Nortonville Health Care Center

Inspectors wroteThe facility had a census of 34, with 14 residents in the sample, and one resident reviewed for substance use disorder. Based on observation, interview, and record review the facility failed to prevent, identify, and intervene in Resident (R) 11's substance use disorder, which placed residents in immediate danger of serious harm or death. R11' Electronic Health Record revealed a history of substance use disorder, charting to indicate signs and symptoms of active substance use, and two instances of the resident having drug paraphernalia in his room. On [DATE] at 02:14 PM facility staff saw a green tackle box and a red basket on the floor in R11's room which contained pill bottles, lighters, books, and other items scattered next to it. The red basket had a torch, four pill bottles, a red lighter, a large knife, and a black pouch containing a drug pipe. [...]

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review the facility lacked a system for records of receipt through disposition of all controlled medications, in sufficient detail to enable accurate reconciliation and ensure drug records were in order. The facility also failed to ensure a record system to account for all controlled medication which was maintained and periodically reconciled. The facility pharmacy lacked onsite presence in the facility to assist in the destruction of controlled narcotic substances from February 2025 until [DATE]. The facility had a locked cabinet inside the medication room used for narcotic medications awaiting destruction. [...]

Inspectors wroteThe facility had a census of 34 residents with 14 in the sample. Based on observation, interview, and record review the facility failed to implement and maintain an effective infection prevention and control program in accordance with a facility assessment, regulatory requirements, and professional standards of practice. Upon entrance to the facility resident rooms had clothing piled on side tables and on the floors, trash cans in resident rooms were full, and staff present failed to maintain infection control practices when transporting laundry, trash, and multi-resident use medical equipment. The facility further failed to implement enhanced barrier precautions (EBP) for residents at risk for the transmission of infectious agents through wounds, catheter use, and/or other medical devices. [...]

Inspectors wroteThe facility census totaled 34 with 14 sampled and one reviewed for change in condition. Based on observation, interview, and record review the facility failed to ensure staff monitored, educated, and documented effectiveness of treatments regarding a change in condition for Resident (R)9. On 08/23/25, while still on antibiotics for cellulitis (skin infection caused by bacteria) the resident had a change in mental status, refused transport to the hospital, and the facility failed to document continued monitoring of the residents change in status. The facility further failed to document any education provided or reapproach provided after the resident's refusal to be seen. [...]

Inspectors wroteThe facility reported a census of 34 residents. The sample included 14 residents, with four reviewed for pressure ulcer/injury. Based on observation, interview, and record review the facility failed to ensure effective interventions, accurate assessments, and consistent monitoring, to prevent the development of a facility acquired stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer/injury of the sacrum (large triangular bone/area between the two hip bones) for dependent and at risk Resident (R)7, who required hospitalization for wound care and intravenous antibiotics for sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). The facility further failed to place effective interventions for R6, with a known history of pressure ulcer/injury development. [...]

Inspectors wroteThe facility census totaled 34 with 14 in the sample. Based on observation, interview, and record review the facility failed to address Resident (R) 16's complaints of pain in her hip. On 07/19/25 the resident voiced pain in the hip after a self-reported fall. After lidocaine (pain medication) patches and Tylenol (pain) were not effective managing the resident's pain the facility placed an order for hydrocodone-acetaminophen (narcotic pain medication) 5-325 milligrams (mg) on the resident's record on 08/12/25, however failed to obtain the medication until 08/25/25. The resident reported pain almost daily at a 1 to 8 on a pain scale where 0 is no pain and 10 is the worst pain imaginable from 08/12/25 until 08/21/25. The facility further failed to ensure R7, received needed dental care and services. R7 refused her dental visit on 10/30/25. [...]

Inspectors wroteThe facility identified a census of 34 residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide a resident centered activities program that incorporated resident interests, hobbies, and cultural preferences for a meaningful life.

Inspectors wroteThe facility census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessments, plans of care and utilizing the facility assessment.

