abdomen. R1 required supervision during meals; supervision and assistance were not provided. Soup temperature following R1 suffering burns and after meal service was 177 degrees. The facility's failure to provide adequate supervision and assistance during meals and the failure to ensure foods and fluids were served at a temperature that would not cause burns created a finding of immediate jeopardy which began on 10/13/24. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all incidents involving potential abuse were thoroughly investigated for 1 of 4 residents (R) 6. R6 swung arm out and hit R5 in the chest as R5 came by in R5's wheelchair. Facility did not interview other residents in the facility for potential abuse.

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect 75 of 76 residents residing in the facility.

Inspectors wroteBased on observations and interview, the facility did not prepare and distribute food under sanitary conditions. Dishwasher temperatures did not reach correct levels, staff did not perform hand hygiene with glove use, and staff with a beard did not wear a beard net. This has the potential to affect 75 of 76 residents.

Inspectors wroteBased on observation and interviews, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used a clothing protector to wipe R37 and R35's face during dining. Facility staff were heard sharing R30, R54, R1, and R24's personal information in public areas of the facility. Facility staff did not respond in a respectful manner to R14. This occurred for 7 of 76 residents. This is evidenced by: The facility policy, entitled Dignity, dated reviewed on 01/24, states in part: Dignity means that in their interactions with residents . Demonstrating courtesy, patience, and friendliness in all interactions . Provision of care instruction in privacy . Promoting residents' independence and dignity in dining. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 76 residents (R). (R52, R28, R60, R233, and R70) Staff observed passing medication without proper hand hygiene. Staff observed rinsing a urine soiled commode bucket in the resident's bathroom sink.

Inspectors wroteBased on interview and record review, the facility did not complete the required Preadmission Screen and Resident Review (PASRR) screens for 1 of 2 residents reviewed, (R18). This is evidenced by: The facility policy, entitled Resident Assessment PASRR Requirements, dated 11/28/17, states: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not develop comprehensive person centered care plans for 3 of 21 sampled residents. (R1, R30, and R7) This is evidenced by: The facility policy, entitled Resident Assessment Care Plan Development, dated updated on 05/24/2022, states in part: Reflect changes in the residents' preferences and goals as they change throughout their stay .The comprehensive care plan will be developed and maintained .Updates will be made to the comprehensive care plan as needed. Example 1 R1 was admitted to the facility in October 2023 and has diagnoses that include chronic respiratory failure, obstructive sleep apnea, type 2 diabetes mellitus, obesity, and schizophrenia. R1's care plan dated 10/26/23 document, goal resident will be clean/well-groomed daily approaches include. [...]

Inspectors wroteBased on record review and interview, the facility did not revise or update resident (R) care plans for 1 of 21 sampled residents (R35). This is evidenced by: The facility policy, entitled Resident Assessment Care Plan Development, updated on 05/24/2022, states in part: Reflect changes in the residents' preferences and goals as they change throughout their stay .Updates will be made to the comprehensive care plan as needed. R35 was admitted to the facility on [DATE], with diagnoses including Parkinsonism, adult failure to thrive, and R35 is currently on hospice. R35's care plan lists approaches under activities; including: Visitors: Family window visits. R35's care plan lists goals; including: Will not deteriorate in ability to ambulate AEB: ability to ambulate 50 feet independently with walker. The Short Term Goal Target Date: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a pressure injury (PI) or at risk for PIs received necessary treatment and services, frequent repositioning, pressure relieving interventions that are consistent with professional standards of practice, to prevent the development of PIs and to promote healing for 3 of 6 residents (R) reviewed for PIs. (R74, R23, and R25)

Inspectors wroteBased on interview and record review, the facility did not ensure to obtain rationale for catheter use and physician's order for a catheter for 1 of 4 sampled residents (R)7.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when COVID precautions of appropriate Personal Protective Equipment (PPE) were not followed and employee fit testing for N95 masks were outdated. This has the potential to affect all 76 residents residing in the facility at the time of survey. This is evidenced by: The facility policy entitled, Covid-19 Prevention, Response and Reporting, dated 05/2023, states: .HCP [Health Care Provider] who enter the room of a resident with suspected or confirmed SARS-CoV-2 [COVID] infection should adhere to standard precautions and use a NIOSH [National Institute for Occupational Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (contact and droplet precautions) . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 5 residents (R) of 5 sampled residents (R3, R4, R5, R6, R7) were provided the most recent covid booster, the covid booster was not offered or provided to any residents in the facility having the potential to affect all 76 residents that reside in the facility. This is evidenced by: The facility policy entitled Covid-19 Vaccine Program, dated 09/2023, states: [...]

Inspectors wroteBased on record review, interviews, review of Facility Reported Incident (FRI), and policy review, the facility failed to ensure that one resident (Resident (R) 3) of three residents reviewed for abuse was free from physical abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report timely, within two hours and not later than 24 hours, for initial notification to the state survey agency (SSA), for three of three sampled residents (R2, R3, and R5) which included an allegation of an injury of unknown origin for R5 and a resident-to-resident incident for R2 and R3 reviewed for facility reported incidents (FRIs). Failure to report allegations of injuries of unknown origins and/or resident-to-resident incidents could potentially lead to abuse and neglect.