North Bend Post Acute

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 4 (Q4, October 2025, November 2025, December 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Inspectors wroteBased on interview and record review, the facility failed to complete the appropriate transfer notifications for 1 of 4 residents (Residents 48) reviewed for hospitalization, and 1 supplemental resident (Resident 61). Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRR - a mental health screening required prior to most nursing home admissions) screenings were accurate for 3 of 6 (Residents 48, 3, & 29) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet health needs, and other health concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were comprehensive, resident-specific and/or implemented for 4 of 17 residents (Residents 3, 54, 6, & 58) whose CPs were reviewed. This failure placed residents at risk for unmet care needs and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct care conferences to ensure person-centered care for 8 of 18 residents (Residents 7, 10, 41, 43, 48, 54, 32, & 29) sample residents. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility environment was free of accident hazards. The failure to: ensure residents who smoked complied with facilities policies for 3 of 3 residents reviewed for smoking (Residents 6, 41 & 58), ensure safe hot water temperatures were maintained for 2 of 2 units (North and South Units), ensure fire exits were free of obstructions for 1 of 2 units (South Unit), and failure to ensure shower rooms did not contain unsecured hazards for 1 of 2 shower rooms (South Shower room) placed residents at risk for smoking hazards, burns, cuts, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure controlled medications were accurately reconciled for 2 of 2 (South Medication and Central Medication) carts reviewed for medication storage and reconciliation. Failure to ensure an accurate account of resident narcotic medications placed the residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing. The failure to: clarify physician's orders when required for 2 of 4 residents (Residents 32 & 6) reviewed for pain management, follow physician's orders for 3 of 18 sample residents (Residents 6, 54, & 10), and discontinue obsolete orders for 1 of 18 sample residents (Resident 29), placed residents at risk for unmet care needs, unneeded care, and other negative health outcomes. <Facility Policy>According to the facility's 2025 Weight Monitoring policy, the facility would ensure residents maintain acceptable nutritional status and body weight parameters. The facility would develop and consistently implement individualized interventions, monitor effectiveness, and revise them as necessary. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL - grooming, bathing, personal hygiene etc.) to dependent residents for 1 of 3 residents (Resident 54) reviewed for ADL.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate ileostomy (a surgically created hole allowing waste to void into a bag, bypassing the large intestine) care was provided for 1 of 1 residents (Resident 3) reviewed for ileostomy. This failure placed residents at risk for unmet care needs and infection control concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders, assessment and care planning were in place for 1of 1 resident (Resident 41) reviewed for respiratory care. These failures placed the resident at risk for potential negative outcomes such as poor/under oxygenation and a decreased quality of life. <Policy>According to the facility's 2026 Oxygen Administration policy, staff were to administered oxygen to residents according to professional standards of practice, physician orders, comprehensive person-centered care plans, and resident goals and preferences. According to the 05/04/2026 Quarterly Minimum Data Set (MDS-an assessment tool), Resident 41 admitted to the facility on [DATE] with severe impaired memory, chronic obstructive pulmonary disease (COPD-breathing difficulty) and respiratory failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate for 3 of 17 (Residents 29, 7, & 3) whose records were reviewed. The failure to ensure admission documents were added to the chart timely and ensure device assessments were documented placed residents at risk for incomplete records and undocumented care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) provided at least eight hours of direct care supervision per day for 5 of 31 days reviewed. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure and designate a qualified staff person to serve as the Infection Preventionist (IP) and that the IP physically worked onsite in the facility at least part time hours as determined by the Facility Assessment. This failure placed residents at risk for unmet infection control issues and prevented a lack of over site of the facility staff's infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and resolve grievances identified through a resident council meeting or provide a grievance log entry for 3 (Residents 14, 39, & 24) of 4 sample residents reviewed and 1 (Resident 35) supplemental resident, reviewed for grievances. The failure to thoroughly investigate a grievance and either resolve the resident grievance timely or provide an explanation the grievance could not be resolved placed residents at risk for frustration and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide baseline Care Plans (CP) to 6 (Residents 23, 25, 7, 58, 40 & 55) of 17 residents reviewed. The failure to provide the resident and/or their representative with a summary of their baseline CP placed residents and/or their representatives at risk for not being informed of their initial plan for delivery of care and services, and placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received and/or participated in care conferences for 3 (Residents 23, 58, & 20) of 17 residents reviewed and failed to ensure Care Plans (CP) were updated and/or revised to reflect person-centered care for 5 (Residents 7, 25, 53, 8, & 58) of 17 sample residents. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL) related to cleanliness and grooming for 6 (Residents 8, 22, 41, 37, 27, & 55) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving, bathing, and nail care placed the residents at risk for poor hygiene, unwanted long facial hair, embarrassment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 of 9 (Residents 49, 14, 7, & 25) residents reviewed for Pressure Ulcers (PU - injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, implement wound provider recommendations, and preventative skin measures placed all resident's at risk for deterioration in skin condition(s), pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure planned breakout menus were followed during meal service and 5 (Resident 53, 25, 30, 40, & 20) residents with specialized diets were provided meals that were in alignment with their prescribed diets. These failures placed residents at risk for less than adequate nutritional intake, consuming meal portion sizes and calories other than as planned by a Registered Dietician (RD), and unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance, palatable, and served at the proper temperature. Observations of meal services, a facility test tray, and interviews with 4 (Residents 25, 23, 12 & 45) sample residents identified concerns about the taste, temperature, and palatability of the food served by the facility. These failures placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included developing an Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 1 sample (Resident 8) and 1 supplemental (Resident 35) of 5 residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABOs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 3 of 13 residents (Resident 27, 112, & 57), reviewed for dining observations. This failure placed residents at risk for a diminished self-worth and over-all well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 4 of 5 residents (Residents 9, 1, 41, & 37) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 5 sample residents (Resident 9, 1, & 37) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 4 (Resident 25, 53, 1, & 41) of 17 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 6 (Resident 23, 1 & 27) residents and 1 supplemental resident (Resident 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop the care plans for 3 of 17 sampled residents (Resident 53, 58, & 25) reviewed for care planning. This failure placed the residents at risk for inadequate care, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to clarify diagnoses on physician's orders and to monitor and document resident's behaviors while on antipsychotic medications for 3 (Residents 8, 25, & 61) of 17 sample residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care interventions, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge planning process to effectively transition residents to a community setting for 2 residents (Resident 23 & 60) of 17 residents reviewed for discharge planning. This failure placed the residents at risk for an unsafe discharge and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and identify changes in a resident's skin condition timely for 1 (Resident 25) of 7 sampled residents reviewed for skin conditions. These failures placed residents at risk for complications, worsening conditions, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a restorative program was provided for 2 of 5 (Residents 41 & 23) sample residents reviewed for restorative nursing services. These failures placed residents at risk for a decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide social services interventions for 1 of 5 residents (Resident 1) reviewed for unnecessary medications. The failure to initiate further assessment and appropriate interventions when the resident answered positively to a self-harm question, placed the resident at risk for unmet care needs and non addressed mental health concerns.

