North Village Park

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services to attain the highest practical, physical, mental and psychosocial wellbeing and assure adequate social services were implemented for three residents (Resident #9, #10 and #11), in a review of 11 sampled residents. The facility failed to make arrangements for a transfer to another facility for Resident #9 and #11 and failed to assist Resident #11 with transition of care arrangements to the other facility, assuring post discharge medications were available. The facility also failed to provide Resident #10 with a written response of actions taken to resolve his/her grievance. The facility also failed to employee a qualified social worker since 06/22/26. The facility census was 160. During an interview on 07/22/26 at 1:30 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents with mental disorders (Resident #2 and #1), in a review of 11 sampled residents, received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. Resident #2 had poor insight and judgement, a history of verbal and physical aggression and was at risk for self-harm as indicated on his/her Preadmission Screening and Resident Review (PASRR, a screening for serious mental illness and intellectual or developmental disabilities to ensure the most appropriate placement setting) and Care Plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 42 sampled residents, was free from abuse when Resident #2 struck Resident #1 in the head and face with a closed fist after pinning Resident #1 against the wall in their shared bedroom. Resident #1 sustained injuries including pain, two chipped lower teeth, a laceration to his/her lower lip, and lost a tooth, which required medical treatment. The facility census was 165. The administrator was notified of the past noncompliance on 03/26/26, which occurred on 03/14/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight for one resident (Resident #5) in a review of nine residents, when Resident #5 eloped through the service hall exit door without staff knowledge. On 2/25/26 at 11:32 A.M., Floor Tech A turned the service hall exit door alarm off, entered the door lock code, exited the door without ensuring a spotter (a second staff member to monitor the exit door while unalarmed) was in place. Floor Tech A did not reenter the building through the service hall exit door but entered through a different door later, leaving the service hall exit door unalarmed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #13), in a review of 16 sampled residents, was free from abuse by Housekeeper N. Resident #13 had diagnoses that included personality disorder (mental health condition characterized by long-term, rigid, and unhealthy patterns of thinking, feeling, and behaving that differ significantly from cultural norms), major depressive disorder, recurrent severe without psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and severe methamphetamine use disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a thorough review of one resident's (Resident #1) behavioral health emergencies and take steps to develop person-centered behavioral care plans to support the resident's changing behavioral health care needs. The facility failed to and revise behavioral care plans to include effective interventions for the resident. On 1/27/26, the resident was hospitalized after exhibiting behaviors including threatening another resident and throwing a wet floor sign, which injured a staff member. The resident was hospitalized and returned to the facility 1/29/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to convey resident funds within 30 days of discharge to the resident and/or responsible party for one resident (Resident #11), in a review of 15 sampled residents. The facility census was 177. Review of the facility's Resident Trust policy, revised on 9/21/25, showed the following:-Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance;-The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge. The Resident Trust Clerk shall provide a complete accounting record of the funds along with the check. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #7), in a review of 15 sampled residents, was free from sexual abuse when Certified Nurse Aide (CNA) B sent sexual content via text messages and pictures to the resident's cell phone. The resident reported he/she and CNA B had kissed and had a sexual relationship including touching each other's genitals. The facility census was 177. On 1/14/26 at 4:11 P.M., the Administrator was notified of the past noncompliance which occurred on 1/4/26. On 1/4/26, the Administrator became aware of the employee to resident sexual abuse allegation involving CNA B and Resident #7. Upon discovery, the facility suspended CNA B, separated Resident #7 from the other residents to allow one on one time for the resident to vent and verbalize feelings. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained a lithium level (a laboratory test to monitor the concentration of lithium (mood stabilizing medication to treat bipolar disorder (mental illness) in the blood) for Resident #24 as ordered by the psychiatric Nurse Practitioner in October 2025. Resident #24 had a physician order for lithium 600 milligrams twice daily with an order start date of 09/20/24. Review showed Resident #24 was found in his/her room unresponsive on 11/24/25. The resident had vomited and was incontinent (abnormal for this resident). The resident's color was pale (normal color pink) and yellow. The resident's heart rate was 111 beats per minute (normal 60-100) and his/her oxygen saturation (blood oxygen level) was 70 percent (%) on room air (normal 95-100%). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain walls, flooring, resident sleeping rooms, resident restrooms, resident common areas, light fixtures, ceilings, shower and toilet rooms, plumbing fixtures, window blinds, heating/ventilation units, exhaust fans, and room fixtures such as call lights, soap dispensers, and paper towel dispensers throughout the facility to be clean and good repair. The facility census was 172. Review of the undated facility Resident Agreement (part of the admission packet) showed the facility will provide basic maintenance, replacement and repair to the resident's room as required by normal wear and tear. 1. Observation and interview on 12/08/25 at 6:18 P.M. in two of two public restrooms near the main entrance, showed a heavy buildup of fuzzy debris on both exhaust fans. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, or date food items. Staff did not practice proper hand and glove hygiene and did not properly wear hair restraints in the kitchen. Staff did ensure personal beverages were not consumed in the food preparation areas. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris. Staff did not maintain range hood baffle filters free from an excess buildup of grease. Staff failed to ensure an air gap was present at the facility's ice machine drain to prevent possible backflow from the drain back into the ice machine. The facility census was 172. 1. Review of the facility policy, Resident Food Storage: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current infection control standards for two residents (Residents #14 and #4), in a review of 47 sampled and five additional residents (Resident #23, #110, #180, #172 and #72). The facility failed to follow infection control practices while performing blood glucose monitoring (also known as accu check, a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for two residents (Resident #23 and #110) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for sugar it contains) after use to protect against contamination. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure checking account fees deducted from the resident trust account were replaced by the facility. This affected 127 residents for which the facility managed funds. Further review showed the facility failed to ensure residents had reasonable access to their personal funds. Residents were unable to gain access to their funds unless it was between the hours of 10:30 A.M. and 2:00 P.M. Monday-Friday. The facility census was 172. Review of the facility's policy, titled Resident Trust, last revised 09/21/2025 showed the following:-The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 127 residents. The facility census was 172. Review of the facility's policy, titled Resident Trust, last revised 09/21/2025 showed the following:-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete accounting principles;-A reconciliation of the bank statement, checkbook, and the Point Click Care (PCC) Trust Funds module must be completed monthly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents (Resident #131 and #178) who participated in group interview, received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 172. Review of the facility's policy, Resident Rights, revised 09/21/25, showed the resident has the right to privacy in written communications, including the right to send and promptly receive mail that was unopened. Request was made for, but the facility did not provide a policy regarding mail delivery at the facility. 1. Resident council/group interview on 12/09/25 at 9:59 A.M. showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (this indicator disqualifies an individual from working in the facility) for three of ten newly hired employees (Maintenance Assistant I, Certified Nurse Aide (CNA) J and Dietary Aide L) reviewed. The facility also failed to check the Employee Disqualification List (EDL) for three of ten newly hired employees (Maintenance Assistant I, Dietary Aide L and Licensed Practical Nurse (LPN H) reviewed. The facility census was 172. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer discharge to seven residents (Resident #85, #113, #30, #38, #5, #6, #75) or the resident representatives, in a sample of 47 residents reviewed, that included the reason for discharge/transfer, location being discharged to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocacy for residents with mental illness. Further review showed the facility did not provide a bed hold policy to one resident (Resident # 113) or their representative at the time of their transfer. The facility census was 172. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for six residents (Residents #11, #20, #103, #179, #45, and #167), in a review of 47 sampled residents. The facility census was 172. