North Bay Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was free from physical abuse when Resident 2 struck the back of Resident 1's head and forcefully shook Resident 1's wheelchair. This failure placed Resident 1 at risk for actual and potential physical and psychosocial harm. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Wernicke's Encephalopathy (a medical condition caused by a severe deficiency of thiamine (Vitamin B1) which is liked with alcohol abuse. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke) and Hemiplegia (paralysis on one side of the body) affecting the left side. [...]

Inspectors wroteBased on interview and record review, the licensed nurses did not revise a care plan for one resident (Resident 2) of two sampled residents after Resident 2 was involved in a physical altercation with another resident. This failure decreased the facility's potential to implement interventions to prevent further physical harm among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare, food under sanitary conditions and in accordance with professional standards for a census of 92 when shelf surfaces in the walk-in refrigerator were observed to be discolored with rust-colored markings, indicating deterioration and potential contamination risk. This failure had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident health information for a census of 92 when meal tickets were disposed of in the facility's regular trash. This failure decreased the facility's potential to protect and safeguard resident confidentiality and personal privacy.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the accuracy of assessments for four out of four sampled residents for Preadmission Screening and Resident Review level 1 (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care), when Residents: 5, 58,72 and 55's PASARR did not indicate their diagnosed serious mental illness (MI, disorders that affect your mood, thinking and behavior). This failure could result in residents not being accurately identified with MI, missing further evaluation, and not receiving care/services in setting most appropriate to their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents safety and well-being, focusing on basic needs and resident-specific information) for four out of four sampled residents (Residents 5, 58, 72 and 106) were completed within 48 hours of admission. This failure could result in residents' delayed or inconsistent care and increased vulnerability to immediate harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician within 24 hours of a significant change in condition for one of one sampled resident with a change in condition (Resident 33), when nursing staff identified ongoing confusion, urinary frequency, and symptoms consistent with a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure resulted in delayed medical evaluation and treatment of Resident 33's UTI.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 21, Resident 31, and Resident 54) were provided a comfortable and homelike environment when: 1. Resident 21's ceiling had an area in mid-repair state; and2. Resident 31 and Resident 54's walls showed significant surface deterioration, cracking, and extensive paint peeling. These failures had the potential to negatively impact the residents' comfort and create an environment that was not homelike.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an abuse allegation of misappropriation of property (when someone in a position of trust steals, misuses, or benefits personally from assets belonging to another) for one out of two sampled resident (Resident 106) when the allegation was not reported to the state licensing agency and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours. This failure could put Resident 106 at risk for continued financial and emotional distress.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to deliver professional standards of quality for one of 22 sampled residents (Resident 7), when a physician order was not obtained prior to the application of bordered dressing (a multi-layered wound care product with a central absorbent pad and an adhesive border that secures it to the skin ) on Resident 7's Deep Tissue Injuries (DTI, purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear)This failure could put the patient at risks for physical harm and worsening wound conditions.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure two out of two sampled residents (Residents 37 and 80's) received care to maintain grooming when fingernails were long with brownish material underneath. This failure could negatively affect the resident's sense of dignity and be an infection control concern.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the bed cane (a type of bed rail that is a bar that attaches to the side of a bed, to help a person get in and out of bed) for one of 24 sampled residents (Resident 8), was in proper use when:it was installed without completed assessment of risk of entrapment;Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was not obtained prior to installation; andIt was installed incorrectly. These failures increased the risk of resident injury, including falls or entrapment, which could result in serious harm or death.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain accurate records of controlled medications (medications that the use and possession of are controlled by the federal government) for one out of 92 residents of the facility (Resident 24), when a dose of Resident 24's Oxycodone Hydrochloride (Oxycodone, a controlled medication that treats pain) was not documented as administered in the Medication Administration Record (MAR a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure had the potential for a medication error to occur, which could cause Resident 24 to experience increased sedation (increased sleepiness), respiratory depression (condition where breathing becomes dangerously slow and shallow) and/or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident for dental services (Resident 6) received timely and appropriate dental evaluation and treatment, when the resident had broken teeth, and a history of uncompleted dental referrals with no follow-up or treatment plan. This failure resulted in Resident 6 not being able to eat effectively, placing the resident at risk for decreased nutritional intake and potential further decline.

