Normandy Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one resident, (Resident #2) with a history of falls, when staff left the resident unattended on the toilet. The resident attempted to transfer him/herself from the toilet to his/her wheelchair without assistance and fell. When the nurse assessed the resident, he/she guarded his/her right hip and complained of pain. X-ray results showed the resident sustained a fractured right hip. In addition, the facility failed to address falls on the care plan. The sample was four. The census was 95. Review of the facility's Fall Management policy, dated 02/28/23, showed:-Policy: To provide an environment free of accident hazards. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's (Resident #2) representative after the resident had a change in condition. The resident had an unwitnessed fall on 04/26/26. The resident complained of pain. The physician ordered x-rays on 04/26/26. The resident refused the x-rays on 04/27/26. The x-rays were reordered on 04/29/26. The x-rays showed the resident had a fractured right hip. The resident was sent to the hospital on [DATE] for evaluation. Staff did not notify the resident's POA of the x-ray refusal, results and transfer to the hospital. The sample was four. The census was 95. Review of the facility's Notification of Change in Condition policy, revised 01/20/26, showed:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1) when the facility failed to provide follow up care and treatment after Resident #1 had an abnormal lab result which showed an acute hepatitis C infection (viral infection that causes liver swelling, called inflammation. Hepatitis C can lead to serious liver damage). The sample size was 7. The census was 96. Review of the facility's Change in Condition Policy, revised 2/6/25, showed:-Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations;-Responsibility: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 8 sampled residents, who were involved in resident-to-resident incidents were free from physical abuse (Residents #27 and #37, Residents #39 and #65, Residents #4 and #1 and Residents #86 and #49). The resident-to-resident altercations resulted in injuries. The sample was 19. The census was 95. Review of the Abuse Prevention policy, revised 10/21/22, showed: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and other staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual; -Definitions: -Abuse: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food properly in the walk-in cooler and freezer by stacking smashed and wet boxes on top of each other. Staff failed to ensure food items on the menu were consistently available. This resulted in residents receiving alternate meals not equal in nutritional value due to inadequate inventory and improper food storage practices. This had the potential to affect all residents. The sample was 19. The census was 95. Review of the facility's walk-in cooler food storage chart, showed: -Chart showed photos of which food items stored on each shelf; -Top shelf showed ready to eat fruit and vegetables; -The second shelf showed fish, pork and beef; -The third shelf showed ground meats; -The fourth shelf showed chicken and poultry; -The bottom shelf showed thawing foods. 1. Observation on 5/12/25 at 12:50 P.M. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe, and comfortable environment for residents, staff and the public by failing to maintain resident rooms, resident use areas, and public use areas air temperatures below 80 degrees Fahrenheit (F) on the second and third floors. The census was 95. During an interview on 5/13/25 at 9:53 A.M., Resident #33 said the building is always warm it seems, and he/she would like it to be cooler for it to be comfortable for him/her. During an interview on 5/14/25 at 11:00 A.M., Nurse B said the building is always hot and there is always trouble with the chiller system because the building is old. He/She would like it to be cooler inside the building. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resident (Resident #18). In addition, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents for one of one housekeeping closet on the first floor. This had the potential to affect all residents with access to the first floor. The sample was 19. The census was 95. 1. Review of the facility's Gait belt policy, reviewed 10/22, showed: -Position your body close to the resident face to face; -Transfer resident by grasping the gait-belt using an underhand grip; -Allow resident to stand for a moment to gain his/her balance; -Instruct resident to pivot to bear weight; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure appropriate infection control practices during perineal care (cleansing from the front of the hips, between the legs and buttocks) for one resident (Resident #26). Staff also failed to follow the facility policy on transporting laundry when staff pressed a resident's clean laundry against their uniform. The sample was 19. The census was 95. 1. Review of the facility's incontinent care policy, dated 7/21/22, showed: -Policy: the facility will provide incontinent care as directed by the plan of care. Care will promote hygiene and prevent infection; -Procedure: -Perform hand hygiene and apply gloves; -Remove soiled brief; -Cleanse the perineal area; -Use a clean wipe for each area; -Remove soiled gloves, perform hand hygiene and apply clean gloves; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. The facility failed to provide curtains and/or blinds in a resident room and failed to maintain ceiling tiles in good repair for one of 19 sampled residents (Resident #33). The census was 95. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/25, showed the resident was cognitively intact. Review of the resident's medical record, showed diagnoses of schizoaffective disorder (mood disorder) and morbid obesity. Observation on 5/13/25 at 9:00 A.M., showed the resident's private room without blinds or curtains over the window. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #74), who chose to perform services for the facility, had a care plan developed to address the services to be provided and the decision for these services to be paid or unpaid. The census was 95. Review on of Resident #74 quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 4/17/25, showed: -Cognitively intact -Diagnosis of Schizophrenia. Review of the resident's care plan, dated 4/17/25 and in use at the time of the survey, showed: -No documentation of the resident's desire for work; -No plan specified regarding the nature of the services performed and whether the services are voluntary or paid; -Do documentation if there is payment or if the work is voluntary. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion for one resident (Resident #45). The facility failed ensure policies and procedures were developed with clinical criteria for placement on the secured unit and to ensure residents who resided on the secured unit were assessed for appropriateness. As a result, the resident had been placed on and remained on the secured unit without clinical rationale. The facility staff failed to notify the resident's next of kin of the relocation from the first floor to the secured unit. The facility failed to assess continued appropriateness of the placement following the move on to the secured unit. Staff were unaware of the rationale for the resident's placement onto the secured unit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a communication policy, clinical assessment, and individualized criteria in place to ensure that a resident's abilities in activities of daily living do not diminish when staff failed to accommodate one resident's communication needs (Resident #45). The sample was 19. The census was 95. Review of the facility's Residents' [NAME] of Rights policy, revised 6/23, showed: -Policy: Get Proper Medical care; -Definitions: To be fully informed about your total health status in a language resident understands. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/25, showed: -Diagnoses included stroke, aphasia (difficulty speaking), paralysis, seizures, anxiety, depression, and bipolar disease; -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) for two of two perineal care observations (Resident #26 and Resident #18). The sample was 19. The census was 95. Review of the facility's Incontinent Care policy, dated 7/21/25, showed: -Policy: the facility will provide incontinent care as directed by the plan of care. Incontinent care will promote hygiene; -Procedure: -Staff cleanse the perineal area with cleanser; -For female residents: separate the skin, cleanse one side and then the other, then cleanse down the center of the skin in a front to back manner; -Cleanse the thighs, area between the buttocks. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to treat wounds for one of two sampled residents found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to treat pressure related wounds for one of one sampled resident found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis agreements between the dialysis center and the facility for residents that receive dialysis (the process of filtering toxins from the blood in individuals with kidney failure). The facility identified two residents who receive dialysis. Both receive dialysis at different outside dialysis centers. Both were included in the sample and concerns were identified with both residents (Residents #35 and #60). The sample was 19. The census was 95. During an interview on 5/16/25 at 10:00 A.M., the Administrator said they do not have a dialysis policy. They just use the dialysis pre and post assessment forms. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff MDS, dated [DATE], showed: -admission date: 3/14/25; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, three errors occurred, resulting in a 11.11% error rate (Resident #60 and Resident #1). The census was 95. 1. Review of the facility's Medication Administration policy, revised 8/14, showed: -Policy: medication are administered as prescribed in accordance with good nursing principles and practices; -Procedures: -Preparation: -Five rights: right resident, right dose, right drug, right route, right time are applied for each medication being administered; -Prepare the dose, the dose is removed from the container and verified against the label and Medication Administration Record (MAR); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as prescribed by the attending physician and/or according to their care plan, for one resident with an order for renal diet (Resident #35). In addition, the facility failed to ensure residents with orders for a mechanical soft diet received the appropriate texture after residents were served grilled cheese. This had the potential to affect all residents. The sample was 19. The census was 95. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/25, showed: -Severe cognitive impairment; -Receives dialysis; [...]