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plans to reflect current care needs for six residents (Resident #45, #4, #172, #14, #87 and #10), in a review of 47 sampled residents. The facility census was 172. Review of the Resident Assessment Instrument (RAI) Manual dated October 2025 showed the following:-4.7 The RAI and Care Planning as required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool;-It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for seven residents (Resident #24, #47, #118, #127, #113, #77 and #4) in review of 47 sampled residents. The facility failed to follow physician orders and obtain ordered bloodwork related to therapeutic medication level monitoring and bloodwork for five residents (Residents #24, #47, #113, #118 and #127). Further review showed no documentation the resident's physicians were notified when bloodwork was not obtained and/or documented as uncollected. Facility staff failed to obtain a blood pressure or pulse prior to administering a medication for high blood pressure, with ordered parameters on when to give the medication and when the medication should be held and not given for one resident (Resident #77). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five nurse aides (NA) (NA T, NA U, NA MM, NA QQ and NA UU), who performed resident care, completed a nurse aide training program within four months of their employment in the facility. The facility census was 172. Review of the facility policy titled, Nurse Aide Training Program Policy, dated 05/18/24 showed the following:-The facility, with oversight from the Director of Nursing, shall be responsible for the coordination and/or provision of nurse aide education;-The policy did not include nurse aides completing a nurse aide training program within four months of hire. 1. Review of the employee roster provided by the facility showed NA T was hired on 07/19/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food items to residents at a safe and appetizing temperature. The facility census was 172. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperature to ensure food safety; -Record temperature reading on Food Temperature Chart form at beginning of tray line and during the tray line. Take the temperature of each pan of product before serving; -Acceptable serving temperatures include: -Greater than 135 degrees Fahrenheit (F), but preferably between 160 to 175 degrees F, for the following food items: gravy, casseroles, meat, entrees, potatoes, pasta, soup, pureed foods, hot pureed foods, vegetables; -Less than 41 degrees F: hazardous salads, milk, juice, and desserts; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served food items according to the menu for three residents (Residents #36, #127, and #135), in a review of 47 sampled residents, and for one additional resident (Resident #125), who had physician's orders for a mechanical soft diet. The facility census was 172. 1. Review of Resident #36's physician order sheet (POS) for December 2025, showed the resident had an order for a regular diet with mechanical soft texture (original order dated 11/20/25). Review of the facility's resident Diet Orders listing, printed 12/7/25, showed the resident had an order for a regular diet, mechanical soft texture. Review of the facility's diet spreadsheet menu for the breakfast meal served on 12/8/25 (Day 9 of menu cycle) showed residents on a mechanical soft diet were to receive ground sausage patty with gravy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nourishing snacks when substantial meals were scheduled 14 hours apart. Multiple residents during the group interview said snacks were not specifically offered and were not substantial. One resident (Resident #167), in a review of 47 sampled residents, and three additional residents (Resident #83, #39 and #95) said snacks were not offered on a routine basis at the facility. The census was 172. Review of the undated facility policy, Snacks, showed the following:-Policy: Daily snacks are provided in accordance with the prescribed diet and in accordance with state law. Individual and/or bulk snacks are available at the nurses' station for consumption by residents whose diet orders are not restrictive;-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective pest control measures to eliminate mice from areas throughout the facility, including resident rooms, the facility's dry food storage room, and nourishment kitchens. The facility census was 172. Review of the facility policy, Pest Control Program Policy, revised 05/14/24, showed the following:-It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats). 1. During an interview on 12/07/25 at 11:50 A.M., Resident #118 said the following:-Mice were bad at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to ensure staff completed weight monitoring, notifications with weight loss, provision of ordered supplements and reevaluation of the care plan for two residents with weight loss (Resident #45 and #103) in a review of 47 sampled residents. The facility census was 172. Review of the facility policy, Weight Monitoring Policy, revised 05/07/24, showed the following: -Purpose: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Monitoring weight: weight can be a useful indicator of nutritional status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents, family members, and legal representatives. The facility census was 172. Review of the facility policy, Resident Rights, revised 09/21/25, showed residents have the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility in a place readily accessible to residents, must be clearly labeled, and the facility must post a notice of their availability. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the facility name, the current date, the census, and the total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift daily and in a location readily accessible to residents and visitors. The census was 172. Review of the facility policy, Nurse Staffing Posting Information Policy, revised 06/26/24, showed the following: -It is the policy of this facility to make nurse staffing information is readily available in a readable format to residents and visitors at any given time;-The Nurse Staffing Sheet will be posted daily and will contain the following information:- Facility name; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for a mechanical soft diet (foods that are chopped or ground to be easily chewed and swallowed to prevent choking) for one resident (Resident #8), who had a history of choking and was on an assist to dine program, when staff prepared and served the resident a regular diet tray including pork loin for the resident's lunch on 11/30/25. The resident choked while eating the meal and became unresponsive and stopped breathing. Staff began cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) and called Emergency Medical Services (EMS). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident, (Resident #1), in a review of eight sampled residents, was free from abuse when Resident #2 pushed Resident #1 to the ground and kicked Resident #1's head while Resident #1 was down. Resident #1 was sent to the emergency room for right arm pain and was diagnosed with a nondisplaced spiral fracture of the right humerus (a spiral break in the upper arm). The facility census was 174. The administrator was notified of the past noncompliance on 12/04/25, which occurred on 11/28/25. Immediately after the incident, the facility placed Resident #2 on one-on-one monitoring. The facility began their investigation into the allegation and in-serviced staff on duty at the time on abuse, behavioral health services and behavioral emergency policies. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's guardian (Resident #1) of eight sampled residents regarding the extent of the resident's injuries and upcoming surgery after the resident was in a physical altercation with another resident. The facility failed to notify the guardian the resident was transported by ambulance to a hospital to be evaluated by an orthopedic specialist, or the results of the evaluation which showed the resident sustained a right humeral fracture (a break in the upper arm bone) that required surgical repair. The facility census was 174. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident, (Resident #2), in a review of seven sampled residents, was free from abuse when Resident #3 attempted to strike Resident #2, then grabbed Resident #2 by the hair and pulled him/her to the ground causing Resident #2 to strike her head on the ground, and then striking the resident in his/her side. Resident #2 was sent to the emergency room for a closed head injury after he/she developed a large knot on his/her head. The resident experienced headaches, a bruised knot on his/her forehead, a black eye, a bruise on his/her right hip, and rib pain. The facility census was 176. The administrator was notified of the past noncompliance on 12/04/25, which occurred on 11/12/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report physical abuse to the state agency and law enforcement for one resident, (Resident #2), in a review of seven sampled residents, when Resident #3 assaulted Resident #2. Resident #3 grabbed Resident #2 by the hair and pulled him/her to the ground causing Resident #2 to strike her head on the ground; Resident #3 then struck the resident again in his/her side. Resident #2 was sent to the emergency room for a closed head injury after he/she developed a large hematoma on his/her head. The facility census was 176. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident with mental disorders (Resident #3) of 22 sampled residents, received individualized treatment and services to meet the resident's needs. The facility failed to implement interventions consistent with Resident #3's plan of care to address his/her behaviors and psychosocial needs. The resident refused medications off and on for a few months and became easily irritated and aggressive. This resulted in verbal and physical altercations with other residents. On 8/10/25, the resident threatened a staff member and another resident got involved. A physical altercation occurred between the two residents and Resident #3 sustained a fracture of the medial orbital wall (eye socket nearest the nose) on the right side. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary treatment and services for wound care for two residents (Residents #9 and #10) in a review of 22 sampled residents. Resident #9 was being treated for trauma wounds on his/her left foot. Resident #10 was being treated for diabetic pressure wounds on both of his/her feet. The facility did not adequately assess and document the condition of the residents' wounds, clearly identify the sites of the wounds, and failed to ensure the residents arrived at outside wound clinic appointments. Staff failed to complete dressing changes as ordered. Staff failed to ensure residents followed the non-weight bearing status as ordered by the physician and failed to notify the physician when the residents were noncompliant with physician orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infections for two residents (Resident #9 and Resident #10) in a review of 22 sampled residents. Staff failed to utilize the appropriate personal protective equipment (PPE), including gowns, when providing care for Residents #9 and #10 who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities). The facility also failed to post EBP signage outside the door and provide PPE near the room for one sampled resident (Resident #9). The facility census was 174. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident, Resident #5, in a review of 17 sampled residents, was free from abuse when staff physically took the resident down to the ground and caused injury. The resident sustained injuries including a bruised chin, a swollen sprained right ankle, and bruising to the right knee. The resident felt staff abused him/her. The facility census was 177. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and administer medications for three residents (Resident #15, #12, and #17) in a review of 17 residents. Resident #15 had diagnosis of congestive heart failure (CHF) and missed several doses of medications for fluid retention prior to a hospitalization for fluid overload. Resident #12 experienced increased pain from missing ordered pain medications. The facility reported their pharmacy had not supplied the medications. Many of the medications were available in the facility's eKit (emergency medication supply), but staff did not use the available medications to ensure resident's received administration of ordered medications. The facility census was 177. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize behavior triggers and provide early interventions of coping skills for two residents (Residents #13 and #14), in a review of 17 sampled residents, with mental disorders and who lived on a secured behavioral unit. Staff witnessed both residents in an argument during a smoke break and did not intervene or initiate coping skills. The residents left the smoke room and a verbal altercation ensued which led to a physical altercation where the residents hit each other. Resident #13 hit Resident #14 over the head with a laptop computer. Resident #14 obtained a laceration to his/her nose, a swollen and bruised eye, and an abrasion over his/her eyebrow. Resident #13 sustained a laceration on his/her finger. The facility census was 177. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2), in a review of 12 residents, was free from abuse when Resident #1, who was being monitored by staff one on one, entered Resident #2's room by the connecting bathroom and took a power strip cord, labeled with Resident #2's name. Resident #2 confronted Resident #1 about the missing power strip cord. Both residents' voices were raised and Hall Monitor A, the one on one staff, said he/she stood in front of Resident #2 to prevent him/her from entering Resident #1's room. Hall Monitor C entered the room to assist, pulled the power strip cord out from underneath Resident #1's leg and gave it back to Resident #2. Hall Monitor C left the room to locate a cord for Resident #1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of two residents (Resident # 9 and #10) who resided on a locked behavioral unit when a physical altercation occurred between the two residents. Hall Monitor D said Resident #9 came at his/her with fists up and tried to attack him/her. Resident #10 told Resident #9 to leave Hall Monitor D alone. Resident #9 turned around and went after Resident #10 and shoved him/her. Resident #10 shoved Resident #9. The residents shoved each other a second time. Staff working on the hall did not have walkie talkies available, or a functioning intercom system to call a Code [NAME] (behavioral health crisis) to access help. Hall Monitor D had to open the locked door to the unit and yell for assistance. The facility census was 177. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were employed with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for residents who resided on locked behavioral health units. Hall Monitor A was the only staff assigned to the [NAME] Senior 300-Hall when he/she called a Code [NAME] (behavioral emergency) for one resident (Resident #15) in a sample of 24 residents who was experiencing a behavioral health crisis in the outside smoke area. Additional staff did not respond to the Code [NAME] to assist Hall Monitor A. Hall Monitor A became upset, left the unit and left residents unsupervised. A resident-to-resident physical altercation occurred while Hall Monitor A left the unit unsupervised. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 11 sampled residents, remained free from verbal, mental and physical abuse when Human Resource Manager (HR) A cursed, taunted, threatened and grabbed the resident by the shirt forcefully, putting him/her into a chair. The staff member aggressively and forcefully shoved the resident against the wall during a Code [NAME] (behavioral emergency). The facility census was 176. Review of the facility's policy titled, Abuse and Neglect, revised on 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an allegation of staff to resident abuse. Two staff members reported Human Resource (HR) Manager A was abusive to one resident (Resident #1) of 11 sampled residents during a Code [NAME] (behavioral emergency). The facility did not interview or obtain written statements from all witnesses that were present during the Code [NAME] or review video camera footage of the incident. The facility census was 176. Review of the facility's policy titled, Abuse and Neglect, revised on 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight of one resident (Resident #23), in a sample of 25 resident, when the resident burned the back of his/her left hand with a cigarette during a supervised smoke break. The resident said he/she was mad so he/she burned his/her hand. The resident had a history of self-harm and burned himself/herself earlier in the year with a cigarette. The facility failed to ensure all residents' smoking materials, including a nicotine vape pen (also known as an e-cigarette, a battery-operated device that heats a liquid into an aerosol that the user inhales. The liquid, often called e-liquid or e-juice, typically contains nicotine, flavorings, and other chemicals) were collected from the resident and secured at the end of smoking breaks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight and a safe environment for one resident (Resident #1) who was assessed to be an elopement risk, had a history of a previous elopement from the facility, and resided on a secured behavioral unit. Staff allowed the resident into the exterior courtyard unsupervised, and failed to ensure the door was securely latched when the resident returned inside the facility. The resident went back out this unlatched door and left the premises without staff knowledge. Staff failed to complete hourly face checks on the resident from 7:30 P.M. until approximately 11:30 P.M. per facility policy. The resident was missing for over 12 hours before being located by staff. The facility census was 178. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 178. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperatures to ensure food safety; -Acceptable serving temperatures are: -Cereal, greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Meat, entrees: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Potatoes, pasta and soup: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Hot vegetables, greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Pastries, cakes, greater than 60 degrees Fahrenheit; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Resident #7 and #8) in a review of 14 sampled residents were free from physical abuse. Activity Aide A heard Resident #1 call Resident #7 a name and accused the resident of being sexually inappropriate with Resident #1's significant other. Activity Aide A did not report the comments to staff responsible for Resident #1 and Resident #7's care and supervision. Resident #1 went into Resident #7's room and hit him/her multiple times. The residents were separated. Resident #7 was sent to the hospital for evaluation and treatment. Resident #7 returned the facility with a diagnosis of general assault. Hall Monitor D saw Resident #6 leave his/her room and heard the resident say his/her hand hurt from hitting Resident #8. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when staff failed to ensure ordered medications were available for administration for two residents (Resident #15 and #17), in a review of 20 sampled residents. In addition, the facility failed to follow discharge instructions for pain medication after an emergency room visit for one resident (Resident #20). The facility census was 180. Review of the facility's policy, Transcription of Orders/Following Physician's Orders, revised 05/18/24, showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 18 sampled residents, received care and treatment in accordance with professional standards of practice. Staff failed to assess and obtain treatment for seven days following the resident's complaints of urinary urgency (a sudden and strong need to urinate) and dysuria (difficulty urinating) and failed to obtain a urinalysis (a diagnostic laboratory procedure used to determine urinary changes and infection) as ordered by the physician. The resident was admitted to the hospital with acute pyelonephritis (a bacterial infection of the kidneys that caused inflammation. A severe urinary tract infection), and complicated urinary tract infection. Upon readmission staff failed to obtain and administer four doses of the physician ordered antibiotic for the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) in a review of 18 sampled residents, was treated with dignity and respect when Licensed Practical Nurse (LPN) A tried to prevent the resident from taking a cup from the dining room back to his/her room. The resident attempted to take the cup from LPN A and the drink mix ended up on both the resident and LPN A. The facility census was 181. Review of the facility policy Dignity and Respect, dated 6/29/23, showed the following: -Every resident had a right to be treated with dignity and respect; -All staff would speak to and treat all residents with dignity and respect. 1. Review of Resident #1's Care Plan, updated 7/28/24, showed the following: -Diagnoses of depression, weakness and abnormal gait and mobility; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight for one resident (Resident # 3) with psychiatric diagnoses, and a history of suicidal ideation, who lived on a secured behavioral unit, when the resident obtained a disposable razor on 7/23/24 from another resident (Resident #8) and cut his/her wrist several times. The facility census was 178. The Administrator was notified on 7/24/24 at 2:45 P.M. of the Immediate Jeopardy (IJ), which began on 7/23/24. The IJ was removed on 7/25/24, as confirmed by surveyor onsite verification. Review of the facility's Behavioral Emergency Policy, dated 6/26/24, showed the following: -It is the policy of the facility to provide a safe environment and provide humane care to all residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2) in a review of 13 sampled residents, who was monitored one on one by Certified Nurse Aide (CNA) F, was free from abuse when Resident #1 entered Resident #2's room and started a verbal argument. The verbal argument escalated and CNA F did not intervene. Resident #1 hit Resident #2 in the head and neck repeatedly with a closed fist which resulted in the resident being sent to the hospital where he/she was diagnosed with a neck contusion (bruising). Resident #2 remained fearful and scared of Resident #1 and was moved to another hall for his/her safety. The facility census was 178. Review of the facility Abuse and Neglect policy, dated 6/12/24, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #4) of 13 sampled residents, with mental disorders who lived on a secured locked unit, received individualized treatment and services to meet the resident's needs. The facility failed to ensure the resident received timely and appropriate treatment or services, including administering medications that were prescribed by the physician. The facility census was 178. Review of the facility policy Behavioral Health Services, dated 6/26/24, showed the following: -It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper serving size for residents with a regular diet order was given to each resident or an alternative vegetable given if the resident did not like the vegetable served specified on the menu. The facility census was 178. Review of the undated facility policy, Standard Portions, showed the following: -Uniform food portions shall be established for each diet and served to all residents; -Instruct all dietary employees in the procedures of standardized portions. The dietary manager will monitor the cooks and their use of portion control utensils on tray line. Dietary employees will follow the portion sizes listed in the menu binder. Review of the undated facility policy, Substitutions, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 178. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperatures to insure food safety; -Acceptable serving temperatures are: -Meat, entrees: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Potatoes, pasta and soup: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Hot vegetables: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Pastries, cakes: greater than 60 degrees Fahrenheit; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) in a review of six sampled residents, remained free from misappropriation of property when Hall Monitor A took $40.00 of the resident's money by cash app (an electronic application on a cellular telephone in order to receive and send money electronically). The facility census was 169. On 5/15/24 at 12:40 P.M. the administrator was notified of the past noncompliance which occurred on 5/8/24. On 5/9/24 the administrator became aware of the violation of misappropriation of resident money. Upon discovery, the facility suspended Hall Monitor A, conducted an investigation, and notified appropriate parties. Staff reviewed the facility misappropriation policy, and all facility staff was educated on the facility misappropriation policy. Hall Monitor A was terminated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), who had behavioral difficulties and required 24-hour monitoring and management and was at risk for elopement per the resident's Pre-admission Screening and Resident Review (PASARR), and resided on a secured behavioral unit. On 3/15/24, Hall Monitor A left residents unattended in the gated courtyard during the 9:00 PM smoke break. Resident #1 placed a chair in the corner of the courtyard next to a 12 foot tall fence and used the chair to climb up and over the fence. The resident left the facility without staff knowledge and walked for approximately two miles, crossing a busy four lane highway intersection, then along an outer road before he/she was located at approximately 10:00 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were employed with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for residents who resided on locked behavioral health units. The facility failed to ensure staff who provided one on one (1:1) supervision to residents were fully informed of the reason for the 1:1 monitoring they provided. The facility pulled staff from activities, laundry, housekeeping, and maintenance, away from their normally assigned duties, to monitor residents' smoking times and to provide 1:1 monitoring of residents who had experienced a behavioral health crisis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or their representatives had the right to participate in the development and implementation of the resident's person-centered plan of care when facility staff did not invite two residents (Resident #1 and #3) or the residents' representatives to routine care plan meetings. A sample of 16 residents was selected for review. The facility census was 178. Review of the facility policy, Comprehensive Care Plans and Base line Care Plans, dated 1/19/22, showed the following: -The purpose of this policy is to ensure that the facility develops a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #5), of 14 sampled residents, received necessary care and services in accordance with professional standards of practice. Resident #5 had a left breast needle biopsy (a diagnostic procedure used to investigate masses or lumps) completed on 6/8/23 after a mass was found. The facility failed to follow up and report the biopsy results to the physician until 2/5/24, approximately eight months after the needle biopsy was completed. The biopsy results indicated infiltering duct adenocarcinoma (the most common form of breast cancer and if caught and treated early the survival rate is high). The facility also failed to ensure the resident attended a scheduled follow up appointment with the resident's oncologist to discuss his/her treatment plan. The facility census was 175. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2 and #11), of 14 sampled residents with mental disorders who lived on secured behavioral units, received individualized treatment and services to meet their needs. Residents displayed verbal and physical behaviors on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 175. Review of the facility's Behavioral Emergency Policy, last revised 1/5/23, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraint for three of 42 sampled residents (Residents (R)136, R70, and R31) along with implementing behavioral health interventions to prevent injury and excessive force and failed to investigate emergency events that led to an injury for R136. The census was 178. Immediate Jeopardy related to this failure was identified on 11/15/23 and was determined to first exist since 07/11/23 when the facility failed to ensure R136 wasn't physically restrained while sustaining an injury. On 11/15/23 at 5:31 PM, the facility's Administrator was notified of the Immediate Jeopardy. The facility Administrator was notified the Immediate Jeopardy was removed on 11/20/23. After the immediacy removal, the noncompliance remained at a D scope and severity level. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure chemical restraints were not used unless medically necessary for two of 42 sampled residents (Residents (R)31 and R70). As needed intramuscular injections of psychotropic medication were administered to both residents while physically restraining them and without their willing consent. The residents were exhibiting behaviors, however facility staff did not first attempt to utilize the residents' assessed and care planned de-escalation techniques to calm them down. The facility's failure to ensure all appropriate non-pharmacological interventions were attempted for R31 and R70 prior to the administration of as needed injections of psychotropic medication, increased the likelihood of the residents experiencing serious physical and/or psychosocial harm related to being chemically restrained. The census was 178. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to develop and implement behavioral health interventions to ensure the physical and psychosocial well-being of four of 42 sample residents (Resident (R)120, R136, R70, and R31). The facility failed to assess R120's mental health status after the resident was found with a cord wrapped around his/her neck and later the same day was found appearing non-responsive requiring an emergency code to be called. The facility failed to update the resident's care plan interventions to ensure adequate monitoring, ensure pharmacological and non-pharmacological interventions were implemented and failed to ensure staff working with the resident were aware of the resident's current behavioral support needs. [...]