Inspectors wroteThe facility reported a census of 34 residents. Based on interview and record review the facility failed to provide evidence of no less than twelve hours of in-service education provided to the Certified Nurse Aides annually, which were based on their individual performance reviews. This failure had the ability to affect the care of all 34 residents.

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review revealed the facility failed to ensure effective administration in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure affected all 34 residents in the facility.

Inspectors wroteThe census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to conduct an effective facility-wide assessment to determine the resources necessary to care for its residents competently during day-to-day operations.

Inspectors wroteThe facility reported a census of 34 residents. Based on interview and record review the facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program and plan, through the lack of effective involvement by governance and leadership. Administrative Staff A could not provide evidence the QAPI program was effective in the identification of quality concerns, when the current survey identified Immediate Jeopardy and Substandard Quality of Care.

Inspectors wroteThe facility reported a census of 34 residents. Based on interview and record review the facility failed to show evidence the Quality Assurance Performance Improvement (QAPI) program developed and implemented action plans to correct identified quality deficiencies cited on prior and current survey, lacked evidence the QAPI program were aware of the systemic issues which rose to the level of Immediate Jeopardy and Substandard Quality of Care on the current survey, and lacked evidence the QAPI program were monitoring facility practices to prevent adverse events.

Inspectors wroteThe facility reported a census of 34 residents. Based on interview and record review the facility failed to ensure the required members attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly, as required by federal regulation. This failure had the ability to affect all 34 residents.

Inspectors wroteThe facility had a census of 34 residents with 14 in the sample. Based on observation, interview, and record review the facility failed to develop a program for antibiotic stewardship and failed to implement a system to monitor antibiotic use. Record review revealed the facility failed to follow up on prescribed antibiotics, the infectious organisms, and/or the use of antibiotics for residents identified with multi-drug-resistant organisms including methicillin-resistant Staphylococcus aureus (MRSA - per The Centers for Disease Control and Prevention MRSA is a type of staphylococcus that can be resistant to several antibiotics, which anyone can get or carry. [...]

Inspectors wroteThe census totaled 34 with 14 in the sample. Based on observation, interview, and record review the facility failed to provide evidence they designated one infection preventionist who was qualified by education, training, experience and/or certification that worked at least part time on the facility infection control program and completed specialized training in infection prevention and control. This failure created the likelihood for the transmission of infectious agents, subsequent infection, and caused actual severe infection with significant outcomes.

Inspectors wroteThe census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to provide evidence they offered influenza (highly contagious viral infection) immunizations to residents for the 2025 influenza season, when the vaccines were made available for the year and/or beginning approximately October 1st, 2025. The facility further failed to provide signed consents/declinations and/or evidence of vaccination administration related to the influenza and/or pneumococcal (type of bacterial infection) vaccine for Residents (R) 2, R6, R7, R11, and R16.

Inspectors wroteThe facility census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure staff had the appropriate competencies and skill sets related to the facility Quality Assurance and Performance Improvement (QAPI) program to provide nursing and related services to ensure staff were aware of goals and aspects of the program that assured resident safety and attained or maintained the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessments, plans of care and utilizing the facility assessment.

Inspectors wroteThe facility census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure measure the adequacy of any in-service training provided to staff by the failure to evaluate competencies and skill sets of Certified Nurse Aides (CNAs) to ensure the implementation of interventions necessary to meet resident's needs and as identified in the facility assessment.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents with seven residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to respond to and maintain medication regimen reviews (MRR) conducted by the Consultant Pharmacist (CP) for R1, R32, R3, and R24.

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review the facility failed to store schedule II-V controlled narcotic medications in manner in which only authorized staff had access and failed to ensure the quantity stored was minimal in order to identify potential drug diversion and/or missing doses, to include narcotic medications awaiting destruction. The facility had one locked cabinet inside the medication room, which was used for narcotic medications awaiting destruction. The administrator and facility staff did not know who had the key for the locked narcotic destruction cabinet and required maintenance staff to cut the lock off of the cabinet on [DATE], revealing the cabinet was full of narcotic controlled medications which had not been destroyed since at least February 2025. [...]