Inspectors wroteBased on observation and interview, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution when staff failed to keep the kitchen equipment and floors clean, free of dust, grease, and grime. Additionally, the facility failed to keep soap dispenser in the main kitchen filled. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 10. The census was 97. Review of the facility's Nutritional Service Sanitation policy, revised 11/21/24, showed: -Policy: Nutritional service shall ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety; -Responsibility: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not keep one resident's (Resident #5) shower clean and free of feces and failed to clean his/her bathroom, prior to the resident's bathroom being locked for service repair. The facility failed to maintain resident showers in good condition and/or repair by not having all sides of the shower wall finished (Resident #4) and failed to replace/repair the cove base that had separated from the wall of the shower in another resident's room (Resident #1). Additionally, the facility failed to keep clean the community bathroom and clean utility room sink on the 3rd floor. The sample size was 10. The census was 97. Review of the facility's essential functions of the Housekeeping Supervisor, revised 05/2022, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program by not ensuring resident rooms were free from bed bugs (small, oval, brown insects that feed on the blood of animals and humans) (Residents #8 and #10). The sample was 10. The census was 97. Review of the facility's Pest Control policy, last reviewed 8/31/24, showed: -Policy: The facility maintains an effective pest control program to remain free of pest and rodents. Pest control strategies are developed emphasizing kitchens, cafeterias. Laundries, central supply areas, loading docks, construction activities, and other regions prone to pest infestations. Environmental services/Designee will maintain records of pest control protocol and contracts with pest control services; -Responsibility: Maintenance Director, Environmental Services, and Administrator; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident (Resident #4) was hit in the face by another resident (Resident #9), which caused a scratch under his/her left eye. Resident #4 did not want to return to his/her room because of being fearful of being attacked again. The sample was 6. The census was 99. Review of the facility's Abuse Policy, dated 10/21/22, showed the following: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to administer an antipsychotic medication prescribed for behaviors for one resident by the psychiatric Nurse Practitioner (NP) (Resident #1). The sample was three. The census was 100. Review of the facility Physician's Order Policy, dated 9/28/22, showed the following: -Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines; -Responsibility: Licensed Nurses, Nursing Administration, & Director of Nursing; -Procedure: -Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders; -Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #141, #140 and #87). The sample size was 18. The census was 88. 1. Review of Resident #141's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $30.64; -No documentation of TPL completed. 2. Review of Resident #140's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $842.44; -No documentation of TPL completed. 3. Review of Resident #87's medical record, showed: -Effective/Expired on [DATE]; -Ending balance of $4354.37 -No documentation of TPL completed. During an interview on [DATE] at 12:58 P.M., the Regional Business Office Manager said TPLs were not done for the residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 88. Review of the facility's list of current employees, provided on 12/13/23, showed a Director of Nursing (DON). No other full-time RNs were employed. Review of the Facility Assessment Tool, last reviewed on 1/6/23, showed: -Number of licensed beds: 116; -Average daily census: 76. Review of the facility's payroll-based journal (PBJ) report, showed: -No RN hours in April 2023, on Saturday 4/15/23; -No RN hours in May 2023, on: -Saturday 5/6/23; -Saturday 5/13/23; -Sunday 5/14/23; -Saturday 5/20/23; -Sunday 5/21/23; -Saturday 5/27/23; -Sunday 5/28/23; -No RN hours in June 2023, on: -Saturday 6/3/23; -Sunday 6/4/23; -Saturday 6/10/23; -Saturday 6/17/23; -Sunday 6/18/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified six medication carts and three medications rooms. There were two medication carts and one medication room on each floor. Four medication carts and three medication rooms were checked, and issues were found with all. Staff failed to secure controlled substances (drugs or chemicals that have the potential to be addictive or habit-forming) under double lock on the second floor, failed to date medications and biologicals when they were opened on all floors, failed to separate medication from food items in the refrigerator on the first floor, and failed to separate medication and topical treatment medications on the third floor. The census was 88. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide residents with super cereal (highly fortified food that provides extra calories and/or protein) for one breakfast. The census was 88. The sample was 18. Review of the facility's Nutritional Supplements Policy, dated 12/1/22, showed the following: -Policy: The Facility will have a formulary of Nutritional Supplements to be utilized as interventions to help ensure nutritional needs are met; -Procedure: Nutritional needs and nutritional intakes are reviewed by the Registered Dietitian upon admission and as needed. Supplements may be recommended and initiated by the Registered Dietitian and/or Nursing to address but not limit to weight loss and wound healing or altered labs. Nursing and/or Designee to monitor acceptance and tolerance. Supplements may be discontinued if not accepted or tolerated. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine had an air gap. This had the potential to affect all residents. The census was 88. The sample was 18. Observation on 12/11/23 at 10:05 A.M., showed the ice machine in the dining room did not have an air gap. During an interview on 12/14/23 at 7:38 A.M., the Maintenance Director said he was not aware the ice machine did not have an air gap. He expected for the ice machine to have an air gap so the ice does not get contaminated if the pipes backed up. During an interview on 12/14/23 at 10:06 A.M., the Administrator said she was not aware the ice machine did not have an air gap. She expected for the ice machine to have an air gap.

Inspectors wroteBased on interview and record review, the facility failed to provide information and education to each resident or the resident's representative for the pneumococcal vaccines. This affected four of five sampled residents (Resident #25, #19, #23 and #10). This deficient practice had the potential to affect all residents. The census was 88. Record review of the facility's Pneumococcal Vaccine policy, reviewed and approved on 4/28/22, showed: -Policy: The opportunity to receive the Pneumococcal vaccine will be extended to all residents, the facility will provide pertinent information regarding the risks/benefits of receiving the vaccine; -Procedure: -Residents will be offered the Pneumococcal vaccine upon admission. Administration of additional doses will be completed in accordance with Centers for Disease Control and Prevention (CDC) guidelines; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a mental health disorder and/or individuals with intellectual disabilities had a DA-124 Level One Screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Annual Resident Review (PASARR) Level Two Screen was required), as required for one of two residents sampled (Resident #33) for PASARR. The sample was 18. The census was 88. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/23, showed: -Entry date (date of this admission/re-entry into facility): 11/21/23; -admitted : 1/14/22; -Diagnoses included dementia, depression, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide diets and supplements as ordered to ensure residents maintained acceptable nutritional status for one resident (Resident #69) who experienced a significant weight loss. The sample size was 18. The census was 88. Review of the facility's Weight Variances policy, revised 8/9/23, showed: -Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by the Registered Dietician (RD). Recommendations from RD to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes. Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing staff. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the federal survey results for all residents and visitors to view. The sample was 18. The census was 88. Observations of the facility on 12/18/23 at 10:30 A.M., showed no posting of the survey results. During the Resident Council interview on 12/13/23 at 11:14 A.M., six residents, whom the facility identified as alert and oriented, said they did not know where the survey results were located. During an interview on 12/14/23 at 10:03 A.M., the Administrator said there is no sign posted notifying residents and family members of the location of the federal survey results. She also said the survey binder is in the front office and not accessible. She said the survey binder and sign have not been accessible for at least a year. She expected the survey results to be posted and accessible to residents and family members. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents/resident representatives with a written letter stating the reason the resident was transferred to the hospital and failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of residents who were transferred/discharged from the facility. The facility identified 21 residents who were transferred to an acute care hospital. The census was 88. Review of the facility's admission and Discharge Report, dated 9/15/23 through 12/11/23, showed 21 residents were transferred to the hospital. During an interview on 12/14/23 at 9:39 A.M., the Director of Nursing (DON) said when a resident was transferred to the hospital, the facility sent a copy of the face sheet and the physician orders. During an interview on 12/12/23 at 9:11 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave (absences for purposes other than required hospitalization or hospitalization) Policy, when the resident was transferred to the hospital. The facility identified 21 residents who were transferred to the hospital. The census was 88. Review of the facility's Resident Bed Hold Policy, dated last reviewed 11/15/22, showed: -Policy: The facility will provide written information to the resident and/or the resident representative regarding bed hold policy prior to transferring a resident to the hospital or therapeutic leave as required by State/Federal guidelines; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of one of two sampled residents (Resident #1) when a cognitively impaired resident, whose diagnoses included schizophrenia and vascular dementia, left the building unaccompanied. Staff last saw the resident on 10/12/23 at approximately 11:00 P.M. The resident left pillows and clothing in a form under the blankets. Staff did not visualize the resident. Staff did not administer ordered morning medications or provide breakfast. On 10/13/23 at approximately 12:30 P.M., a nurse pulled the covers back, and saw the resident was not there. The resident was found on 10/13/23 at a homeless shelter. He/She tried to find a bus station, but became confused and went to the shelter. The census was 85. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with reasonable access to a telephone and privacy for phone conversations when three of 12 sampled residents (Residents #173 and #20 and #75) were observed making a personal phone calls in the open area of the 200 and 100 halls. The census was 25. 1. Review of Resident #173's medical record, showed the following: -An admission date of 5/11/20; -Diagnoses included diabetes, respiratory disorder and paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves including delusions and hallucinations). Observation of the 200 hall on 9/14/20 at approximately 9:45 A.M., showed the resident sat in the open area across from the nurse's station at an over the bed table where the 200 hall resident phone was located. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician's orders were followed by not properly performing pain assessments, not administering pain medicine as ordered, not obtaining an order for oxygen (O2) administration and not recording heart rate as ordered before medication administration. The facility also failed to clarify orders with the physician regarding a medication's dosage, the correct diagnosis for a medications administration and have a diagnosis to support the administration of another medication. Furthermore the facility failed to return a controlled substance medication to the pharmacy after it was discontinued, failed to obtain orders for the administration of two different medications and failed to administer all morning medications for two different residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received showers as scheduled and on a routine basis. In addition, staff failed to shave three residents on a consistent basis and failed to provide fingernail care for one resident who repeatedly asked for assistance. These deficient practices affected four of 12 sampled residents (Residents #16, #20, #8, and #2). The census was 25. 1. Review of Resident #16's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/20, showed the following: -Adequate short term and long term memory; -Independent decisions, consistent and reasonable; -Required extensive assistance with bed mobility, dressing and personal hygiene; -Unable to ambulate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program during a Coronavirus disease 2019 (COVID-19) pandemic, by not following current infection control standards. Staff failed to properly wear facemasks while preparing and serving food and failed to provide soap on the second floor hall resident use bathrooms. The sample size was 12. The census was 25. Review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes, updated 6/25/20, showed the following: -Implement Source Control Measures: -Health care personnel (HCP) should wear a facemask at all times while they are in the facility; -Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices: -Hand Hygiene Supplies: -Make sure that sinks are well-stocked with soap and paper towels for handwashing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, two errors occurred, resulting in an 8% error rate (Resident #6). The census was 25. Review of Resident #6's medical record, showed the following: -Diagnoses included heart failure, lung disease, bipolar (a mental health condition that causes extreme mood swings that include emotional highs and lows) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); -An order, dated 4/30/20, to administer Lithium (mood stabilizer used to treat bipolar) 300 milligrams (mg), one tablet daily; -An order, dated 7/30/20, to administer Vitamin D 2000 units, one tablet daily. Observation on 9/11/20 at 8:22 A.M., showed Certified Medication Technician (CMT) C, administered the resident's morning medications. [...]