Inspectors wroteBased on observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 92 when a food item was not properly labeled and another food item was past the expiration date. These failures had the potential to result in residents consuming spoiled or contaminated food, increasing the risk of foodborne illness and adverse health outcomes.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure smoking safety was practiced for one out of four sampled residents who smoke when:1.a smoking evaluation was not completed upon Resident 72's admission,2. quarterly smoking assessments were not completed for Resident 72, and3. Resident 72 kept a pack of cigarettes at his bedside. These failures increased safety risks for Resident 72 and other residents who could have gained access to Resident 72's cigarettes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident 1) when licensed nurses did not remove a transdermal medicated patch (an adhesive patch that delivers a specific dose of medication through the skin and directly in to the bloodstream over a controlled period of time) before a new one had been applied. This failure had the potential to cause unwanted side effects due to a higher than prescribed dose of the medication being absorbed through the skin.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident 1) of two sampled residents was free from physical abuse when Resident 2 punched Resident 1 in the eye. This failure resulted in Resident 1 sustaining a bruise on the left eye.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the provision of a sanitary environment that would prevent the development and transmission of infections for one out of four residents (Resident 2) when:1. Resident 2's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine also known as a urinary catheter) bag (a drainage bag connected to the FC) was touching the floor.2. Staff did not wear a gown, in accordance with enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDRO, microorganisms (germs), that are resistant to one or more antibiotics]) while handling Resident 2's FC.These failures had the potential to cause and spread infections among residents and staff.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a call light (a communication tool used in healthcare settings to allow patients/residents to request assistance from staff) was provided to one out of three sampled residents (Resident 2) when the call light was not within Resident 2's reach. This failure could result in late provision of care, unmet needs and increases the risk of accidents.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy when Certified Nursing Assistant B (CNA B) was allowed to return to work after a physical and sexual abuse allegation was made against him, and prior to the facility completing their abuse investigation. This failure caused Resident 1 to feel unsafe, and potentially placed other residents, who were cared for by CNA B, at risk of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents received care which met services provided to meet professional standards when nursing assessments related to changes in Resident 1's skin integrity (skin health) was not documented in Resident 1's medical record. This failure resulted in inaccurate assessment documentation which had the potential to prevent Resident 1's skin integrity from further impairment.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of COPD (chronic obstructive pulmonary disease; a chronic lung disease causing difficulty in breathing) and cancer in her lungs received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes). Resident 1 experienced a medical emergency (a serious and sudden situation that requires immediate medical attention to prevent serious injury, disability, or death) on the morning of 3/23/25 that included respiratory distress (difficulty breathing associated with inadequate oxygenation) and critical hypoxia (low level of oxygen in the blood), but licensed nursing staff: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary (clean manner that prevents the spread of diseases), safe, and comfortable environment when: 1. All 21 residents' bathrooms were in disrepair. 2. Resident 54's privacy curtain (curtain used as divided between residents' beds) was not kept in a sanitary manner. 3. Comfortable water temperatures were not maintained in the bathrooms for 5 Residents' rooms (room [ROOM NUMBER], 114, 141, 143 and 146). These failures violated the residents' rights to live in a sanitary, safe, comfortable, homelike environment and had the potential to result in injury and illness in a medically compromised population. The facility census was 94.

