Northstar Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to effectively and efficiently manage operations to ensure the agency staff received training and orientation on facility policies, procedures, and resident care expectations prior to being assigned to provide care. This deficient practice resulted in agency staff delivering care without demonstrating competency or knowledge of critical safety policies (including infection control, abuse reporting, emergency procedures, and proper use of care equipment), placing residents at risk for compromised quality of care and safety.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure residents were offered and administered influenza (flu) or pneumococcal (PNA) vaccinations as required by facility policy for 12 of 12 residents reviewed for vaccination compliance (Residents #6, #19, #24, #5, #3, #7, #37, #8, #53, #9, #10, and #1). This deficient practice had the potential to result in residents contracting a preventable disease and resulting in prolonged illness and debilitation.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure physician visits were completed timely for 5 of 15 sampled residents (Resident #37, #24, #53, #11 and #5). This deficient practice has the potential to result in delayed assessment and management of residents' medical conditions, which could lead to adverse health outcomes.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure Controlled Drug Records (CDR) were completed in a timely manner to provide accurate reconciliation of controlled medications for 5 of 11 residents (Resident #51, #4, #52, #37, and #10) documented in the B wing Controlled Substance logbook. This deficient practice had the potential to result in inaccurate medication accountability, delayed identification of discrepancies, and increased risk of medication diversion or resident harm.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure medications were administered with an error rate of less than five percent (5%). There were 33 medication administration opportunities and 14 medication errors, resulting in a medication error rate of 42.42%. This deficient practice had the potential to cause residents to receive incorrect dosages, miss necessary medications, or experience adverse health outcomes, including ineffective treatment and harm.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met quarterly, at a minimum for 2 of 4 quarters reviewed. This deficient practice had the potential to result in widespread resident care and staffing concerns not being identified or addressed and causing residents to suffer actual harm.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 5 of 20 sampled employees (Employees #11, #12, #14, #16, and #20) and 4 of 9 employees sampled for investigation of complaints (Employees #26, #27, #28, and #29). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure 1) a resident consented to receive psychotropic medications prior to the administration of the medications and the consents accurately documented the correct diagnosis or symptom the medication was prescribed to treat for 2 of 15 sampled residents (Resident #9 and #4) and 2) 1 of 15 sampled residents (Resident #5) and/or the resident's representative consented to the use of a Wander Guard (a device secured to a resident's body or wheelchair which triggered an alarm if the resident attempted to exit the building) prior to the facility's implementation of the device. [...]

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to provide a homelike environment when 1 of 15 sampled (Resident# 10) expressed concern regarding excessive noise within the resident's room. This deficient practice had the potential to negatively affect the resident's psychosocial well being.

Inspectors wroteBased on clinical record review, interviews, and document review, the facility failed to ensure 1 of 15 sampled residents (Resident #53) was free from neglect when staff did not reconcile medications from the acute care hospital discharge summary, contact the physician to verify and obtain orders for care and medications, and administer medications during the first two days following admission. This deficient practice had the potential to result in physical and emotional harm to the resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident receiving psychotropic medications had non-pharmacological interventions in place to manage the resident's behaviors for 1 of 15 sampled residents (Resident #9) and residents receiving psychotropic medications had adequate monitoring for behaviors and side effects and appropriate indication for usage for 2 of 15 sampled residents (Resident #4 and #37). This deficient practice had the potential to result in a resident receiving unnecessary medications or lack of nonpharmacological interventions resulting in a resident receiving increased doses of psychotropic medications and adverse drug reactions.

Inspectors wroteBased on interview and document review, the facility failed to ensure the facility did not employ a Registered Nurse (RN) with a disciplinary action against the RN's professional license as a result of a finding of abuse of a patient. This deficient practice placed all residents in the facility at risk for abuse.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to identify and report neglect of a resident to the State Agency (SA) for 1 of 15 sampled residents (Resident #53). This deficient practice had the potential to result in allegations and incidents of possible abuse, neglect, and mistreatment of residents not being investigated by the facility and/or the SA.Resident #53Resident #53 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset and personal history of transient ischemic attack and cerebral infarction without residual deficits. An acute care hospital Discharge summary dated [DATE], documented Resident #53 was admitted to the hospital on [DATE] from a behavioral health crisis center for fever and sepsis. [...]

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure a thorough investigation was conducted and documentation was completed and/or retained for 1 unsampled resident (Resident #71) who eloped from the facility. This deficient practice had the potential to result in psychosocial and physical harm to residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident's behaviors were care planned with non-pharmacological interventions and a resident care plan was implemented to ensure residents were able to smoke independently and safely for 2 of 15 sampled residents (Resident #9 and #7). This deficient practice had the potential to result in a resident not receiving the necessary care to alleviate behavioral symptoms of psychiatric diagnoses and causing unnecessary pain and suffering and a resident suffering physical harm from smoking related injuries.

Inspectors wroteBased on observation, record review, interviews and document review, the facility failed to revise and reinitiate the comprehensive care plan to address the continued or renewed use of a psychotropic medication after the care plan was marked resolved for 1 of 15 sampled residents (Resident #37) and the care plan for 1 of 15 sampled residents (Resident #5) included the current use of a Wander Guard. This deficient practice resulted in the resident receiving a psychotropic medication and facility use of a Wander Guard without an active care plan to guide staff interventions, monitoring, and evaluation, placing the resident at risk for unmet needs and adverse outcomes.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to 1) ensure the smoking evaluation was fully completed by the interdisciplinary team (IDT) as required by facility policy and failed to maintain safe smoking practices by providing adequate supervision to prevent accidents for 1 of 15 sampled residents (Resident #7), resulting in the resident having access to smoking materials and a lighter without documented confirmation of safe smoking ability, placing the resident at risk for injury or fire hazard; and 2) provide the supervision necessary to prevent the elopement of 1 unsampled resident (Resident #71). These deficient practices had the potential to result in physical and emotional harm to both residents.

Inspectors wroteBased on observation, record review, interview and document review, the facility failed to ensure interventions implemented to care for a resident with dementia were revised based on assessment of the resident's condition when quarterly elopement and wandering risk assessments for 1 of 15 sampled residents (Resident #5) documented a wander alarm was not indicated and a Wander Guard device remained in use. This deficient practice had the potential to result in a resident being unnecessarily confined within the facility and experiencing feelings of isolation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure: 1) a medication cart containing resident medications was secured, 2) insulin pens for 3 of 15 sampled residents (Resident #4, #69, and #36) were stored separately to prevent cross-contamination; and 3) temperatures for the medication room and medication refrigerator were monitored and documented as required. These deficient practices had the potential to result in unauthorized access to medications, increased risk of medication errors or contamination, and compromised medication integrity, which could negatively impact resident health and safety.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee maintained an ongoing, facility-wide, and data-driven QAPI program and identified widespread concerns with vaccination programs and employee training and background checks. This deficient practice had the potential to result in residents suffering adverse outcomes and decreased quality of life due to widespread concerns not being identified by the QAPI committee.

Inspectors wroteBased on observation, clinical record review, document review, and interview, the facility failed to ensure appropriate infection control measures were maintained while administering medications to 1 of 15 sampled residents (Resident #69). This deficient practice had an increased risk of infection for residents related to cross contamination during medication administration.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure residents and staff were screened to receive the Coronavirus (Covid) vaccine for 4 of 5 residents reviewed for Covid vaccination compliance (Residents #24, #3, #8, #10). This deficient practice had the potential to result in residents and staff not having the opportunity to accept the vaccine and potentially suffering severe and prolonged illness, with the risk of spreading to others in the facility, if they contract the virus.:

Inspectors wroteBased on interview and record review, the facility failed to provide an effective training program for agency staff to ensure they were knowledgeable about facility policies and resident care procedures. This deficient practice had the potential to negatively impact the quality of care and safety of residents.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial effective communication with residents and family training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial resident rights and responsibilities training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely per facility policy for 1 of 19 sampled employees (Employee #11). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial and annual infection control training was completed timely per facility policy for 3 of 19 sampled employees (Employee #4, #6 and #11). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial and annual compliance and ethics training was completed timely per facility policy for 3 of 19 sampled employees (Employee #2, #11 and #12). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations.

Inspectors wroteBased on personnel record review, interview, and document review, the facility failed to ensure initial behavioral health care training related to dementia, was completed timely for 4 of 20 sampled employees (Employees #11, # 12, #19, and #20). This deficient practice had the potential to prevent residents with dementia care needs from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to maintain staffing hour records for at least 18 months as required by federal regulation. This deficient practice has the potential to impede the facility's ability to demonstrate compliance with staffing requirements and hinders transparency for regulatory review.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to offer a bowel and bladder retraining program for residents assessed to be candidates for retraining for 11 of 49 residents (Resident #13, #47, #22, #24, #34, #18, #23, #41, #20, #28, and #45). This deficient practice had the potential to affect all residents' ability to maintain and achieve their highest continent status and increase the risk of related health issues.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure expired medications were removed from 1 of 2 inspected medication carts and from 1 of 1 inspected medication storage rooms. This deficient practice had the potential to place residents at risk of receiving expired/outdated medications.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 25 opportunities and two medication errors. The error rate was 8%. This deficient practice resulted in a resident receiving a medication at a different concentration than ordered in the electronic Medication Administration Record (eMAR) and had the potential for medication errors and adverse effects.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen and hospice medication orders were entered timely into the electronic medical record (EMR) for 1 of 13 sampled residents (Resident #205). This deficient practice had the potential to expose a resident's private and protected health information and for records to be incomplete, placing a resident at risk of not receiving physician ordered medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a Registered Nurse (RN) performed hand hygiene between administering medications to different residents. This deficient practice had the potential to affect all residents receiving medication from the RN and placed residents at risk for spread of infection.