Inspectors wroteBased on observation, facility document review, and interviews, the facility failed to ensure the kitchen floors, walls, cabinets, and equipment were kept clean and in good repair; failed to ensure staff utilized proper hand hygiene; and utilized appropriate thawing methods in the kitchen. This deficient practice had the potential to affect 178 of 178 residents who received meals prepared in the facility. The census was 178.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a water management plan was in place to prevent a potential Legionella (a potentially dangerous water-borne bacterium capable of causing pneumonia) outbreak in the facility of 42 sample residents. The census was 178.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident rights to make choices about aspects of his or her life in the facility that are significant to the resident for four residents (Resident (R)27, R47, R98, and R5) of five residents reviewed for choices of 42 sample residents. The facility failed to ensure a resident's right to smoke, unless medically contraindicated for R27; the resident's right to sexual relations for R47; and the resident's right to receive additional food for R98, R27, and R5. The census was 178.

Inspectors wroteBased on observations, interviews and review of facility procedures, the facility failed to ensure housekeeping and maintenance services were conducted to maintain a sanitary and orderly interior and to protect residents' property from loss or theft for five of 10 units. This had the potential to affect 100 residents on these units. The census was 178.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely reporting of allegations of abuse for five residents (Residents (R)89, R137, R73, R21, and R31) of 42 sample residents. This failure could place residents at increased risk of abuse. The census was 178.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were thoroughly investigated for three residents (Residents (R)31, R89, and R137) of 11 residents reviewed for abuse out of 42 sample residents. The census was 178.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an individualized and consistent program of activities for four residents, (Residents (R) 1, R59, R5, and R27), of eight residents reviewed for activities out of 42 sampled residents. Activities were not provided routinely for residents per their assessed preferences and plans of care. In addition, activities posted on the activity schedules in each of the facility's units were not provided per the posted schedule. The census was 178.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to follow menus for therapeutic diets, plan a vegan diet in advance, and serve substitutes of similar nutritive value for the facility and five (Residents (R) 428, R27, R4, R158, R59) of 16 residents reviewed for menus of 42 sample residents. The census was 178.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to provide bedtimes snacks that were suitable and nourishing for three residents (Resident (R)27, R85, and R158) of four residents reviewed for bedtime snacks. The census was 178.

Inspectors wroteBased on observation and interview, the facility failed to ensure the lids of two of two outside dumpsters remained closed. The census was 178.

Inspectors wroteBased on observation and interview with facility staff, the facility failed to ensure two of nine total units had handrails on either side of the corridor. This has the potential to affect 41 residents on the 300 and 700 units. The census was 178.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of two of eight residents reviewed for physical abuse (Resident (R) 21 and R70) to be free from physical abuse by R73 and R85 out of a total sample of 42 residents. The census was 178.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure precautions were implemented to ensure one resident's smoking environment was safe for one resident (Resident (R) 48) of 42 sample residents. The census was 178.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure one (Resident (R) 20) of 42 sampled residents maintained acceptable parameters of nutritional status such as usual body weight. The census was 178.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate and sanitary respiratory services for two (Residents (R) 172 and R86) of two residents reviewed for respiratory care out of 42 sample residents. Orders were not obtained for R172's use of oxygen and R86's oxygen tubing and concentrator filter were not changed or labeled appropriately. The census was 178.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of behaviors and side effects of psychotropic medications and failed to ensure risk and benefit review was obtained for administration of psychotropic medications for two of five residents (Resident R61, and R172) reviewed for unnecessary medications of 42 sample residents This facility failure placed these residents at risk for unnecessary medications being administered.

Inspectors wrote28. Review of Resident #62's Care Plan, dated 10/17/19, showed the resident is able to propel himself/herself in his/her wheelchair without difficulty. The resident is a fall risk. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of Alzheimer's disease; -Required supervision and set up for transfers and locomotion on and off the unit; -Required limited physical assistance of one staff member for bed mobility. Observation on 3/31/21, at 11:45 A.M., showed the following: -The resident sat in his/her wheelchair in the dining room on Homestead; -CMT YY propelled the resident down the hall to his/her room; -The resident's feet slid along the floor; -The resident's wheelchair did not have foot pedals. Observation on 3/31/21, at 5:45 P.M., showed the following: -The resident sat in his/her wheelchair by the door to Homestead; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure additional resident (Resident #48), was free from abuse, including mental anguish, when staff refused to allow the resident to smoke if he/she did not feed him/herself meals. The resident had tremors in his/her hands and arms and required assistance to eat. The smoking restriction had no basis and caused the resident to feel awful and to go hungry. Additionally, the facility failed to ensure sampled resident, Resident #141, was free from abuse when Resident #2 hit him/her on the head with a porcelain toilet tank lid. The resident sustained two lacerations and three facial fractures as a result. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's weight loss policy for weekly weights, re-evaluation of the care plan and interventions with continued weight loss, notification of the physician for continued weight loss, and failed to provide assistance with eating for one sampled resident (Resident #32) of 65 sampled residents, who had a 10% weight loss in one month and one additional resident (Resident #48) who had a 22% weight loss in six months. The facility staff also failed to re-evaluate the resident's care plan for weight loss, provide adaptive equipment, provide assistance, and provide desserts and all items on the menu for a diabetic resident (Resident #62), who had significant weight loss in the previous six months. [...]

