Northrise Wellness & Rehabilitation

Inspectors wroteBased on observation, record review, and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 2 (R #24, and R #25) of 3 (R #24, R #25, and R #26) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan revisions occurred for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for care plan accuracy, when staff failed to revise R #1's care plan with the most current resident information. This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who enters the facility with diagnosis of urinary tract infection (UTI) received appropriate treatment for 1 (R #24) of 2 (R #24 and R #25) residents reviewed for UTI, when they failed to ensure that a resident received all doses of antibiotic as prescribed to treat the UTI. This deficient practice could result in residents being susceptible to worsening infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues).

Inspectors wroteBased on record review and interview, the facility failed to ensure resident record were complete and accurate for 1 (R #24) of 3 (R #24, R #25, and R #26) residents reviewed for pressure ulcers, when they failed to obtain an order and documentation R #24's wound care treatment. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records.

Inspectors wroteBased on record review and interview, the facility failed to provide infection control training (training that helps staff recognize various infection control prevention to help stop the spread of infections) for 4 (LPN #1, LPN #2, LPN #3 and CNA #1) of 4 (LPN #1, LPN #2, LPN #3 and CNA #1) staff sampled for enhanced barrier precautions (EBP; Infection control measures in nursing homes that require staff to wear gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms [MDRO's bacteria or fungi that are resistant to one or more classes of antimicrobial agents]) training. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the required discharge or transfer information for 3 (R #38, R #40, and R #57) of 7 (R #15, R #30, R #31, R #38, R #40, R #47, and R #57) residents reviewed for discharges and hospitalizations when staff failed to: 1. Notify R #38, R #40, or R #57 and their representative(s) of the residents' discharge or transfer to the hospital in writing and in a language and manner they understand. 2. Ensure the discharge or transfer notices for R #38, R #40, or R #57 included: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. [...]

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 5 (R #20, R #38, R #46, R #47, and R #49) of 5 (R #20, R #38, R #46, R #47, and R #49) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plans for 8 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, and R #59) of 8 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, and R #59) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents and worsening of the pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan revisions occurred for 3 (R #13, R #28, and R #57) of 9 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, R #57, and R #59) residents reviewed for care plan accuracy, when staff failed to:1. Ensure the IDT members participated in a care plan meeting within 7 days of the completion of the admission MDS assessment for R #13, R #28, and R #57.2. Revise R #13's care plan with the most current resident information. These deficient practices could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteRecite from complaint survey on [DATE]Based on record review and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 3 (R #30, R #31, and R #46) of 3 (R #30, R #31, and R #46) residents reviewed for code status, when they failed immediately document R #30's, R #31's, and R #46's code status in their medical record. This deficient practice is likely to delay potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation.

Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #31 and R #59) of 2 (R #31 and R #59) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on interview and record review the facility failed to have a qualified activity professional to direct an ongoing program of activities for 2 (R #31 and R #59) of 2 (R #31 and R #59) residents sampled for activities, when staff failed to ensure the Activities Director (AD) had the qualifications necessary to perform the duties of an AD. This deficient practice could lead to a less engaging and beneficial program for residents and could negatively impact residents' well-being and quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #13, R #38 and R #57) of 5 (R #13, R #20, R #38, R #54 and R #57) residents reviewed for accuracy of documentation, when staff failed to: 1. Document information when R #13 left the facility to have a Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) tube placed and after she returned from having a PEG tube inserted. 2. Document administration of R #13's enteral feedings and residual amounts.3. Thoroughly document information for circumstances leading R #38 to be transferred to the hospital on [DATE].4. Document information regarding R #57's discharge from the facility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program for 4 (R #13, R #30, R #49, and R #54) of 5 (R #13, R #28, R #30, R #49, and R #54) residents reviewed for Transmission Based Precautions (additional infection control measures used in healthcare settings alongside Standard Precautions. They prevent the spread of known or suspected pathogens) when staff failed to:EBP A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were aware of the process to file a grievance for 1 (R #30) or 1 (R #30) resident sampled for missing items. If the facility does not ensure that residents know how to file grievances, then residents are likely to feel that their issues and/or concerns are not taken seriously.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #28 and R #54) of 5 (R #13, R #15, R #28, R 46, and R #54) residents reviewed for unnecessary medications, when staff failed to ensure PRN psychotropic medications were not prescribed for longer than 14 days without a written rationale from the provider. This deficient practice could likely result in residents receiving medications longer than needed without a rationale from the provider causing a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview, the facility failed to implement an effective discharge planning process for 2 (R #40 and R #57) of 6 (R #15, R #30, R #31, R #40, R #47, and R #57) residents reviewed for discharge, when staff failed to: 1. Conduct IDT discharge planning for R #40 and R #57. 2. Update comprehensive care plans and discharge plans with treatment preferences and needs for R #40 and R #57.3. Document a discharge plan of care that included treatment preferences and needs for R #57. These failures have the potential for unsafe discharge and an increased risk of resident harm.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #28) of 3 (R #15, R #28, and R #41) residents reviewed for pressure ulcers. This deficient practice could likely result in residents' needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to complete and transmit an MDS assessment after discharge for 1 (R #4) of 1 (R #4) residents reviewed for MDS assessment. This failed practice could lead to the facility not reporting information in a timely manner (within 14 days) to the Federal Agency.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS was accurate for 1 (R #15) of 7 (R #13, R #15, R #28, R #30, R #31, R #41 and R #57) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to provide services that meet professional standards of practice for 2 (R #30 and R #31) of 2 (R #30 and R #31) residents randomly reviewed, when staff failed to monitor R #30's and R #31's weight as ordered. This deficient practice could likely result in staff being unaware of weight gain/loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received quality treatment and care for 1 (R #48) of 5 (R #15, R #28, R #41, R #48, and R #49) residents reviewed for edema and wound care, when staff failed to identify edema (swelling caused by excess fluid trapped in body tissues, commonly affecting the legs, feet, ankles, hands, or abdomen. It is often a symptom of underlying issues like heart failure, kidney disease, liver cirrhosis, or venous insufficiency) in R #48's legs. This deficient practice could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #13) of 1 (R #13) residents sampled for tube feeding (enteral nutrition, delivers essential nutrients, fluids, and medications directly into the stomach or small intestine for individuals unable to take adequate nutrition by mouth), when staff failed to:1. Monitor R #13's weight as ordered.2. Monitor R #13's enteral feedings as ordered.3. Monitor R #13's residual volume (the amount of formula, water, and digestive secretions remaining in the stomach, often checked to assess tube feeding tolerance and aspiration risk) as ordered. These deficient practices could likely result in residents losing weight without the facility being aware and causing worsening of medical conditions.

Inspectors wroteBased on record review and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #54) of 3 (R #54) residents reviewed for respiratory care when the staff failed to ensure R #54 had an order for oxygen therapy. This deficient practice is likely to result in staff not being aware of residents' respiratory status and worsening of their condition.

Inspectors wroteBased on record review, interview, and observation the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 2 (R #20 and R #46) of 2 (R #20 and R #46) residents reviewed for pain, when the facility failed to assess and monitor pain levels for R #20 and 46. This deficient practice could likely result in residents experiencing unnecessary or uncontrolled pain causing residents to experience a decline in physical and emotional health.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) center for 1 (R #59) of 1 (R #59) residents reviewed for dialysis, when staff failed to: 1. Obtain orders for dialysis treatment. 2. Monitor R #59 for complications before and after dialysis treatments. 3. Provide ongoing communication, coordination, and collaboration between the facility and dialysis staff. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure drug records were in order and account of all controlled drugs for 1 (R #54) of 1 (R #54) residents randomly reviewed for medication storage, when staff failed to document dispensed narcotics. This deficient practice could likely result in an inaccurate accounting of resident narcotics.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented comprehensive antibiotic stewardship practices (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for 1(R #15) of 1 (R #15) resident's reviewed for antibiotic use when they failed to provide an end date for R #15's antibiotics. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to antibiotic resistance (significant risk associated with long-term antibiotic use when bacteria change to resist antibiotics that used to effectively treat them) and multi-drug resistant organisms (pathogens, primarily bacteria, that have developed resistance to multiple antibiotics, making them less susceptible to standard treatments)

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a functional system in place to ensure staff could initiate/not initiate CPR (Cardiopulmonary Resuscitation lifesaving technique, aims to blood and oxygen flowing through the body) during an emergency for 1 (R #1) of 2 (R #1 and R #2) resident reviewed for hospitalization, when staff failed to honor the code status (type of emergency treatment a person would or would not receive if their heart or breathing were to stop) wishes of R #1's POA. [...]