Inspectors wroteBased on employee record review, document review and interview, the facility failed to ensure timely completion for initial and annual training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 3 of 20 sampled employees (Employee #2, #9, and #13). The deficient practice had the potential to place residents at risk for abuse and neglect.

Inspectors wroteBased on observation and interview, the facility failed to ensure current nursing hours were posted for the facility. The deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the type and number of nursing staff on duty.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure physician ordered medications were administered to a resident during the morning (AM) medication pass on 08/02/2024, and administered timely during the AM medication pass on 08/01/2024, for 1 of 5 sampled residents (Resident #5).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure a resident admitted for orthopedic aftercare following a surgical amputation had the severe pain managed according to the physician's order for 1 of 14 sampled residents (Resident #403) resulting in the resident experiencing actual severe pain.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to develop care plans for 1) the placement of beds against the wall for 31 of 49 residents (Resident #37, #25, #42, #18, #7, #34, #28, #21, #38, #22, #1, #31, #32, #26, #2, #29, #153, #36, #3, #12, #13, #20, #27, #40, #45, #355, #19, #39, #47, #307, and #308), 2) the use of bed rails for 1 of 14 sampled residents (Resident #34), 3) the administration and monitoring of anticoagulant medications and diuretic medications for 1 of 14 sampled residents (Resident #39), and 4) the monitoring and care of a urinary catheter (catheter) and monitoring and treatment of lymphedema for 1 of 14 sampled residents (Resident #308).

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 20 of 20 sampled employees (Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the privacy of residents' protected health information (PHI) was maintained for 1 of 14 sampled residents (Resident #27), and for 5 of 49 residents residing in the facility whose names were visible on an unstaffed and open computer screen (Resident #19, #26, #40, #355, and #103).

Inspectors wroteBased on interview and document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 11 of 20 sampled employees (Employee #1, #4, #7, #11, #12, #13, #15, #16, #17, #18, and #20)

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to obtain informed consent for a psychoactive medication prior to the administration of the medication for 1 of 14 sampled residents (Resident #12). Psychoactive medications Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE] and 08/11/23, with diagnoses including unspecified dementia, moderate, with mood disturbance, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder, single episode, unspecified. A physician's order dated 01/09/24, documented buspirone hydrochloride (HCl) 5 milligrams (mg), give two tablets by mouth two times a day for anxiety. A physician's order dated 02/13/24, documented mirtazapine tablet 7.5 mg, give one tablet by mouth at bedtime for depression. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a call light was within reach for 1 of 14 sampled residents (Resident #308).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to honor a resident's request for a room change for 1 of 14 sampled residents (Resident #35).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for 3 of 14 sampled residents (Resident #306, #12, and #305).

Inspectors wroteBased on interview and clinical record review, and document review the facility failed to ensure a resident received a Notice of Medicare Non-Coverage (NOMNC) prior to dicharge for 1 of 3 unsampled residents (Resident #55).

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to report an allegation of abuse to the State Agency within the required timeframe for 1 of 14 sampled residents (Resident #153).

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure 1 of 14 sampled residents (Resident #30) and the Resident's Representative, received written notification of transfer or discharge.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a physician's order for wound care, wound vacuum, and dialysis was transcribed onto the admission orders for 3 of 14 sampled residents (Resident #2, #403 and #404).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was developed to address the use of a wound vacuum for 1 of 14 sampled residents (Resident #403), oxygen therapy and dialisys for 1 of 14 sampled residents (Resident #404).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to update a plan of care after a resident was discharged from hospice for 1 of 14 sampled residents (Resident #34).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure services provided met professional standards of quality of care by admitting a resident for orthopedic aftercare following surgical amputation without wound treatment or monitoring orders, physician orders were followed for the administration of pain medication, and the Director of Nursing provided assistance to a resident dependent on staff for activities of daily living (ADLs) when the resident attempted to disrobe the resident's pants for 1 of 14 sampled residents (Resident #403). Resident #403 Resident #403 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of encounter for orthopedic aftercare following surgical amputation. [...]

Inspectors wroteBased on observation and document review, the facility failed to ensure the Director of Nursing provided assistance to a resident dependent on staff for activities of daily living (ADLs) when the resident attempted to disrobe the resident's pants for 1 of 14 sampled residents (Resident #403).