Inspectors wrote1. Review of email communication from the administrator, dated 4/14/21 at 11:11 P.M., showed there was no facility policy for block medication times. 2. Review of www.accessdata.fda.gov/drugs, showed the following: -Morphine sulfate tablets are an opioid agonist indicated for the management of acute and chronic pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate; -Recommended dose for morphine sulfate tablets: 15 to 30 mg every 4 hours as needed; -Risks of addiction, abuse, and misuse with opioids, even at recommended doses; -Do not abruptly discontinue morphine sulfate tablets in a physically dependent patient because rapid discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain walls, floors, furniture, window coverings, doors, bathroom fixtures, mattresses, floor drains, shower rooms, main kitchen beverage preparation sink; and failed to provide a safe, clean, comfortable, and homelike environment through the facility. The facility census was 170. Observations on 03/29/21 between 9:50 A.M. and 4:40 P.M., showed the following: -The single-well sink, located next to the ice machine at the beverage preparation area in the kitchen, was not functional. The sink well was covered with gray serving tray. The drain pipe in the bottom of the sink was missing and was not connected. A stack of Styrofoam cups were placed on a section of piping under the sink covering up the open end of drain pipe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine was free of a buildup of debris; failed to maintain the range hood to be free of grease and debris; failed to maintain the floor in front of the fryer to be free of grease and debris; failed to cover trash cans when not in use; failed to maintain the walk-in cooler at 40 degrees F (Fahrenheit) or colder; failed to ensure leftover food items were discarded; failed to ensure sanitary practices were used in scooping ice and handling ready to eat food items; and failed to ensure the can opener was free of a buildup of debris. The census was 170. Review of the undated facility policy, Ice Machine, showed the following procedures: -Daily: Wash exterior machine, use sanitizing solution and clean cloth, and allow to air dry; -Monthly: [...]

Inspectors wroteBased on observation, interview and record review the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 170. 1. Observations during survey from 3/29/21 through 4/15/21 showed the following: -No system for administration and tracking of influenza and pneumococcal vaccines; -No yearly staff education regarding care of residents with dementia; -Staff not following infection control measures consistently; -Dietary services not provided in a sanitary environment and not provided to meet residents individual needs on an ongoing basis; -Medication administration not provided consistently according to professional standards and without errors; -Pharmacy services and procedures not followed during count and control of narcotic medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director worked with the facility's clinical team to assure residents attain or maintain their highest practicable physical, mental and psychosocial well-being and failed to ensure the medical director participated and was involved in conducting the Facility Assessment and the Quality Assessment and Assurance (QAA) Committee. 1. During an interview on 4/12/21 at 4:30 P.M., the administrator said she became the facility administrator in June 2020. She verified the medical director did not attend the QAA committee meetings. During an interview on 4/12/21 at 3:58 P.M., the Director of Nursing (DON) said the following: -The QAA committee met monthly and staff gathered information for the meetings weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against influenza and pneumococcal disease in accordance with national standards of practice as indicated by the current Centers for Disease Control (CDC) guidelines. Facility staff failed to administer pneumococcal vaccines when requested by the resident or the resident's responsible party for 21 residents (Resident #143, #83, #63, #6, #124, #159, #31, #9, #134, #100, #157, #175, #43, #138, #177, #27, #135, #45, #165, #69, and #8) in a review of 65 sampled residents and one additional resident (Resident #145). Resident #157 and Resident #45 developed pneumonia and were hospitalized . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff utilized Styrofoam plates and bowls, plastic silverware and disposable plastic cups for meal service. The facility also failed to ensure staff spoke to one resident (Resident #175) in a dignified manner; failed to implement interventions following incidents of smoking in unauthorized areas or when in possession of smoking products during unauthorized smoking times which did not infringe upon the rights of three residents (Residents #22, #130, and #152); and failed to post the residents' rights on each unit where it would be visible to residents. The facility census was 170. Review of the facility policy, Resident Rights, last revised 3/22/17, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to provide quarterly statements, including written documentation of deposits and withdrawals from the resident trust, to residents and their guardians or legal representatives. The facility managed resident funds for 127 residents. The facility census was 170. Review of the facility's policy, Resident Trust, dated 3/1/17, showed the following: -A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis; -The Resident Trust Clerk is responsible for sending out the quarterly statements; -Make copies of all statements and date stamp them with a date they were mailed. Retain the copies for the facility files; [...]

Inspectors wroteBased on record review and interview, the facility failed to timely submit an accounting of residents' personal funds to the Department of Social Services following death of four residents (Residents #305, #306, #307, and #308), who received aid from the Department, and failed to timely return personal funds to one resident (Resident #302) upon discharge from the facility. The facility census was 170. Review of the facility's policy, Resident Funds, dated [DATE], showed the following: -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance and personal possessions; -The resident shall be issued a check for all remaining personal funds in his/her account within five days of discharge; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required employee background screenings by failing to provide documentation of criminal background checks (CBC), employee disqualification list (EDL) checks, and/or nurse aide registry checks completed prior to employment for eight of 14 newly hired employees (hired since the last survey). The facility census was 170. 1. Review of the facility's policy and procedure, Pre-Employment Screening and Employee Screening, dated 03/2021, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment and misappropriation of resident property were reported to the state survey agency immediately but no later than two hours after the allegation was made regarding three residents (Resident #43, #52, #152) in a review of 65 sampled residents and for one additional resident (#304). The facility also failed to ensure the results/conclusions of investigations from self-reported allegations were sent to the State Survey Agency within five working days of the incident for nine sampled residents (Resident #6, #10, #17, #43, #52, #63 #102,#152 and #169) and eight additional residents (Resident #3, #19, #57, #106, #139, #579, #679 and #680). The facility census was 170. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #32, and #62), in a review of 65 sampled residents and one additional resident (Resident #48), within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 170. 1, Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care consistent with residents' specific conditions, needs, and risks for five residents (Residents #31, #60, #67, #141, and #144), in a review of 65 sampled residents. The facility census was 170. Review of the facility policy, Comprehensive Care Plans and Baseline Care Plans, last revised 2/1/20, showed the following: -The purpose of this policy is to ensure the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and report blood sugar levels outside of set parameters to the physician and failed to administer scheduled insulin as ordered to one resident (Resident #178) with a hemoglobin A1C (test used to determine blood glucose levels over three months) last documented at 15.6 (normal range 4.1 to 6.1); failed to flush one resident's (Resident #159)'s peg tube (tube inserted through the abdominal wall for nutrition) before administering medications or enteral feedings according to acceptable standards of practice; failed to document accuchecks (finger stick blood test that measures the amount of glucose in the blood) were completed for three residents (Resident #56, #62, and #176) as ordered by the physician; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four residents (Residents #31, #32, #62 and #69), in a review of 65 sampled residents, and two additional residents (Residents #48 and #145), who required assistance with activities of daily living received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 170. Review of the facility policy, Care of Nails (fingers and toes), dated 2/12/01, showed the following: -Soak the hands for five minutes in a basin of lukewarm water; -Scrub the nails gently with a brush and remove from basin; -Put hands on a towel, trim and clean nails, if necessary. A nurse is to cut a diabetic resident's fingernails. Review of the facility's policy, Perineal Care, dated 10/22/02, showed the following: -Purpose: To keep the female and male genital area clean; -Procedure: [...]

Inspectors wroteSurveyor: [NAME], [NAME] 7. Record review of Resident #85's Pre-admission Screening and Resident Review (PASRR), dated 9/21/16, showed if the resident were admitted to a nursing facility, he/she would need services of structured socialization activities to diminish tendencies toward isolation and withdrawal. Review of the resident's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident's diagnoses were autistic disorder, attention deficit hyperactivity disorder, bipolar disorder, mood disorder and major depressive disorder. Record review of the resident's care plan, revised on 1/20/20, showed the following: -The resident required encouragement and reminders to attend groups, he/she participates in the [NAME] of Focus(WOF) program; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents with limited range of motion (ROM), received appropriate treatments and services to increase ROM and/or prevent further decrease in ROM. The facility failed to provide restorative therapy services for two residents (Residents #32 and #104) in a review of 65 sampled residents and two additional residents (Residents #48 and #51), who the facility identified as in need of restorative therapy services and who had physician orders for restorative therapy services. The facility census was 170. Review of the 2001 revision of the Nurse Assistant in a Long-Term Care Facility manual showed the reasons for providing restorative nursing included: -Follow basic nursing care measures to maintain present function and keep resident functioning at his/her highest potential; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were clean and free of body odors for three residents (Resident #32, #62, and #69 ) in a review of 65 sampled residents and one additional resident (Resident #48). The facility also failed to provide sufficient staffing to ensure medications were passed timely for two sampled residents (Residents #56 and #157). Additionally, the facility also failed to provide sufficient staffing to ensure restorative nursing services were provided as ordered for residents to maintain or improve in activities of daily living (ADLs) for two sampled residents (Resident #32 and #104), and two additional residents (Resident #48 and #51). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ten residents (Resident #6, #52, #138, #124, #152, #131, #178, #85, #102 and #169) of 65 sampled residents and three additional residents (Resident #94, #139 and #158), with mental disorders who lived on secured behavioral units, received individualized treatment and services to meet their needs. Residents displayed verbal and physical behaviors directed towards staff and other residents on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 170. Review of the facility's [NAME] of Focus Program: An Accountability and Responsibility System. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule III through IV controlled substance medication were reconciled by at least two qualified staff to ensure accountability. Further review showed Certified Medication Technician (CMT) YY documented administering narcotics to residents but did not document he/she had removed the medications from the medication cards and documented removing medications from the medication cards when he/she had not. The facility also failed to inventory a schedule IV controlled substance medication for one resident (#58) that requested the medication and was unable to be found by staff. The facility census was 170. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Residents #31, #100 and #135) of 65 sampled residents and two additional residents (Residents #101 and #148) orders for as needed (PRN) psychotropic medications (medications that affects brain activities associated with mental processes and behavior), were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications with an error rate of less than five percent (%) for three residents (Resident #11, #65 and #69), in a review of 65 sampled residents, and for two additional residents (Residents #78, and #144). There were 55 opportunities with 12 errors, which resulted in an error rate of 21.8%. The facility census was 170. Review of the facility's policy, Medication Administration and Monitoring, dated April 2017, showed the following: -Medications are to be given per the physician's orders; -Medication error is defined as a mistake in prescribing, dispensing, or administering medications. A medication error occurs when a resident receives an incorrect medication, medication dose, dosage form and quantity, route of administration, concentration, or rate of administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when facility staff failed to date the label of multi-use vials of insulin when first accessed and administered insulin from the opened, undated multi-use vial of insulin. The facility failed to ensure outdated/expired medications were removed from the medication cart. The facility census was 170. Review of the facility policy Blood Glucose Monitoring dated 4/2017 showed no information regarding storage and labeling of multi-use insulin vials. 1. Review of the Insulin Administration Student Reference Manual, Revised 2001 showed the insulin expiration date must be checked on the vial. Outdated insulin must not be given. 2. Review of www.drugs.com showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received food to meet their nutritional needs, and failed to ensure residents received condiments with meals/snacks. The facility census was 170. Review of the undated facility policy, Dietary Department Objectives, showed the following: -The purpose and scope of the dietary department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of therapeutic and/or modified diets in accordance with primary care physician's orders. Consideration is given to the resident's physical, psychological and social needs. Recognition is also given to the patient's individual preferences and eating habits, which are sometimes influenced by cultural or religious background. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served to meet the needs of the residents. The facility failed to provide a spreadsheet menu that could be utilized by staff when preparing and serving meals, failed to follow a spreadsheet menu by not providing the correct portion sizes for supper on 3/29/21 for residents on a pureed or a mechanical soft diet; failed to prepare and serve all items according to the spreadsheet menu for lunch on 3/30/21 and failed to serve appropriate portion sizes to the residents in the Assist to Dine dining room. The facility also failed to post menus in visible accessible locations for the residents. The facility census was 170. Review of the undated facility policy, Cycle Menus, showed the following: -Menus are implemented by the dietary manager in conjunction with the registered dietician; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility also failed to prepare and serve food items by methods to conserve flavor and appearance. The facility census was 170. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperature to ensure food safety; -Record reading on Food Temperature Chart form at beginning of tray line and during the tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. 1. During an interview on 3/29/21 at 10:22 A.M., Resident #157 said the food was lousy. The hot foot was always served cold. Once in a while the food was warm; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared to the proper texture and consistency for residents on pureed diets. The facility identified five residents on a physician-ordered pureed diet. The facility census was 170. Review of the undated facility policy, Standardized Recipes, showed the following: -Standardized recipes will be used for all products prepared; -Use standardized recipes provided with menu cycle; -The dietary manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added the recipe file, they must be written, standardized and approved by the registered dietician; -Recipes will have diet modifications noted. Review of the facility policy, Pureed Diet, dated 2017, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three sampled residents (Residents #69, #175, and #178), in a review of 65 sampled residents, and one additional resident (Resident #89), were served food items that accommodated their allergies, food intolerances and preferences. The facility failed to provide appealing options of similar nutritive value to residents who chose not to eat the items initially served at the meal. The facility census was 170. Review of the undated policy, Dietary Department Objectives, showed the following: -The purpose and scope of the dietary department is to provide a program that meets the nutritional needs of all the residents; -Standardized methods are practiced in the preparation and presentation of therapeutic and/or modified diets in accordance with the primary care physician's orders; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were sleeping or required assistance to get to the dining room were provided meals and were not omitted from meal service. The facility census was 170. Review of the undated facility policy, Tray Sequence, showed the cook and charge nurse will determine the tray card sequence based on the current situation. This provides an efficient sequence of trays for delivery that help to assure each resident receives his/her tray while the food is at the correct temperature. Review of the undated facility policy, Nursing Department Responsibilities at Mealtime, showed the following: -The nursing department is responsible for distributing food trays to all residents in the facility that are served in their rooms and dining rooms; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special equipment for four residents (Residents #38, #62, #157, and #165), in a review of 65 sampled residents, and five additional residents (Residents #7, #8, #24, #93, and #145), who the facility identified needed the equipment to assist with eating and drinking. The facility census was 170. Review of the undated facility policy, Adaptive Equipment-Feeding Devices, showed the following: -Adaptive feeding equipment is used by residents who need to improve their ability to feed themselves in order to enable residents with physically disabling conditions to improve their eating functions; -Procedure: Upon request, verbal or written, from dietary or nursing, a therapist, when possible, will assess any potential problems; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation that the Quality Assessment and Assurance (QAA) committee met on a quarterly basis and included the appropriate attendees. Additionally, the facility failed to identify, develop, implement, monitor and evaluate system problems. The facility census was 170. Review of the facility's undated Quality Assurance Performance Improvement (QAPI) plan showed: - Purpose: to provide quality excellence in resident care and do a root cause analysis for identified areas of concern and improvement; - The QAA committee will review data from areas the facility believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for the organization; [...]