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing health care programs and health insurance standards) for Quarter 1 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 resident (Resident 43) reviewed for bowel management, 1 of 1 resident (Resident 4) reviewed for Diabetes (unstable blood sugar levels) management, and 1 of 4 residents (Residents 41) reviewed for non-pressure skin management received necessary care and services in accordance with professional standards of practice for quality of care. Resident 43 experienced harm when they were administered a daily laxative incongruent with prescribing provider order, did not receive antidiarrheal medications for prolonged diarrhea, did not have a stool sample obtained for laboratory evaluation or specialized diet initiated per standing orders which resulted in daily watery stools with increased, persistent discomfort and abdominal pain that required the use of a narcotic pain medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1) a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information, and 2) a system by which residents or their representative(s) were notified of the transfer or discharge for 6 (Residents 1, 4, 5, 8, 14, & 19) of 6 residents reviewed for hospitalization. Failure to ensure required notification was provided, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 6 (Residents 1, 4, 5, 8, 14, & 19) of 9 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to 1) engage a full-time Registered Dietician (RD) and 2) provide a dietary manager with the appropriate competencies to manage and supervise the facilities kitchen. This failure placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an adequate number of dietary staff. The failure to provide the kitchen with adequate dietary staff left residents at risk for less than palatable meals, improperly prepared meals, foodborne illness, late food service, and other negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, and distributed in a sanitary manner. The failure to ensure food was stored correctly, surfaces were sanitized, food was prepared in an area free of potential contaminants, food waste was disposed in a fashion to prevent attracting pests, and food was transported in a fashion to prevent exposure to airborne pathogens left residents at risk for foodborne illness, food contamination, less than palatable food, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, comfortable and homelike environment on 2 of 2 units (north and south units), 1 of 1 dining rooms, 1 of 1 resident lounge/ Television (TV) area, and 1 of 1 kitchens. The failure to ensure resident rooms and halls were free of wall gouges and electrical repair, furniture and walls in the dining room and resident lounge were not peeling or gouged, and that essential equipment remained in good repair placed residents at risk for a less than homelike environment and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were reviewed and revised as needed, for 8 of 16 (Residents 1, 31, 46, 19, 17, 5, 8, & 21) sample residents whose CPs were reviewed. Failure to ensure CPs were revised to reflect residents needs for care left residents at risk for unmet care needs, the provision of unneeded care, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 nursing assistants (Staff Z, AA, & BB) with an active Nursing Assistant Registered (NAR) license met the training and competency evaluation requirements under the Nurse Aide Training or Competency Evaluation Program (NATCEP) within four months from their date of hire. This failure placed residents' safety at risk and predisposed residents to receive care from staff with incomplete nurse aide credentials.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system that provided annual nurse aide reviews for 2 of 2 Certified Nursing Assistants (CNAs - Staff CC & DD) whose personnel files were reviewed for CNA performance evaluations. Failure to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs.

Inspectors wrote<Resident 26> According to the 09/22/2023 Quarterly MDS Resident 26 had diagnoses including End Stage Renal Disease (ESRD - an irreversible kidney condition) and a nerve condition that made voiding urine more difficult. Record review showed Resident 26 had a 09/28/2023 Physician's Order (PO) restricting the resident to 1000 Milliliters (ML) of fluid a day. The PO showed the facility's dietary department was responsible for 600 ML daily and nursing would give 125 ML three times a day. Review of the November 2023 MAR showed there were two places for nurses to document how much fluid Resident 26 was provided on night shift. On the first night shift column on 28 of 30 days nurses documented Resident 26 received 950 ML. On the second night shift column on 28 of 30 days nurses documented Resident 26 received 125 ML of fluid. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. 1) The facility failed to ensure staff used Personal Protective Equipment (PPE) for 1 of 7 (Residents 43) residents reviewed for Transmission Based Precautions (TBP). 2) The facility failed to perform Hand Hygiene (HH) during resident care and during dining service for 5 (Resident 43, 8, 19, 28, 31) of 7 residents observed. 3) The facility failed to assess and monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. These failures placed residents at risk for the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of Antibiotics (ABOs) and reduce the risk of unnecessary ABO use for 2 of 3 (Residents 17 & 14) residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABO's. <Facility Policy> The facility's 10/01/2023 Antibiotic Stewardship Program policy showed the purpose for their ABO stewardship program was to optimize the treatment of infection's while reducing the adverse events associated with ABO use. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents of the risks and benefits associated with psychotropic medication therapy (medications that affected the mind, emotions, and behavior), for 3 (Residents 31, 19, & 17) of 5 residents reviewed and gave 1 (Resident 19) a psychotropic medication despite Resident 19 declining to consent for the medication. These failures detracted from the residents' ability to exercise their right to make informed treatment decisions and prevented residents from exercising their right to decline treatment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to initiate and complete a thorough grievance investigation for 2 of 4 residents (Residents 31, & 8) reviewed for missing property. The facility failed to ensure there was a summary statement coming from the resident themselves regarding their lost property and how the event would affect their quality of life if left unresolved. These failures placed residents at risk for frustration and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments, were completed within 14 days for 1 of 1 resident (Resident 8) reviewed for a decline in mental status, Activities of Daily Living (ADLs), and mobility. Failure to identify Resident 8's change in status and to complete a SCSA placed the resident at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Sets (MDS - an assessment tool) were completed and accurate for 2 (Residents 19 & 46) of 16 sample residents. Facility failure to complete accurate MDS assessments prevented the facility from transmitting accurate and complete information to the Centers for Medicare and Medicaid Services for facility quality ratings, and left residents at risk for unidentified and/or unmet needs. <Resident 19> According to a 10/30/2023 Quarterly MDS, Resident 19 was assessed to have no memory impairment and had adequate hearing. This assessment showed Resident 19 had clear speech, was understood by others, and could understand others in conversation. According to this assessment, Resident 19 had no acute change to their mental status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was obtained and/or accurate to reflect the residents' mental health conditions for 2 of 5 (Resident 31 & 5) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to sign only for tasks completed for 1 (Residents 1), clarify Physician's Orders (POs) for 6 (Residents 51, 26, 5, 31, 43, & 14), and follow POs for 1 (Resident 14) of 16 sample residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care interventions, and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensures residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 6 of 11 residents (Residents 26, 51, 31, 4, 14, & 41) reviewed for ADLs. The failure to provide necessary assistance with bathing (Residents 26, 51, 14, & 41), grooming (Residents 31), and nail care (Resident 4) left residents at risk unmet care needs, odors, and a diminished sense of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received proper treatment and care that maintained their ability to hear adequately and effectively for 1 of 1 residents (Resident 31) reviewed for treatment and services to maintain hearing. Failure to ensure residents' hearing deficits were addressed accordingly placed residents at risk for frustrations, decline in communication, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and implement wound treatment orders and care interventions for 1 of 2 residents (Resident 14) with pressure ulcers. This failure placed residents at risk for development and/or worsening of wounds, infection, and medical complications.