Inspectors wroteThe census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to provide evidence they offered Covid-19 (highly contagious respiratory virus) immunizations to residents who resided at the facility. The facility further failed to provide signed consents/declinations and/or evidence of vaccination administration related the Covid-19 vaccine for Residents (R) 2, R6, R7, R11, and R16.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents, with three residents reviewed for beneficiary notification. Based on record review and interviews, the facility failed to provide Form CMS 10055- Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to Resident (R) 29 and R42.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents with seven residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the physician documented a rationale with risk versus benefit and nonpharmacological attempts prior to the use of antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medications for R1, the facility failed to ensure a 14-day stop date for an as needed (PRN) psychotropic (alters mood or thought) medication for R32, and the facility failed to attempt a gradual dose reduction (GDR) or provide a rationale against a GDR for psychotropic medications for R1, R32, and R3.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents. Based on record review and interviews, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Resident (R) 1, R16, and R32, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement a comprehensive, individualized care plan to address Resident (R) 1's dementia diagnosis with behaviors, triggers, and interventions; and failed to develop and implement a comprehensive, individualized care plan to address R16's activities of daily (ADL) status and required assistance with ADLs.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to review and revise Resident (R) 32's comprehensive care plan to include fall prevention interventions following multiple falls in the facility.

Inspectors wroteThe facility census totaled 34 with 14 sampled and one reviewed for catheter use and urinary tract infection. Based on observation, interview, and record review the facility failed to ensure Resident (R) 11 who entered the facility with a urinary catheter received the appropriate treatment and services to prevent urinary tract infections and other catheter associated concerns of wounds to both inner thighs without the use of an anchor for the catheter. The resident admitted to the hospital on multiple occasions, received intravenous antibiotics, and returned to the facility with no monitoring or intervention to prevent further infection or wound development.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents, with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and failed to complete assessments after dialysis for Resident (R) 27.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents. Based on observations, record review, and interviews, the facility failed to provide trauma-informed, individualized care including implementing a resident-specific care plan with identified triggers and interventions related to past trauma for Resident (R) 1.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents with one reviewed for dementia care. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment, which supported R1's individualized care needs.

Inspectors wroteThe facility reported a census of 34 residents with 14 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure Resident (R) 7, who had a history of sepsis, received needed dental care and services. R7 refused her dental visit on 10/30/25. The record lacked evidence of staff attempts to get R7 to a dentist after her 10/30/25 refusal, and approximately two months R7 began complaining of tooth pain. The records revealed R7 had an infection to her left lower molar, which caused her pain, affected her eating, and required antibiotics to treat.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the number of nursing (licensed and unlicensed) staff and actual hours worked were posted for all four days of the onsite survey. The facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months.

Inspectors wroteThe facility identified a census of 38 residents. The sample included three residents for abuse. Based on record review, observations, and interviews, the facility failed to prevent an incident of resident-to-resident abuse and protect one resident, Resident (R) 2, from abuse. On 11/19/25 at 01:53 PM R1, a cognitively impaired resident with known aggressive behavior, entered the dining area and, without provocation, forcefully punched (with a closed fist) R2. There were approximately seven to eight additional residents in the dining area at the time of the altercation. R1 punched R2 two to three times in the left shoulder while R2 and others began shouting. R2 tried to block R1's punches, and both residents fell from their wheelchairs to the floor. Activity Staff Z, who was present in the dining area, was approximately ten feet from R1 and R2. [...]