Inspectors wroteBased on observation, interview, clinical record review, and interview, the facility failed to ensure a resident admitted for orthopedic aftercare following surgical amputation was not provided wound treatment without physician's orders and physician's orders for wound treatment, monitoring and a wound vacuum were obtained upon admission for 1 of 14 sampled residents (Resident #403).

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to ensure a resident with a pressure injury received the necessary treatment to prevent the deterioration and infection of the pressure injury for 1 of 14 sampled residents (Resident #2) and wound care was provided per physician order for 1 of 14 residents (Resident #45).

Inspectors wroteThe facility failed to ensure medications were not left unsecured in a resident's room by allowing a resident to self-administer a medication and creating a potential accident by leaving a medication unsecured for 1 of 14 sampled residents (Resident #17).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure residents with oxygen therapy were administered oxygen per the physician's order for 3 of 14 sampled residents (Resident #12, #355 and #404).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure alternatives were attempted and entrapment risk was assessed prior to installation of bedrails for 2 of 14 sampled residents (Resident #34 and #355) and alternatives were attempted and documented as unsuccessful prior to the installation of a grab bar for 1 of 14 sampled residents (Resident #21).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a sufficient number of Licensed Nurses and Certified Nursing Assistants (CNAs) were scheduled to perform resident care according to the Facility Assessment for 2 of 2 shifts during the weekends in July, August and September of 2023.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure physician ordered medications were available and administered for 2 of 5 residents observed for medication administration (Resident #1 and #47) and 1 of 14 sampled residents (Resident #403).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than five percent (%). There were 30 opportunities and three medication errors. The medication error rate was 10%.

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to complete Medication Administration Records (MAR) for the administration of an anti-diabetic medication, and two antibiotic medications for 1 of 14 sampled residents (Resident #21).

Inspectors wroteBased on observation, clinical record review, document review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Committee failed to identify, develop and implement plans of action for systemic issues related to beds placed against the walls for 37 of 49 residents (Resident #21, #38, #22, #1, #31, #32, #26, #2, #29, #153, #36, #37, #25, #42, #18, #7, #34, #28, #19, #39, #47, #303, #305, #306, #307, #308, #3, #12, #13, #20, #27, #40, #45, #354, #355, #403, and #404), the use of enhanced barrier precautions, and wound care.

Inspectors wroteBased on document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include the Medical Director.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1) the facility's Infection Prevention and Control Plan (IPCP) was reviewed and/or updated annually to included current infection control standards and 2) a Licensed Practical Nurse (LPN) did not perform a finger stick/ blood sugar (FSBS) for one unsampled resident (Resident #19) while the resident was seated at a table in the community dining room.

Inspectors wroteBased on document review and interview, the facility failed to ensure the Antibiotic Stewardship Program (ASP) policy was reviewed and/or update annually with the potential to affect the facility's entire resident census of 49. The facility policy titled Antibiotic Stewardship Program (ASP), last reviewed 11/2017, lacked documented evidence the policy was reviewed and/or updated annually. The policy did not include the following items. -A process for trending and reporting staff and resident infections. -A process for communicating information at the time of transfer when a resident had an infection or was colonized. -A process for surveillance including outcomes such as SHEA's criteria. On 02/15/24 at 12:12 PM, the Director of Nursing (DON) confirmed the policy provided was the most current version of the policy and was last reviewed 11/2017. [...]

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #12) was screened for eligibility to receive an influenza vaccine, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided, and the vaccine was offered and either administered or declined.

Inspectors wroteBased on personnel record review, interview, and document review the facility failed to ensure resident rights training was completed timely for 2 of 20 sampled employees (Employee #4 and #12).

Inspectors wroteBased on personnel record review, interview, and document review, the facility failed to ensure elder abuse training was completed timely for 3 of 20 sampled employees (Employee #4, #9, and #30).

Inspectors wroteBased on interview and document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 3 of 20 sampled employees (Employee #4, #6, and #12).

Inspectors wroteBased on personnel record review, interview, and document review the facility failed to ensure compliance and ethics training was completed timely for 5 of 20 sampled employees (Employee #2, #3, #4, #9, and #20).

Inspectors wroteBased on personnel record review, interview, and document review the facility failed to ensure behavioral health training was completed for 7 of 20 sampled employees (Employee #1, #3, #4, #6, #10, #12, and #16).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a homelike environment when the facility utilized an overhead paging system to communicate with staff. The overhead paging system had the potential to affect the entire facility census.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to protect a resident from being scratched and causing a resident to bleed and have multiple skin tears by another resident for 1 of 4 sampled residents (Resident #2).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure residents were free from physical and verbal abuse for 1 of 5 sampled residents (Resident #1).