Inspectors wroteBased on interview, and record review, the facility failed to identify and initiate an intervention to prevent recurrence for 1 of 3 residents (Resident 41) reviewed for accidents. This failure placed residents at risk for avoidable incidents, injury, and diminished quality of life.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents with Foley Catheters (FC - a tube placed in the bladder to drain urine) received appropriate care and services for 1 of 3 (Resident 43) residents reviewed for indwelling FCs. This failure to obtain and follow Physician Orders (PO) for FCs and FC care, placed residents at risk for infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain and monitor resident's weights for 2 of 4 residents (Residents 1 & 23) reviewed for nutrition and failed to follow dietary orders for 1 of 4 (Resident 41) residents reviewed. The failure to collect weights as ordered and per the facility policy and to serve residents diets outside of Physician Orders (PO) left residents at risk for unplanned weight changes, risk for aspiration, fluid overload, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 1 of 1 (Resident 26) residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained their highest practicable physical, mental and psychosocial well-being as identified by resident assessments and according to individual plans of care, in consideration of the number, acuity and diagnoses of the facility's resident population, and in accordance with the facility assessment. The facility failed to provide education and training that pertained to the current resident population for 2 of 2 Licensed Practical Nurses (LPNs - Staff EE & FF) whose annual in-service training and education records were reviewed for competency. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain eight hours of Registered Nurse (RN) coverage to directly supervise resident care for 2 of 30 days (11/23/2023 and 11/26/2023) reviewed for staffing. This failure placed residents at risk for a delay in identification, response to changes in medical conditions, and provision of care and services by an RN, inadequate assessments, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure PRN (as needed) orders for psychotropic medications were only used when the medication was necessary and the PRN use was limited according the prescribing guidelines for 1 of 5 residents (Resident 31) and failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 (Resident 41) residents reviewed for unnecessary medication use. This failure placed the residents at risk for receiving unnecessary medications with potentially harmful and unwarranted adverse side effects.

Inspectors wrote<Resident 43> In an observation and interview on 12/08/2023 at 8:46 AM, Staff O (LPN) prepared 30 milliliters (ml) of a liquid laxative for Resident 43. The order directed staff to administer 17 grams of the laxative daily. Staff O was unable to explain how they measured 17 grams to be 30 ml. Staff O stated the order was inaccurate. Staff O stated the normal dose for the prescribed laxative was 30 ml and that is why they prepared 30 ml for Resident 43. In an observation and interview on 12/08/2023 at 8:50 AM Staff B (Director of Nursing) assessed the physician orders and the bottle of the laxative. Staff B then directed Staff O to give 30 ml of the laxative, stating you give 30 ml of this laxative. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were palatable and served at the proper temperature. Observation of meal preparation and interviews with 4 sample residents (Residents 41, 5, 27, & 21) identified concerns with the temperature, and overall palatability of food served by the facility. Failure by the facility to ensure meals were at the proper temperature and palatable when served, placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 sample residents (Resident 4) reviewed for choices received food that accommodated the resident's choices, preferences, and intolerances. Failure of the facility placed residents at risk of dissatisfaction with food, unnecessary weight loss, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the Physician's Order (PO) for 2 of 3 residents (Residents 5 & 8) reviewed for rehabilitation with skilled therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the posted daily nurse staffing information included the total number and actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 21 of 30 days (11/16/2023 - 12/07/2023) reviewed for posted nurse staffing information. The failure to post a complete and accurate form on a daily basis that showed the nursing staff working prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement care planned safety interventions for 2 of 3 residents (Residents 1 & 9) who exhibited aggressive behaviors to ensure the care planned behaviors did not escalate to verbal, physical or psychological abuse for 4 of 4 residents (Resident 7, 12, 2, 10), and the facility failed to protect 3 of 3 residents (Resident 6, 7, & 8) from potential abuse when they did not immediately remove (Staff E) from providing care to all residents after allegations of abuse and neglected were reported. These failures resulted in harm for Resident 8 who sustained an acute knee injury that required hospitalization and an increase in pain medications after being roughly handled by Staff E and harm to Resident 2 after being slapped by Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents for resident-to-resident altercations and falls for 4 of 4 (Residents 1, 3, 9, 15) residents reviewed for accidents, hazards, and supervision. The lack of supervision and implementation of safety measures to prevent resident-to-resident altercations allowed Resident 1 and Resident 9 to initiate verbal and physical altercations with multiple residents and caused physical harm to one resident (Resident 2) when they were slapped in the forearm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident's who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying, monitoring, or treating past experiences of Post-Traumatic Stress Disorder (PTSD - a disorder that develop when a person had experienced or witnessed a scary, shocking, terrifying, or dangerous event) for 3 of 3 residents (Residents 13, 12, & 14) reviewed for mood and behavior. These failures caused psychological harm to Resident 13 who was re-triggered and traumatized by facility staff and placed other residents with a trauma history at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure abuse policies and procedures were implemented by failing to identify and investigate allegations of abuse and neglect, and protect residents from potential abuse for 8 of 15 residents (Resident 4, 5, 6, 7, 8, 9, 13, & 15) reviewed for incidents, and failed to conduct background screening for 2 of 3 agency staff (Agency Staff O, & E) reviewed for screening. These failures placed residents at risk for unidentified abuse and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 4 residents (Resident 5, 21, 17, & 16) interviewed, 1 family interview, 4 staff interviews, and observations. The facility had insufficient number of administrative and nursing staff to provide care and services for residents in the areas of supervision, behavior management, wound management, staffing coordination, central supply, infection control and antibiotic stewardship.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information including the total number of and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and the number of current residents residing in the facility. The failure to post required nurse staffing information daily and failure to retain the daily posted documents for a minimum of 18 months placed residents at risk for inadequate staffing and deterred the facility from ensuring adequate staff each shift.