Inspectors wroteThe facility identified a census of 35. The sample included five residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews, the facility failed to follow physician orders to implement preventative wound interventions for Resident (R) 1. On 06/09/25, Consultant GG assessed R1 for a left heel ulcer, ordered suspension boots, and directed staff to clean the wound daily. Staff were to call the provider if the resident's left heel ulcer opened. The facility failed to input the order for suspension boots into R1's Electronic Medical Record (EMR) and further failed to implement the order or apply boots to R1's left heel. [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was independently mobile, at risk for falls, and had impaired cognition. On 07/28/25 at approximately 06:45 AM, Certified Nurse Aide (CNA) N let R1 out of the facility doors after R1 had requested to go outside. Staff reported they were unable to locate R1 in the facility and began searching for him at approximately 08:20 AM. Consultant HH thought R1 may have tried to return to his apartment at the Assisted Living (AL), across the street, and went to look for him. R1 was found in his electric wheelchair, sitting under a gazebo, in front of his previous apartment building. [...]

Inspectors wroteThe facility had a census of 30 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse coverage for eight consecutive hours a day, seven days a week, placing all residents at risk of a lack of assessment and inappropriate care.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to ensure the required annual performance reviews were completed for five of the five staff members reviewed. This deficient practice placed the residents at risk of receiving impaired care.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to have a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation and conduct a periodic reconciliation to account for controlled medications in order to prevent loss or diversion.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide the services of a Consultant Pharmacist to review and identify irregularities in the 30 residents' drug regimen during December 2024. This deficient practice placed the 30 residents at risk for adverse consequences related to medication therapy to the extent possible, from a lack of oversight by a licensed pharmacist, and further placed R5 at risk for adverse consequences from medications.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 30 residents who reside in the facility and received meals from the facility's kitchen, placing them at risk for foodborne illness.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to prioritize improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on data collected. This deficient practice placed the 30 residents of the facility at risk for a lack of quality improvement activities in their facility.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to have a Quality Assessment and Assurance (QAA) committee of the required membership which met at least quarterly and received reports from the Infection Control Preventionist (ICP). This deficient practice placed the 30 residents of the facility at risk for impaired care and services that met accepted standards of quality, identification of problems, and opportunities for improvement.

Inspectors wroteThe facility had a census of 30 residents. Based on record review and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease.

Inspectors wroteThe facility had a census of 30 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 30 residents. Based on observation, record review, and interview, the facility failed to maintain an in-service training program for nurse aides that was appropriate and effective, as determined by nurse aide performance reviews and facility assessment, as specific to the needs of the resident population. This deficient practice placed the residents at risk of inappropriate care and services.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to provide Resident (R) 7 a Bed Hold notice when he was hospitalized . This deficient practice placed R7 at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to remove expired medications from potential use. This deficient practice placed residents at risk of receiving expired or ineffective medication.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 30 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents, with five reviewed for immunizations, including pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to assess Resident (R) 4 and R14 for eligibility to receive further pneumococcal vaccination. The facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify Resident (R) 6's guardian of the discharge and transfer of R6 to another facility until after his discharge from the facility. This placed the resident at risk for further decline and impaired health and well-being.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers or discharge for Resident (R) 7. This deficient practice had the risk of miscommunication between the facility and resident or their representative and possible missed opportunities for healthcare services for R7 and placed R7 at risk for impaired rights.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent falls for Resident (R) 5. This placed the resident at risk for ongoing falls and injuries.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 10, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion) and aggressive behavior toward others, with supervision, treatment, and services to attain or maintain highest practicable physical, mental, and psychosocial well-being. This placed R10 at risk for unmet behavioral and psychosocial well-being needs.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 8 remained free from a significant medication error when staff failed to administer R8 seven physician-ordered medications for three days in a row. This deficient practice placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment.

Inspectors wroteThe facility identified a census of 32 residents. The sample included two residents reviewed for pharmacy services. Based on observation, record review, and interviews, the facility failed to ensure the availability of physician-ordered medications for Resident (R) 1 and R2. This deficient practice had the risk for physical complications and less than desired/therapeutic effects of prescribed medications for R1 and R2.

Inspectors wroteThe facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to immediately respond to a change in health status and failed to obtain physician involvement when Resident (R) 1 had a critical lab result and subsequently developed abnormal blood pressure, lower than the physician ordered parameter. The facility further failed to immediately act upon the resident and/or his representative's request to seek acute care for treatment of his declining health situation. On 08/13/24, R1 fell from a full body lift during transfer. On 08/14/24, R1 complained of intermittent back pain and shakiness. On 08/15/24, a laboratory technician notified Licensed Nurse (LN) H of R1's critical creatinine (lab test used to measure how well the kidneys performed their job of filtering waste from the blood) level at 10:50 AM. [...]

Inspectors wroteThe facility identified a census of 23 residents. The sample included nine residents. Based on observation, record review, and interview, the facility failed to provide appropriate treatment and care for Resident (R) 2's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) including monitoring the resident's status for complications and providing a sterile dressing change per the standards of care for a PICC line at least every seven days. R2 admitted to the facility on [DATE] with a PICC line in place for administration of intravenous (IV - administered directly into the bloodstream via a vein) antibiotics. R2's clinical record lacked evidence that the staff had changed R2's PICC dressing while he was in the facility. [...]

Inspectors wroteThe facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to provide Resident (R) 2 with wound care consistent with standards of practice when staff failed to ensure physician involvement for wound status changes and appropriate treatment orders, and failed to assess wound characteristics consistently and when treatment changes were made. These failures resulted in the deterioration of the wound and the worsening of the infectious process. This also placed R2 at risk for increased pain and other wound-related complications.

Inspectors wroteThe facility identified a census of 23. The sample included nine residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents during a Hoyer lift (full body mechanical lift) transfer. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for further complications.

Inspectors wroteThe facility identified a census of 23 residents and 30 active resident trust fund accounts. The sample included nine residents. Based on record review and interview, the facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation.

Inspectors wroteThe facility identified a census of 23 residents and 30 active resident trust fund accounts. The sample included nine residents. Based on record review and interview, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 5, R6, R7, R8 and R9. This placed the residents at risk for impaired rights and misappropriation.

Inspectors wroteThe facility identified a census of 23 residents and 30 active resident trusts accounts, held by the facility. The sample included nine residents. Based on observation. Interviews, and record review, the facility failed to hold, safeguard, and manage Resident (R)4's trust fund as required when the facility failed to obtain appropriate authorization to disperse or use monies from R4's trust fund. This placed R4 at risk for impaired rights and potential misappropriation.

Inspectors wroteThe facility had a census of 33 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to develop a care plan to ensure staff were aware of skin issues and treatments for Resident (R)13, and failed to develop a care plan fo the use of R15, R24, and R20's bed rails. This placed the residents at risk for complications related to uncommunicated and/or unmet care needs.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure a safe environment, free from accident hazards, when the facility failed to ensure the opening of the side rails used for Resident (R)11, R24, R8 and R15's were within the acceptable safety limits. This placed the affected residents at risk for injuries related to preventable accidents.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure the actual side rail placed into use was assessed for safety for Resident (R)11, R24, R8 and R15's side rails. This placed the affected residents at risk for entrapment or injury.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, facility staff failed to discard outdated vials of influenza (flu) vaccine in the medication room and failed to ensure Resident (R)31's expired insulin (hormone that lowers the level of glucose in the blood) was disposed of. This placed residents at risk for receiving an expired/ineffective dose of the vaccine and R31 at risk to receive expired/ineffective insulin.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to ensure a functional and sanitary environment for residents and staff in the facilty kitchen.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)137, by having an uncovered urinary collection bag visible to guests and other residents, placing the resident at risk for embarrassment and an undignified living environment.

Inspectors wroteThe facility had a census 33 residents. The sample included 15 residents with one reviewed for speech therapy rehabilitation, Resident (R)31. Based on record review, observation, and interviews, the facility failed to provide R31 the frequency of the physician ordered speech therapy sessions. This placed the resident at risk for decline.

Inspectors wroteThe facility had a census of 33 residents. The sample included 15 residents. Based on record review and interview the facility failed to deliver mail to the facility residents on Saturdays.