Inspectors wroteBased on interview and record review, the facility's abuse program failed to protect the residents when: 1. Resident 54's transfer request after a resident-to-resident altercation was not completed. (Cross Reference F745) 2. Reports of abuse were not reviewed and analyzed by QAPI (QAPI, data-driven approach to improving quality in healthcare facilities) per the facility's policy ad procedure. 3. There was no policy and procedure developed to prohibit and prevent retaliation (act of revenge that causes harassment or harm) against residents, families, and visitors who report incidents of abuse, neglect, or other similar violations. These failures had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five out of five licensed nurses (Registered Nurse 3, 4, 5, 6 and Licensed Vocational Nurse 2) were competent (having the necessary ability, knowledge, or skill to do something successfully) in medication administration. This failure resulted in a medication error rate of 24% and had the potential to result in significant adverse events (any undesirable or harmful effects that occur as a result of medical treatment including medications) to a medically compromised population. The facility census was 94. (Cross-reference F759)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when five out of five licensed nurses were observed and made the following medication errors: 1. Potassium (medication used to treat low amount of potassium in the blood) was not administered in accordance with physician order to Resident 36. 2. Resident 81 was not instructed to stay sitting in upright position after being administered Potassium-Phosphate (supplement to increase potassium and phosphate in the blood,) despite manufacturer guidelines to not lie down for 10 minutes after to prevent stomach irritation and discomfort. 3. Resident 81 was administered twice the ordered dose of cholecalciferol (Vitamin D-medication). 4. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) committee failed to maintain documentation and demonstrate evidence that the QAPI program was sustained during transitions in leadership when there were no follow-ups for medication administration audits (observations to help identify potential and actual medication errors at different stages) conducted by Pharmacy (Cross-reference F658, F726, F759, F760). These findings resulted in a medication error rate of 24%, including one considered significant, and had the potential to result in severe adverse effects for all residents. The facility census was 94.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) program failed to identify, address, and evaluate the following systemic quality deficiencies (issues that fall below the standards of quality for a facility's care, which QAPI programs were designed to identify and fix): 1. Nursing Medication Administration Competency (Cross-reference F658, F726, F759, F760) 2. Infection Control (Cross-reference F880, F881) 3. Abuse Program (Cross-reference F606, F607, F943) 4. Incomplete Resident's Records (Cross-reference F842) 5. Social Services (Cross-reference F607, F685, F742, F745, F791) These failures resulted in a lack of oversight over these necessary care services and had the potential to negatively affect the safety and quality of care provided to all residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented when: 1a. Water testing was not done to identify the presence of Legionella bacteria (can cause severe pneumonia [inflammation and fluid in the lungs]) in the building water system (cold and hot water distributed through the water pipes). 1b. Policies and Procedures (P&P) were not revised annually and updated as needed. 1c. Toilet plungers (used to free waste outlets of obstruction) located on the floor next to toilets in restroom of rooms 124, 130, 132, and 146. 1d. Four unlabeled urinals were in the restroom of rooms [ROOM NUMBERS]. 1e. One House Keeping staff did not know the dwell time (the amount of time the disinfectant needed to sit on the surface) of the [name of manufacturer] disinfectant. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide procedures for reporting incidents of abuse and training for seven staff members (Social Services Director (SSD), Registered Nurse (RN) 2, Licensed Vocational Nurse (LVN) 3, Certified Nurse Assistants (CNA) 3, 4, 5, and 6). These findings resulted in staff ineffectively identifying the facility's procedure for reporting incidents of abuse and had the potential to compromise the safety of all residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS- a standardized assessment and care planning tool) were accurate for two of 23 sampled residents (Residents 25 and Resident 391). This failure had the potential to adversely affect the provision of care for Residents 25 and Resident 391.