Inspectors wroteBased on interview and record review the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal regulatory requirements. [...]

Inspectors wroteBased on interview and record review, the Governing Body failed to establish, implement, policies and practices for the nursing home's operations and management. The failure to monitor and support the continuity of management responsibilities during turnover of required positions placed the facility in non-compliance in seventeen areas of resident care and placed residents at risk for incompetent care, unmet needs, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to review and update the Facility Assessment (FA) as necessary, at least annually. The failure to complete an annual review deterred the facility from identifying and implementing programs requiring revision and delegation of tasks of critical staff open positions placing residents at risk for unmet needs and inadequate care.

Inspectors wroteBased on interview and record review the facility failed to have a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed transfer and potential lack of access to care, services, and the hospital in the event of an emergency.

Inspectors wroteBased on interview and record review the facility failed to maintain an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice. The facility failed to demonstrate evidence of an ongoing QAPI program that was completed on at least a quarterly basis, was documented, included systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.

Inspectors wroteBased on interview and record review the facility failed to designate a qualified Infection Preventionist (IP) to oversee the facility's infection prevention and control program. The failure to designate a qualified staff to facilitate an effective infection control program including monitoring for, assessing, implementing transmission-based precautions, and acting on resident infections upon occurrence and failure to ensure antibiotics were used appropriately, placed all residents at risk for infections, inappropriate treatment, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff consistent with their expected roles and based on the Facility Assessment. The failure to provide mandated annual training for 2 of 2 staff (Staff K Licensed Practical Nurse and Staff J Certified Nursing Assistant) employed over one year at the facility placed residents at risk of receiving care from untrained staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure alleged abuse or neglect the facility was aware of or witnessed, was thoroughly investigated for 4 of 15 residents (Residents 1, 2, 9, & 18 ) reviewed for abuse and neglect, and failed to log, report, and thoroughly investigate two falls for 1 of 3 residents (Resident 3) reviewed for falls. These failures placed all residents at risk for unidentified abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 3 of 3 (Residents 16, 3, 17 ) residents reviewed for pressure ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, and implement preventative skin measures placed all resident's at risk for deterioration in skin condition, pain, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure nursing staff was competent and had the skill sets to care for residents' needs as identified through assessment and described in the care plan. The facility failed to ensure nursing staff competency for 5 of 5 Staff (Staff F RN-Registered Nurse, Staff G NA-Nurse Aide, Staff H LPN- Licensed Practical Nurse, Staff J NA, Staff K LPN) Nurse Aides (NA) demonstrated competency in skills and techniques necessary to care for resident needs as described in the residents' care plan. The failure to evaluate nurse competency for 3 of 3 nurses and 2 of 2 NAs placed residents at risk for unmet needs, unsafe care, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to verify nursing assistants met competency evaluation requirements before allowing an individual to serve as a nurse aide. The failure to verify 2 of 2 staff (Staff G and J) for nursing aide competency on the State Agency registry placed residents at risk for incompetent care, unmet needs, and possible injury during care.

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately monitor target behaviors, implement non-pharmacological interventions and assess the interventions effectiveness before increasing psychotropic medications for 3 of 3 residents (Resident 1, 15, & 9) reviewed for accidents and supervision. These failures placed residents at risk for unnecessary psychotropic medications, injuries from falls, unmet needs, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement a system to ensure 1 of 2 (Staff J) Nursing Aides (NA) received required training for continued competency that is no less than 12 hours per year. The failure to have a system in place to provide mandatory training in dementia management, abuse prevention, and other areas of resident special needs placed residents at risk for abuse, neglect, emotional distress, and physical injury.