Inspectors wrote8. Observation on 3/29/21 at 11:37 A.M. showed Dietary Staff P worked in the kitchen and wore an N-95 mask below his/her mouth and nose. Observation on 3/29/21 at 11:49 A.M. showed Dietary Staff P prepared meal trays for the residents from the steam table. Dietary Staff P placed nacho meet onto tortilla chips. Dietary Staff P wore his/her N-95 mask below his/her nose. Observation on 3/29/21 at 12:32 P.M. showed Dietary Staff P assisted with preparing residents' trays during the meal service. He/She wore his/her face covering below his/her nose and mouth during the entire meal service. Observation on 3/29/21 at 2:31 P.M. showed the assistant dietary manager did not wear a mask at all while working in the kitchen. Observation on 3/29/21 at 2:32 P.M. showed the Dietary Staff M and Dietary Staff N did not wear a mask at all while working in the kitchen. Observation on 3/29/21 at 4:07 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective pest control program to address roaches and mice in the facility. The facility census was 170. 1. Review of the administrator's email, dated 04/15/2021, showed the administrator documented the facility did not have a policy for pest control. 2. Observations of the facility on 03/29/21 between 8:50 A.M. and 4:20 P.M., showed the following: -In the 100 hall dining area, the windows were open and there were no screens on the windows. The back exit door had a three inch by four inch area at the bottom that was rusted away and daylight could be seen, the side exit door had a ½ inch gap all the way down the side and the door frame was rusted and daylight could be seen; -In room [ROOM NUMBER] the window was open and the window screen was torn at the bottom; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 170. 1. Review of the facility Training Required for Facilities document, dated 5/2020, showed the following: -Training for Certified Nurse Assistants (CNA) staff to meet 12 hours required training topics; -Hand hygiene; -Safe transfers; -Restorative nursing, bowel and bladder; -Back injury prevention; -Perineal and catheter care; -Empowering residents through Activities of Daily Living; -Infection control and prevention; -Oxygen safety; -Resident rights; -Handling aggressive behaviors; -Effective communication; -Fire safety; -Compliance and ethics training; -HIPAA; -Preventing, recognizing and reporting abuse; -Abuse and neglect; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful to the rights of each resident to make choices about significant aspects of their lives. The facility failed to administer medications per the resident's preference for two residents (Residents #176 and #143) in a review of 65 sampled residents. The facility census was 170. Review of the facility policy Crushing Medications, dated 1/1/2000, showed the following: 1. Medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing, or is a tube-feeder; 2. The following guidelines must be used when the crushing of the medication is necessary: a. The resident's medication administration record (MAR) must indicate the necessity for crushing the medication. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's guardian, emergency contact, and/or next of kin (NOK) after falls or changes in condition for one resident (Resident #179) in a review of 65 sampled residents. The facility census was 170. Review of the facility policy Resident Rights last revised 3/22/17 showed the following: 11. Notification of changes: i. The facility must immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention; B. A significant change in the resident's physical, mental, or psychosocial status (i.e. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #152), was free from misappropriation of his/her property, when the resident's tablet computer went missing shortly after his/her admission to the facility. The facility census was 170. Review of the facility policy Abuse and Neglect, revised 8/2018, showed the following: Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to ensure that a due process for appeals to the accused is outlined related to establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. 1. Review of Resident #152's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's inventory sheet, dated 5/22/20, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that all alleged violations of abuse, neglect, and misappropriation were thoroughly investigated for two of 65 sampled residents (Residents #56 and #152), and for one additional resident (Resident #82). The facility census was 170. Review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this Facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge notices included the resident's appeal rights, how and where to appeal, the ombudsman contact information, and the contact information for the advocacy group for mentally ill individuals for two residents (Resident #157 and #155) of 65 sampled residents when the facility initiated transfer of both residents to the hospital. Additionally, the facility failed to give a written discharge notice for Resident #157 and Resident #155 when the facility initiated transfer to the hospital. The facility census was 170. 1. During an interview on 4/15/21 at 7:30 A.M., the administrator said the facility did not have a policy regarding discharge notices for facility-initiated discharges. 2. Review of Resident #155's medical record showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to assist one resident (Resident #63) out of 65 sampled residents, to obtain vision services when the resident's glasses broke. The census was 170. 1. Review of Resident #63's physician order sheet showed an order for the resident to have eye examinations, treatment and management, dated 11/19/19. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 1/14/21, showed the following: -Diagnoses included anxiety, manic depression, psychotic disorder, and schizophrenia; -Cognition was intact; -The resident wore corrective lenses. Review of the resident's care plan, revised 1/29/21, showed the following: -The resident wore glasses at all times; -The resident would have eye exams and treatments as needed or ordered; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer the correct dose of insulin (a medication used to regulate the amount of glucose (sugar) in the blood) per physician orders for one sampled resident (Resident #144) and one additional resident (Resident #24). The facility failed to dispose of one sampled resident's (Resident #165) and three additional residents' (Resident #11, #16 and #24) insulin per the manufacturer's recommendations and staff administered the expired insulin. Staff failed to obtain ordered insulin for one sampled resident (Resident #144) and borrowed insulin that had expired from other residents. The facility census was 170. Review of the facility policy Medication Administration last revised 4/2017 showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to post the the most recent federal survey and abbreviated survey results and the facility's plans of correction in a place readily accessible to all residents and visitors to view. This affected all residents in the facility. The facility census was 170. Review of the facility policy, Resident Rights, last revised 3/22/17, showed the resident has the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility in a place readily accessible to residents and the facility must post a notice of their availability. During group interview on 3/30/31 at 2:06 P.M., ten of 11 residents in attendance said they did not know where to find survey results in the facility. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop a detailed facility assessment to include residents' acuity levels, the number of residents with special treatments and conditions, and the amount of assistance residents required for activities of daily living. The assessment also failed to correctly identify one resident who required specialty foods or nutrition services based on cultural or religious preferences. The facility census was 170. 1. Review of the facility's assessment, updated 3/30/21, showed the following: -Resident acuity levels were blank; -Special Treatments and Conditions did not include the number or average range of residents who required the listed treatments; -Assistance with activities of daily living was blank; -Mobility was blank; [...]