Inspectors wrote2. During a review of Resident's 191's Face Sheet (demographics), the Face Sheet indicated Resident 191 was admitted on [DATE], with diagnoses including cellulitis of right lower limb (swelling and skin infection of the lower leg); unspecified fracture of shaft of right tibia (a break in the lower leg bone below the knee); initial encounter for closed fracture (the first time a resident is seen by a healthcare provider for a broken bone where the skin is intact), and burn of unspecified degree of right lower leg (the burn cannot be definitely determined at the time of assessment). During a concurrent observation and interview on [DATE] at 9:00 a.m. with Resident 191 in room [ROOM NUMBER] C, there was one collagenase (Santyl) ointment tube located on top of Resident 191's bedside cabinet. Resident 191 was alert and oriented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotic stewardship (monitors the effective use of antibiotics) monitored the effective use of Amoxicillin-Pot Clavulanate (antibiotic to treat urinary tract infections-[UTI- infection in your urinary system]) for the month of October 2024 and November 2024 for Resident 84. This failure had the potential to result in an inappropriate use of antibiotics for Resident 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate space for all 24, three residents residing rooms. This failure resulted in 23 Residents (Resident 1, 5, 11, 21, 23, 31, 51, 54, 56, 59, 61, 64, 65, 68, 69, 70, 74, 79, 81, 190, 191, 193, and 345) not having the required amount of usable living space and had the potential to compromise the safety of residents due to limited space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident hand-outs (weekly menu, activities calendar, guide for translation services) were provided in Resident's preferred language for two of 23 sampled residents (Resident 342 and Resident 8). This failure resulted in Resident 342 and Resident 8 being uninformed on menu options, activities, and how to obtain a translator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident 46. This failure resulted in Resident 46 being unable to contact staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 83) and/or their legal representatives were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Resident 83.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper screening and follow-up for Registered Nurse (RN) 3 who had been found guilty of neglect by a court of law. This finding had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident's transfer notification to the Office of the State Long-Term Care Ombudsman (resident advocacy agency) for two of 23 sampled residents (Resident 77 and 84) when: 1. Resident 77 was transferred to General Acute Care Hospital (GACH) on 11/10/24, and a transfer notification was not sent to the Ombudsman. 2. Resident 84 was transferred to General Acute Care Hospital (GACH) on 11/15/24, and a transfer notification was not sent to the Ombudsman. These failure resulted in the Office of the State Long-Term Care Ombudsman not being aware of Resident 77 and 84's transfers to GACH.

Inspectors wroteBased on interview and record review, the facility failed to identify a mental illness (MI- medical disorder that affects a person's thinking, emotions, or behavior) and subsequently failed to refer one of 23 sampled residents (Resident 71) for a Level II PASRR (Preadmission Screening and Resident Review- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) screening. This failure resulted in Resident 71 not receiving specialized mental health services to meet her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to reduce the risk of injuries from falls for one of 23 sampled residents (Resident 25). This failure resulted in the potential for the resident to suffer an injury during a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of 23 sampled residents (Resident 28), when Resident 28 fell on 1/12/25 and care plan interventions were not revised and updated. This failure placed Resident 28's health and safety at risk when fall care plan interventions were not revised.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when Licensed Vocational Nurse (LVN) 2 prepared two unsampled residents' (Resident 39 and Resident 193) medications and did not observe Resident 39 and Resident 193 ingest medications. This failure had the potential to result in Resident 39 and Resident 193 receiving the wrong medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident 290 received an assistive device for his vision needs when Resident 290 did not receive assistance with making an appointment to get new eyeglasses. This failure resulted in negatively affecting Resident 290's ability to enjoy his favorite hobbies such as crossword puzzles.

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician visits were conducted once every thirty days for Resident 25. This failure had the potential to result in an undetected decline in Resident 25's health and/or potential delays in treatment or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide mental health services to Resident 71. This failure had the potential to negatively affect Resident 71's psychosocial (the mental, emotional, social and spiritual effects of a disease) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. follow up on facility transfer for one of 23 sampled residents (Resident 54) 2. properly screen for Preadmission Screening and Resident Review (PASARR- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) for one of 23 sampled residents (Resident 71) 3. arrange and provide mental/psychosocial counseling services for one of 23 sampled residents (Resident 71) These failures resulted in the delay of Resident 54 and Resident 71's care to maintain their well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Monthly Medication Reviews (MMR- a comprehensive review of all medications a resident receives) were conducted for Resident 61. This failure resulted in the potential for Resident 61 to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR- an attempt to reduce the dose of medications which affect the nervous system to treat mental illness to achieve the lowest dose possible) for one of 23 sampled residents (Resident 61). This failure had the potentialto result in Resident 61 receiving psychotropic medications which were unnecessary and in excessive dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct dosage of insulin (medication that lowers the level of glucose [sugar] in the blood) was in the prefilled pen injector per physician's sliding scale order for Resident 291. This failure had the potential to result in hypoglycemia (medical condition where blood sugar level is too low) and death for Resident 291.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services for Resident 71 for 16 months. This failure had the potential to result in a decline in oral health for Resident 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect equipment from contamination via dust and grease. This failure posed the risk for food borne illness in a medically fragile resident population of 98 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three of five sampled residents (Resident 54, 56, and 341) a designated refrigerator to store personal, perishable food items. This failure resulted in Resident 56, unsafely storing perishable personal food items in her bedside drawer, which had the potential to result in a foodborne illness for Resident 56. This failure resulted in a non-homelike environment for Residents 54 and 341.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician's Progress Notes were documented in the medical record for 3 of 23 sampled residents (Resident 25, 61, and 75). This failure resulted in the potential for communication delays and potential delays in coordination of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a sexual abuse allegation between Unlicensed Staff B (ULS B) and Resident 1 was reported within the 2 hour abuse reporting time frame.

Inspectors wroteBased on interview and record review the facility failed to follow a physician ' s order in obtaining a Keppra (medication to treat seizures), blood level for one of two sampled Residents, (Resident 10), by not having the laboratory company come to the facility to obtain the sample and the nursing Department did not follow up on the missed opportunity for four months. This failure had the potential to result in Resident 10 experiencing subsequent seizures in October and November of 2024 causing pain, distress, and a higher level of care to ensure no further damage to Resident 10 ' s brain.

Inspectors wroteBased on Interview and Record Review the Facility failed to allow residents, who were smokers at time of their admission, the right to self-determination when the facility made the decision to enforce the Smoking Policy without considering the rights of the residents to choose their schedules. Residents, who were smokers, were not allowed input about the changes in the Policy including the timing of smoking breaks. Residents were not given guidance for managing the restrictions nor alternatives to smoking. This change in Policy infringed on the rights of the Residents who smoked, and affected nine of the thirteen residents, who identified as smokers in the facility, among them Resident 3, Resident 11, Resident 2, Resident 7, and Resident 12.

Inspectors wroteBased on interview and record review the Facility failed to follow transfer and discharge requirements when nine of thirteen residents, who at the time they were admitted to the facility, identified as smokers, were given a Notice of Transfer and Discharge for endangering the health of safety of individuals in the facility, all on 10/23/24. The facility did not have appropriate documentation to support that the residents were noncompliant with the smoking policy or that their smoking behavior was a safety risk for the other residents at the facility. The failure to identify and document in each of the nine residents records the behavior that caused the need for the facility to initiate a resident discharge could result in unfair and unsafe discharges.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one of one sampled resident (Resident 1), who left the facility, undetected, and was found on a busy street. A bystander stayed with him until the emergency responders arrived. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (decision maker) (wife) for one of two samepled residents (Resident 1) of the intention to transfer the resident to the hospital. Resident 1's Responsible Party stated she did not know her husband was at the hospital until he called her (with help from the hospital staff.) This failure to notify the Responsible Party in writing and in advance of the reason for transfer disregarded Resident/Responsible Party's right to be informed and to participate in the resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment for food storage and preparation when the kitchen where the residents' food was stored and prepared was found to be infested with rats. This failure resulted in 90 out of 90 residents being served food that had been prepared in a kitchen contaminated with rat droppings and urine. On 4/3/24 at 11:06 a.m., due to the facility's failure to maintain sanitary conditions in the kitchen for food storage and preparation, Administrator and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurse informed Administrator and DON of the surveyor's findings that rat droppings and gnawed food in the kitchen indicated a rat infestation and residents could not be served food from the kitchen. [...]

Inspectors wroteBased on observation interview and record review the facility failed to store garbage in a manner that made it inaccessible to pests. This failure potentially contributed to a rat infestation in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility administrator failed to 1. Follow up on reports of rats in the facility kitchen to ensure the pest control company was controlling the rats, 2. Follow up on letters from the county health department requesting a plan to address code compliance issues in the kitchen (dating back to 8/2023), and 3. Ensure the staffing agency sent nurses to cover shifts as agreed upon. These failures resulted in the facility's kitchen closing for several weeks requiring food to be obtained from an outside source for the residents, and also resulted in nurses working 24-shifts to cover for registry nurses who did not report to work.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when signs of a rat infestation in the kitchen were not adequately addressed. This resulted in rats contaminating the residents' food and the kitchen where food was prepared.

Inspectors wroteBased on interview and record review the facility failed to adequately staff the Noc shift (10:30 p.m. to 6:30 a.m.) when the registry nurses scheduled to work Noc shift did not report to work three nights in a row. This failure resulted in three nurses working a triple shift (three consecutive 8-hour shifts) for those three days, potentially putting residents at risk of medication errors or delay in care when nurses caring for the residents are too fatigued to accurately follow physician orders or provide care.

Inspectors wroteDuring a record review for Resident 59, the Face sheet (A one-page summary of important information about a resident) indicated Resident 59 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), Schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others) and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for resident 59, the Care Plan for ADL (Activities of Daily Living) Self Care Deficit initiated on 7/09/2022 indicated, [Resident 59] ambulating independently without any assistive device. [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure a Quarterly Minimum Data Set ((MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was completed for 9 of 19 sampled residents (Resident 22, 41, 58, 14, 3, 23, 46, 33, and 36) and 2 randomly selected residents (Resident 178, and 176). This failure resulted in inadequate monitoring of Residents 22, 41, 178, 176, 58, 14, 3, 23, 46, 33, and 36's progress and decline, and the lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that met individual resident's needs and preferences, per facility Activity policy and procedure, when 1.a.) 5 of 5 Confidential Residents (CR 1, 2, 3, 4, and CR 5) and 1 of 3 Unsampled Resident (Resident 57) were not provided group/social activities per their liking, 1.b.) Leadership personnel (Infection Preventionist and Activity Director) canceled scheduled group/social activities despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic (widespread disease epidemic over several countries) that began in 2020) and 2) 2 of 3 Unsampled Residents (Resident 172 and Resident 181) were not provided individual activities per their care plans. [...]

Inspectors wroteBased on observation, intervention and record review, the facility: 1). Failed to ensure the Registered Dietitian (RD) provided services to meet the needs of the residents when nutritional assessments (overall nutritional status of patients) were routinely done remotely, without direct observation of the resident and without resident (or responsible party) interviews; 2) Failed to ensure the Registered Dietitian (RD) provided adequate oversight in the kitchen, per job description, when a) dietary staff, did not have documented job related competencies (verified skills required to perform duties) in their employee file and b) the dietary manager was evaluated by the Administrator; and 3) Failed to ensure the RD addressed resident complaints regarding food quality/palatability. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that met individual resident's needs and preferences when 2 confidential residents (CR 2 and and CR 5) were not provided social dining per their preference and the facility routinely closed the dining room despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic beginning in 2020). These failures caused Confidential Residents 2 and 5 to feel isolated and prevented all residents desiring group dining from socializing in the dining room during meals.

Inspectors wroteBased on interviews and records review, the facility failed to ensure the prescribing physician obtained informed consent for one of five sampled residents selected for unnecessary medication review (Resident 24) prior to the administration of a psychotropic medication (medications which affects mood or behavior). This failure did not provide Resident 24's Responsible Party the right to be fully informed regarding care and treatment in order to make health care decisions for the Resident 24.

Inspectors wroteBased on interview and records review, the facility failed to ensure residents' MDS assessments (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences assessments) were transmitted within 14 days after completion for 7 of 19 sampled residents (Resident 14, 25, 28, 37, 52, 56, and 169) and 5 randomly selected residents (Resident 2, 30, 35, 179 and 180). This failure resulted in lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring.

Inspectors wroteBased on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was accurately completed for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175) when they did not receive the recommended Pneumococcal vaccine; however, Section O0300 of their MDS indicated their Pneumococcal vaccination was up to date. This failure resulted in residents not getting the recommended Pneumococcal vaccine and putting them at risk for increased respiratory infections. (Reference F883). Review of the Pneumococcal Vaccine Timing for Adults indicated, CDC recommends 1 dose of PPSV23 at age [AGE] years or older. [...]

Inspectors wroteBased on observation, investigation and record review, the facility failed to ensure 1) there were sufficient and competent nursing staff available to care for residents during both day to day operations and emergencies. 2) the licensed nurses had upon hire and annually, completed the nursing competency check to ensure they were competent to provide safe nursing care to the residents. 3) the call light (a means of communication for patients to their care providers that are outside of the patient's room) was within reach for eight out of eight sampled residents (Residents 9, 17, 34, 41, 49, 120, 218 and 220). This failure resulted in 1. the facility not meeting the nursing staffing needs based on the facility assessment for 30 out of 30 days for November 2022, 31 out of 31 days for the December 2022 and 10 out of 10 days for December 2023. 2. [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure that medication drug regimen for one of five sampled residents (Resident 24), who received psychotropic medication was reviewed for irregularities at least once a month according to facility policy. This failure had the potential to result in side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities.

Inspectors wroteBased on observations, interview and records review, the facility failed to ensure medication error rate was below 5% when three of four Licensed Nurses (Licensed Staff E, F and G) were observed for medication pass and did not follow the manufacturer's recommendations and doctor's order regarding administration of medication for three residents (Residents 176, 28, and 177) which resulted in seven medication administration errors out of 31 administration opportunities (21% error rate). This failure had the potential to compromise the absorption of the medication and the risk of compromising the resident's health and well-being for not getting the right medication and required dose of medication according to the doctor's order.

Inspectors wroteBased on observations, interviews, and records review the facility failed to: 1. Maintain medication room temperature according to manufacturer's guidelines when the facility's emergency kit (E-kit - contain a small quantity of medications that can be dispensed when pharmacy services are not available) containing antibiotics (a medicine that inhibits the growth of or destroys microorganisms) was stored above 77°F (77 degrees Fahrenheit). This failure had the potential risk of bacterial growth and sub-potent antibiotics which could lead to more serious illnesses and antibiotic resistance. 2. Remove an expired bottle of Prosight (eye supplement) with vitamins and minerals from the medication cart; [...]

Inspectors wroteBased on interview, and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) Residents smoking assessments were not being completed timely, the residents were smoking in a non-designated smoking area, by the side of the building a few feet away from the exit door and this area did not contain a fire extinguisher (Cross Reference F689); [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1) Transmission based precautions (additional measures focused on the particular mode of transmission and are always in addition to standard precautions) were not followed for one resident (Resident 168) when Resident 168's wound was positive for MRSA (Methicillin resistant Staphylococcus aureus - infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infection) and his wound drain was intermittently opened and the drainage was not contained. This failure caused potential spread of MRSA in the environment. 2) Four residents (Resident 182, 169, 23 and 3) were not offered hand hygiene before meals. [...]

Inspectors wroteBased on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to the Director of the CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States.) for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result in serious respiratory infections. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1) residents who smokes cigarettes were allowed to smoke in the designated smoking area only for 3 out of 3 sampled residents (Resident 119, 28 and 53), and 2) residents who smoke have a smoking safety screen completed quarterly for six out of eight sampled residents (Resident 50, 53, 28, ,224, 225 and 226). These failures were a safety risk that could lead to unsafe smoking practices.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment for one of 19 sampled residents (Resident 24) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was not completed within 14 days of Resident 24's admission to hospice services. This failure resulted in an inaccurate representation of Resident 24's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning.

Inspectors wroteBased on observations, interview, and record review, the facility failed to meet professional standards during medication pass observation for 2 of 19 sampled residents (Resident 28 and Resident 43) when: 1. Licensed Nurse administered Sodium Chloride tablet (also known as salt) to Resident 28 when there was no physician's order for the medication. 2. Licensed Nurse administered Prosight with vitamins and minerals to Resident 28 that was expired. 3. Licensed Nurse did not provide instruction to Resident 28 on how to properly administer the Albuterol oral inhaler (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness). 4. Licensed Nurse did not notify the physician when Resident 43's blood sugar was 416

Inspectors wroteBased on observation, interview, and records review, the facility failed to ensure that nutritional care and services were provided to one of two sampled residents (Resident 170). Resident 170 had a weight loss of eight pounds which yielded to 9.89 percent weight loss in a month from 12/05/2022 to 01/08/2023. This deficient practice had the potential to result in Resident 170's further unplanned weight loss.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents received Trauma Informed Care (TIC, an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) which accounted for resident's experiences and preferences for two out of two sampled residents (Resident 220 and 171). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) only worked as a charge nurse if the facility census was 60 and below. This resulted in the DON working as a charge nurse on the floor seven times between 10/2022 and 12/2022 on different shifts and there was no DON coverage at those times.