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 1 (R #2) of 2 (R #2 and R #4) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plans for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents reviewed for care plans when staff failed to document pressure ulcers and the need for wound care. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents and worsening of the pressure ulcers.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #1 and R #3) of 3 (R #1, R #2, and R #3) residents reviewed accuracy of documentation when staff failed to accurately document the completion of wound care. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing services for all 121 residents that were in the building between 06/25/24-08/23/24 (residents were identified by the Census Report from 06/25/24-08/23/24 provided by the DON 12/11/25) when the facility employed Staff Member (SM) #1 as LPN when she did not have a license or skill set to provide nursing services to residents. This deficient practice could result in residents receiving inappropriate care and interventions for both routine and emergency situations.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of neglect for 1 (R #2) of 121 residents that were in the building between 06/25/24-08/23/24 (residents were identified by the Census Report from 06/25/24-08/23/24 provided by the DON 12/11/25), when they failed to report missed medications and medications left at the bedside of R #2 by Staff Member (SM) #1. If the facility fails to report allegations of neglect, then residents could be subjected to continued neglect resulting in a worsening condition of health and life.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP.) This failure could affect all 27 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 01/08/24). This deficient practice could likely result in residents being at greater risk of infectious disease.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative(s) of the transfer in writing for 5 (R #184, R #185, R #186, R #187 and R #188) of 6 (R #32, R #184, R #185, R #186, R #187, and R #188) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and resident's representative(s) of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #184. 2. Notify the resident and resident's representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #185, R #186, R #187, and R #188. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #185, R #186, R #187, and R #188) of 4 (R #185, R #186, R #187, and R #188) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 4 (R #4, R #7, R #11, and R #184) of 5 (R #4, R #7, R #8, R #11, and R #184) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #11, R #184, and #R #185) of 3 (R #11, R #184, and #R #185) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 3 (R #7, R #8, and R #184) of 5 (R #4, R #7, R #8, R #184, and R #191) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan requirements were met for 4 (R #4, R #7, R #8, and R #19) of 6 (R #2, R #4, R #7, R #8, R #18, and R #19) residents reviewed for care plans when staff failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #7, R #8, and R #19. 2. Revise the care plan with the most current resident information for R #4. [...]

Inspectors wroteBased on observation, and interview the facility failed to keep the residents free from accidents for all 14 residents on the East Unit (Residents were identified by the resident Census provided by the Administrator on 01/14/25), when they failed to keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) locked when not supervised by staff. This deficient practice could likely result in injury to residents obtaining medical equipment which can cause injury/death:.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications, when staff failed to ensure medications were not expired in medication cart for all 14 residents on the East Unit (Residents were identified by the resident matrix provided by the Administrator on 01/15/25). This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light pull cords in resident's rooms were adequately equipped to allow residents to call for help using the call light system for 3 (R #4, R #8, and R #15) of 3 (R #4, R #8, and R #15) when the facility failed to have proper pull cords on the call light system in the resident's rooms when they could not be reached if the resident was not in bed. This deficient practice could likely result in residents being unable to call for assistance.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (R #11 and R #184) of 2 (R #11 and R #184) residents when staff failed to: 1. Implement convalescent care orders (physician's orders that admit a patient to a nursing facility after a hospital stay) for R #11 wounds. 2. Assess R #11's wounds upon admission. 3. Notify the provider when R #184 developed Moisture Associated Skin Damage (MASD, a condition where prolonged exposure to moisture, such as urine, sweat, wound exudate, or saliva, leads to skin damage). Failure to implement convalescent care orders and notify the provider about changes in resident conditions could likely lead to facility staff and the physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure wound care orders were obtained and implemented and wound care was completed for 1 (R #4) of 3 (R #4, R #11, and R #28) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). These deficient could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with a condom catheter (an external urinary device that collects urine from men with urinary incontinence or difficulty urinating) had an order and clinical condition that demonstrated that a condom catheter was necessary for 1 (R #191) of 1 (R #191) residents reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of a urinary tract infection (bacteria in the urinary tract). A. On 01/15/25 at 1:53 PM, during an interview, R #191 said he had a catheter to streamline the process of elimination. R #191 said that he is continent of bowel and bladder. B. On 01/15/25 at 1:54 PM, during an observation of R #191, revealed R #191 had a catheter. C. Record review of R #191's physicians orders revealed R #191 did not have an order for a condom catheter. D. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care (health care discipline specializing in the promotion of optimum cardiopulmonary function, health and wellness) that was consistent with professional standards of practice for 1 (R #2) of 1 (R #2) resident sampled for respiratory care when staff failed to change R #2's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within 7 days of the previous change. This deficient practice could likely cause the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 1 (R #198) of 5 (R #2, R #7, R #19, R #28, and R #198) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason or when the medication is no longer necessary, placing these residents at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview the facility failed to report the results of all of the investigations of alleged medication diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and injuries of unknown origin within five days of the incident to the State Agency. This deficient practice has the potential to affect all 27 residents in the facility. If the facility fails to report the results of the investigations to the State Agency within five days, then corrective action may not be taken and medications may not be available to residents during an emergency and/or residents may suffer serious bodily injury due to injuries of unknown origin.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis that included the following: 1. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift to include: a. Registered nurses. b. Licensed practical nurses. c. Certified nurse aides. This deficient practice could likely result in residents not knowing which staff is working.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan on the resident's individualized discharge goals and needs for 3 (R #11, R #12, and R #13) of 3 (R #11, R #12, and R #13) residents reviewed for discharge planning. This deficient practice is likely to prevent a safe transition from the facility to the resident's post-discharge setting.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, their representatives, or the Ombudsman received a written notice of transfer as soon as practicable for 2 (R #19 and R #122) of 2 (R #19, and R #122) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged .

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #128) of 2 (R #125 and R #128) residents reviewed for care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper care for pressure ulcers (an injury that breaks down the skin and underlying tissue), for 1 (R #125) of 3 (R #125, R #126, and R #128) residents sampled for pressure ulcers, when they failed to have the prescribed air mattress for R #125. This deficient practice could likely result in the development and/or worsening of pressure ulcers.

Inspectors wroteBased on observation and interview, the facility failed to keep residents free from accidents for all 10 residents in the East Unit of the facility (residents were identified by the Census Report provided by the Administrator on 10/31/23), when they failed to secure a treatment cart. This deficient practice could likely result in residents obtaining medical equipment that could be harmful to them resulting in injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley catheter (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #128) of 2 (R #128 and R #126) residents sampled for urinary catheter, when they failed to: 1. Keep R #128's Foley catheter tubing and collecting bag off the floor, and 2. Have a current order for R #128's Foley catheter. This deficient practice could likely result in residents getting infections and having the Foley catheter longer than needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing staff demonstrated competency in skills and techniques necessary to weigh residents safely and correctly for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) employees sampled for training. This deficient practice could likely result in staff working who are not competent to weigh residents.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews at least every 12 months for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications in the medication storage room for all 19 residents (residents were identified by the resident matrix provided by the Administrator on [DATE]) that were randomly sampled, when they failed to dispose of expired Shingrix (A zoster vaccine is a vaccine that reduces the incidence of herpes zoster, a disease caused by reactivation of the varicella zoster virus, which is also responsible for chickenpox) in the medication refrigerator. This deficient practice could result in residents obtaining vaccinations that are expired resulting in adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 18 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 10/31/23), when they failed to: 1. Keep the dry storage area floors clean, 2. Ensure that spices in the kitchen were labeled and dated, 3. Stored a plunger in the dry storage area. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation and interview, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 2 (R #126 and R #173) of 3 (R #126, R #127 and R #173) residents reviewed for call lights. If the facility does not have a functioning call light system then residents are unlikely to get their immediate needs met by facility staff.

Inspectors wroteBased on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to 1 (R #24) of 3 (R #22, R #23, and R #24) residents sampled for beneficiary notices. If residents are not provided with the beneficiary notices, then they may not make an informed decision about the services provided to them and could likely result in a decline in health and function.

Inspectors wroteBased on record review and interview, the facility failed to have the physician document the required discharge information in the resident's medical records for 1 (R #122) of 1 (R #122) residents reviewed for facility discharges. This deficient practice could likely cause an unsafe discharge due to a lack of information or documentation.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or their representatives received a written notice of their bed hold policy indicating the duration the bed would be held for 1 (R #19) of 1 (R #19) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to create a Baseline Care Plan that accurately reflected the resident's current condition for 1 (R #175) of 2 (R #5 and R #175) residents sampled for falls. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 1 (R #128) of 3 (R #122, R #125, and R #127) residents reviewed for code status, when they failed immediately know R #128 would like CPR in an emergency. This deficient practice is likely to delay potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the enteral tube feeding [a device utilized to provide liquid nutrition and medications via a tube into the stomach or intestine] was administered per physician's orders for 1 (R #125) of 1 (R #125) resident reviewed for tube feeding when they failed to continuously administer R #125's feeding. This deficient practice could likely lead to malnutrition and weight loss.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure that staff received the appropriate training and skills to provide services for 1 (R #25) of 1 (R #25) resident reviewed. This deficient practice is likely to result in residents not getting the care and assistance they need.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #179) of 3 (R #123, R #124, and R #179) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication.