Nurse Care of Buckhead

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility failed to ensure that the Facility Assessment included an accurate and comprehensive review of the facility's resident population, including the identified secure memory unit located on the fifth floor. The failure to identify a secure unit for dementia care or behavioral health meant the facility assessment plan had potentially missed critical care needs, updating the assessment to reflect residents needing secured care, and revising emergency/care plans to include secure protocols and dedicated spaces. This deficient practice had the potential to affect the care provided to the facility population and the training required for both direct and indirect care staff.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure incontinence pads were available for one resident (Resident (R) 21), reviewed for incontinence supplies from a sample of 45. This failure had the potential to increase skin breakdown for R21.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to report allegations of abuse within two hours and/or submit timely investigations for four of ten (R1, R2, R24, R25, R36 and R35) reviewed for abuse out of a total of 43 sample residents. This deficient practice had the potential to place residents at increased risk of abuse.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, the facility failed to conduct a thorough investigation for incidents of potential abuse for seven of ten residents (Resident (R) 1, R2, R24, R25, R35, R36, and R37) reviewed out of 43 sampled residents, for potential physical resident-to-resident abuse for R1 and R2, R24 and R25, and R35 and R36, and verbal resident-to-resident abuse for R35 and R37. The failure to investigate potential allegations of abuse for facility residents placed the residents at risk of abuse.

Inspectors wroteBased on interviews, record review, and review of the facility's policies titled Applied Body Mechanics - Resident Handling Techniques and Wandering and Missing Residents, the facility failed to ensure one of 45 sampled residents (R) (R21) was safely transferred. In addition, the facility failed to ensure adequate supervision and monitoring for three of 45 sampled Rs (R4, R5, and R3) related to elopement. These deficient practices had the potential to place R21, R4, R5, and R3 at risk of avoidable accidents, injuries, and a diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Insulin Administration, the facility failed to administer insulin as ordered by the physician for one of three residents (Resident (R) 40) reviewed for medication administration out of a sample of 45. This failure had the potential to cause the resident to have uncontrolled blood sugar levels.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services were provided in accordance with professional standards of practice for two of seven residents (R) (R49 and R87) who are dependent on dialysis three times weekly for end-stage renal disease (ESRD) received reliable transportation to attend life-sustaining dialysis treatments. This failure resulted in missed dialysis sessions and avoidable hospitalizations due to volume overload and severe hyperkalemia. On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, staff interviews, and review of the Job Description for the Administrator and the Director of Nursing (DON), it was determined that the facility's Administration did not adequately address issues related to Dialysis and Transportation procedures. Furthermore, they failed to provide sufficient oversight and supervision related to dialysis transportation for two of seven residents (R) (R49 and R87). The facility administration failed to establish systems or offer administrative support to guarantee that residents receive the physician-ordered life-sustaining dialysis treatments. This oversight led to numerous missed dialysis appointments and subsequent hospitalizations. [...]

Inspectors wroteBased on observations, staff and resident interviews, and review of the facility's policies titled Falls and Fall Risk, Managing and Self-Administration of Medication”, the facility failed to provide an environment free of accident hazards for three of 106 sampled residents (R) (R371, R14, and R159) related to failing to conduct a fall risk assessment and implement fall interventions after a fall that resulted in a major injury for R371 and failed to secure medications at the bedside for R14 and R159. Harm was identified as having occurred on 7/3/2024, when R371 had not been assessed after a fall, resulting in a delay in diagnosis and treatment for a left displaced femoral neck fracture and a closed left hip fracture.

Inspectors wroteBased on observations, staff interview, record review and review of the facility's policy titled, Coordination- Pre-admission Screening and Resident Review (PASARR) Program, the facility failed to coordinate/ incorporate PASARR recommendations into for four of four resident (R) (R12, R104, R117, and R33) assessment, care planning and transitions of care. This failure had the potential to cause duplication of services and failure to provide the services necessary for individuals with mental disorders, intellectual disability, or a related condition for level two residents.

Inspectors wroteBased on record review, staff interviews and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to develop and implement action plans; measure the success of actions and track performance; conduct at least one process Improvement Plan (PIP) and regularly review, analyze and act on data collected for three of 106 sampled residents (R) (R80, R2, R55, and R392) not receiving scheduled medications.

Inspectors wroteBased on observations, resident and staff interviews, records review and review of the facility's policies titled Infection Prevention and Control Program, Standard Precautions, Water Management Program, Wound Care, Hand Hygiene, Pressure Ulcer Treatment, and Housekeeping and Laundry Services, the facility failed to maintain infection control processes and procedures related to (1) failing to maintain a sanitary living environment for four of ten resident rooms (224, 225, 227 and 305); (2) failed to comply with proper hand hygiene practices; (3) failed to comply with appropriate infection control practices regarding laundry services; (4) failed to maintain an effective Infection Prevention and Control Program (ICPC), and Antibiotic Stewardship program and a Water Management Program; [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to establish an Infection Prevention and Control Program (IPCP) and an Antibiotic Stewardship program. The facility failed to develop and implement protocols to optimize and monitor the treatment of infections and reduce the risk of adverse events from unnecessary or inappropriate use of antibiotics. This failure had the potential to place all residents, staff, visitors, contracted staff, and volunteers at risk for infection and the development of antibiotic-resistant organisms. The facility census was 212.

Inspectors wroteBased on observations, staff interviews, records review and review of the facility policy titled Infection Prevention and Control Program (IPCP), the facility failed to minimize the risk of influenza and pneumococcal disease by ensuring that four of four newly admitted residents (R) (R48, R54, R96 and R217) residents (R) and staff were educated on the risks and benefits of immunizations; were provided opportunities to receive immunizations; and failed to maintain documentation of the information/education provided, the administration of, or the refusal of vaccinations. This failure placed the entire facility at risk for increased complications or even death related to an outbreak of the influenza or pneumococcal virus.

Inspectors wroteBased on observations, staff interviews, records review, and a review of the facility's policy titled Infection Prevention and Control Program, the facility failed to develop and implement policies and procedures to ensure the availability of Coronavirus disease (COVID-19) vaccine to all staff and residents, offer COVID-19 vaccine, educate staff and residents/resident representatives regarding the risk, benefits and potential side effects of the COVID-19 vaccine and keep proper documentation surrounding vaccination, refusal or contraindications for four of four sampled residents (R) (R48, R54, R96 and R217).

Inspectors wroteBased on observations, resident and staff interviews, and review of facility policies titled Safe Environment and Maintenance service, the facility failed to maintain a safe, functional, and sanitary environment in 14 of 108 resident rooms (214, 217, 218, 224, 225, 226, 322, 325, 326, 405, 417, 421, 505, and 526) related to resident rooms containing debris in packaged terminal air conditioner (PTAC) units, dirty air vents in common areas, and holes/cracks in drywall and doors.

Inspectors wroteAMENDED Based on staff interviews, resident interviews, and record review, the facility failed to ensure that routine and as-needed (PRN) medications were available for administration to three of 106 sampled residents (R) (R2, R55, and R394). This deficient practice had the potential to cause delays in physician-ordered medical interventions.

Inspectors wroteBased on observation, staff interviews and resident interviews, facility records, and review of facility policy titled Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance, and provide meals that were palatable, attractive, and held at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for breakfast were at or above 135 degrees Fahrenheit (F). These deficient practices had the potential to affect 207 of the 212 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and reviews of the he facility policies titled General Food Preparation and Handling, Uniform Policy, and Food Brought in from the Outside, the facility failed to properly discard expired food and ensure that food items were labeled and dated in the kitchen refrigerator, freezer, dry storage, and emergency supply area. The facility also failed to maintain sanitary practices concerning hand hygiene, covering of hair with restraints, and up-to-date sanitizer test strips for dietary staff in the kitchen. These deficiencies had the potential to impact 207 out of the 212 residents who were on an oral diet.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. The facility census was 212.

Inspectors wroteBased on observations, record review, interviews, and a review of the facility's policies titled Assistance with Meals, the facility failed to provide a dignified existence for three of 106 sampled residents (R) (R187, R159, and R108) related to exposed catheter bags for R187 and R159, and during meals for R108. This deficient practice had the potential to negatively impact the residents' sense of self-worth and overall well-being.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administration of Medication and Administering Medications, the facility failed to assess one of 106 sampled residents (R) (R2) for self-administration of medications.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and a review of the facility's policy titled Residents' Rights, the facility failed to honor the resident rights for one of 25 sampled residents (R) (R12) related to the choice to be transferred out of bed daily. This failure had the potential to cause a decrease in the residents' mental and emotional progress.

Inspectors wroteAMENDEDBased on record review, staff interviews, and review of the facility policy titled Advance Directives, the facility failed to ensure one of 106 sampled residents (R) (R48) Advance Directives was completed and followed up on.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to notify the responsible party and attending physician about a change in residents' condition for two of 106 sampled residents (R) (R371 and R170). Specifically, the facility failed to notify R371's responsible party and attending physician following a fall and failed to notify R170's responsible party of a change in condition.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations and investigations of abuse, including injuries of unknown source, were reported timely to the State Survey Agency (SSA) for one of five sampled residents (R) (R128) reviewed for abuse.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations of abuse, including injuries of unknown source, were thoroughly investigated for two of five sampled residents (R) (R128 and R379) reviewed for abuse.

Inspectors wroteBased on observations, staff interview, record review and review of the facility policy titled Coordination- Pre-admission Screening and Resident Review (PASARR) Program and MDS Error Correction, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for four of 106 sampled residents (R) (R12, R104, R117 and R33, and 133).

Inspectors wroteBased on record review, staff interviews and review of the facility's policy titled Care Plan, the facility failed to revise care plans for three of 106 sampled residents (R) (R96, R214, and R159) regarding denture care for R96, regarding diabetes mellitus for R214, and related to for midline dressing for R159.

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Food and Nutrition Services, the facility failed to serve the correct diet for one of 11 residents (R) (R2) ordered to receive a puree diet.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility's policy titled Pain and Administering Medications, the facility failed to ensure that one of 106 sampled residents (R) (R80) received her pain medication in a timely manner.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled Storage of Medications and Control of Drugs, the facility failed to remove expired items from the second and third floor medication rooms and the 200 and 300 hall medication carts. The facility also failed to have an open date on glucometer strips and failed to have all signatures on the 400 hall narcotic count sheets. This deficient practice had the potential to cause worsening of medical conditions for the residents. The facility's census was 212.

Inspectors wroteBased on resident and family interviews, record review, staff interviews, and review of the facility policy titled Resident Rights Policy, the facility failed to provide quarterly resident trust fund statements to 2 of 2 residents (R) R36 and R148 who have a resident account in the facility and are cognitively intact.

Inspectors wroteBased on record review, resident and staff interviews, and the review of the facility documents titled, admission Packet, admission Packets & Compliance Advance Directive Audit, the job description, admission Marketing Director (non-clinical), and emails, the facility failed to provide and obtain signatures of six of 31 sampled Residents (R) (R24, R25, R26, R27, R28, and R31) admission packets that contained written information about how to apply for and use Medicare and Medicaid benefits.

Inspectors wroteBased on staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia, the facility failed to provide evidence of implementation and maintenance of an effective training program for three of thirty Certified Medication Aide Techs (CMAT LL, CMAT MM, and CMAT NN) selected for review of their medication administration skills competency check off. The deficient practice had potential to adversely affect the care given to all residents in the facility. The facility census was 208 residents. Review of the facility's Nursing Care Center Pharmacy Policy and Procedure Manual dated January 2024 revealed under Consultant Pharmacist Services Provider Requirements: [...]

Inspectors wroteBased on observations, record review, resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation of Residents, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for two of 31 sampled Residents (R) (R29 and R30).

Inspectors wroteBased on staff interviews and review of the facility policies titled, Abuse, Neglect and Exploitation of Residents and Background Screening and Investigation, and the Human Resource Director Job description, the facility failed to have two of fourteen employee files selected on site for review, failed to ensure that a criminal background check was completed for one of two Registered Nurses (RN) and one of one Licensed Practical Nurse (LPN), failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for two of two Administrators, three of three Certified Medication Aide Techs, one of one Certified Nursing Assistants (CNA), one of one Regional Director of Business Development, and one of one Maintenance Director. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure physician's orders were followed for two of 31 sampled Residents (R) (R1 and R29) to obtain laboratory tests.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Abuse, Neglect and Exploitation of Residents and the Human Resource Director Job description, the facility failed to ensure that one of six employee files selected for review had evidence they were verified with the State of Georgia's Nurse Aide Registry.

Inspectors wroteBased on observation and staff interviews, the facility failed to have up-to-date facility staffing information posted on 2/11/2025. On 2/12/2025, the staffing information posted was unreadable. In addition, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months.

Inspectors wroteBased on Staff/Resident interviews, record review, and review of the facility's policies titled, Resident Grievances and Resident Council and Family Group, the facility failed to ensure that resident grievances were resolved within 72 hours.

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's Assessment tool the facility failed to have sufficient direct care staff coverage to achieve the highest practicable level of well-being for all residents. The facility census was 189.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that essential equipment was maintained in a safe and operable manner related to wheelchairs, ice machines, and the walk-in freezer.

Inspectors wroteBased on observation and interview, the facility failed to ensure that handrails were securely affixed to the wall and had end caps on four of five floors (Second Floor, Third Floor, Fourth Floor, and Fifth Floor).

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled facility policy, titled Pest Control Policy, the facility failed to have an effective pest control program in place. The census was 189.

Inspectors wroteBased on staff interviews and record review, the facility failed to have residents' funds available for withdrawal after hours and on weekends. This failure has the potential to affect 122 residents who have trust fund accounts. The facility census was 189.

Inspectors wroteBased on observations, interviews, record review, and review of facility policies, the facility failed to provide a safe and sanitary homelike environment, when staff failed to provide residents clean bedding, clean clothing, and clean bath linens on the second and fifth floor; failed to maintain the ceiling/roof in good repair on the second floor and failed to provide an environment free of persistent odors on the third floor. The census was 189.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled, Hydration and the Elderly and High-Risk Population, the facility failed to ensure hydration was easily accessible for four of eight sampled residents (R) (R34, R37, R38, and R48) reviewed for hydration. This failure placed the residents at risk of dehydration and increased health complications.

Inspectors wroteBased on record reviews and interviews, the governing body failed to ensure that the facility had adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meals for residents in a timely manner. The facility census was 189.

Inspectors wroteBased on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program to resolve ongoing concerns related to resident grievances and laundry services. The facility census was 189.

Inspectors wroteBased on observation, interview, record review, and review of facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during care for one of three residents (R) (R53) reviewed for high-contact care.

Inspectors wroteBased on resident, and staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation the facility failed to protect the residents' right to be free from misappropriation of property by facility staff for one of four sampled residents (R) (R32).

Inspectors wroteBased on observations, interviews, and a review of the policy titled Abuse Prevention Policy Instruction, the facility failed to ensure that one of five sampled residents (R) (R11) was free from involuntary seclusion.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital for one of five sampled residents (R) (R15).

Inspectors wroteBased on interviews and record review, the facility failed to provide timely respiratory care consistent with professional standards of practice for one of six residents (R) (R45) requiring tracheostomy care.

Inspectors wroteBased on observations, interviews, record reviews, and a review of facility policy titled Activities of Daily Living (ADL), the facility failed to ensure incontinent care was provided promptly for two of 10 residents (R) (R35 and R36) sampled for ADL care. This failure placed the residents at risk for skin breakdown and a diminished quality of life.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the tube feeding pump was turned on during the hours that the resident was to receive nutrition, per the physician's orders for one of one sampled resident (R) (R53) with parental nutrition. This failure placed the resident at risk for weight loss.

Inspectors wroteBased on interviews, record review, and review of facility policy titled Dialysis, Care of the Resident Receiving Dialysis, the facility failed to ensure the pre/post dialysis communication form was provided to two of two sampled residents (R) (R14 and R52) upon leaving for dialysis.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure physician visits were done every 60 days, per the requirement, and documentation of those visits was in the medical record for one of five sampled residents (R)(R53).

Inspectors wroteBased on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for three days in January 2024.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure that three of five residents (R) (R13, R32, and R67) were free from significant medication errors.

Inspectors wroteBased on interviews, record review, and review of facility policy titled Influenza and Pneumococcal Immunizations, the facility failed to assess for eligibility and ensure residents were offered and/or administered influenza and pneumococcal vaccines; and failed to provide documentation that the resident and/or resident representative were informed of the risks verse benefits of refusing the vaccines for two residents of five sampled residents (R) (R28 and R55) reviewed for immunizations. This failure placed residents at risk of complications from being unvaccinated.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Testing of Resident and Staff for COVID-19, the facility failed to offer/administer or provide documentation of consent or refusal by the resident representative for the COVID-19 vaccines for one of five sampled residents (R) (R28) reviewed for COVID-19 vaccinations. This failure placed the resident at risk for complications related to being unvaccinated.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policies titled, Call System/Light and Food Preferences, the facility failed to ensure the facility made prompt efforts to resolve continued resident grievances regarding food choices and call light response time. This failure affected the resident council and six residents who voiced concerns (Resident (R) 433, R14, R435, R434, R20, and R21) of 47 sampled residents. The deficient practice created the potential for care needs to go unmet or a lack of staff response in case of emergency.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled, Dialysis Care and Services, the facility failed to ensure ongoing communication between the facility and the dialysis unit following a residents hemodialysis treatment for two of three residents (Resident (R) 65 and R39) reviewed for dialysis services. The sample size was 47.

Inspectors wroteBased on observations, resident and staff interviews, record review, the facility failed to maintain an effective pest control program regarding flies which affected all five floors of the facility, specifically for ten (Residents (R) 21, R23, R50, R57, R87, R92, R105, R123, R153, and R167) of 47 sampled residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean, comfortable, and homelike environment for 189 of 189 residents who resided at the facility.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Transfer or Discharge, Emergency, the facility failed to ensure two (Resident (R) 140 and R179) of six residents reviewed for hospitalization received written notice of transfer to the hospital that included a statement of the resident's appeal rights and the contact information for the office of the Ombudsman. The deficient practice had the potential to cause a lack of understanding of appeal rights and resources should the resident not be permitted to return or disagree with the reason for transfer.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) assessment for one (Resident (R) 164) of 46 sample residents accurately reflected R164's nutritional status. This failure had the potential to lead to ineffective or inaccurate care planning for R164.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled, Activity of Daily Living Policy, the facility failed to ensure staff provided the necessary level of assistance with positioning and food tray set-up to meet the needs of one (Resident (R) 173) of one resident reviewed for Activities of Daily Living (ADLs). Specifically, care plan interventions were not implemented to assist with positioning in bed and food tray set-up in accordance with accepted standards of practice, the care plan, and the resident's choices and needs and/or preferences.

Inspectors wroteBased on observation, staff interviews, and review of the manufacturer's guidelines, the facility staff failed to follow the proper administration process for a medication, Advair Diskus (used for treating the symptoms of chronic obstructive pulmonary disease) for one of four residents (Resident (R) 339) during the medication administration pass. Specifically, R339 was not instructed to rinse his mouth out with water then split it out into a cup after Advair Diskus administration. The deficient practice had the potential to cause a fungal infection in the mouth for R339.

Inspectors wroteBased on observations, record review, resident and staff interview, and the review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure one (Resident (R) 104) of four residents reviewed for range of motion (ROM) received a palm guard/orthotic as needed to address his limited range of motion in his right hand. The deficient practice had the potential for further reduction of ROM and/or mobility for R104.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to lock the medication cart when the nurse was not in attendance for one of eight carts; and failed to store medications in a locked medication cart for one Resident (R) 340 of four residents in the medication administration pass observation. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure one (Resident (R) 21) of three residents reviewed for dental services received assistance to obtain dentures. This failure had the potential to contribute to weight loss and nutritional problems due to a dislike of a mechanically altered diet, decreased self-esteem, and increased discomfort for R21.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Documentation Policy, the facility failed to ensure the medical record for one (Resident (R) 286) of 46 sample residents accurately reflected the resident's condition. This failure had the potential to lead to care needs not being met for R286.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy titled, Call System/Light, the facility failed to ensure the call system for one (Resident (R) 7) of 47 sampled residents was functioning. This failure created the potential for R7's needs to go unmet or an inability to summon staff in an emergency.

Inspectors wroteBased on observations, policy review and staff interviews, the facility failed to use or discard emergency food supply prior to the expiration date and failed to discard molded food items in dry storage. In addition, the facility failed to maintain sanitary conditions of the kitchen equipment and failed to demonstrate proper use of the three-compartment sink; failed to maintain the holding temperatures of hot foods on the steam table above 135 degrees. The census was 172 and the sample size was 50.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. The facility census was 172.

Inspectors wroteBased on record review, policy review and staff interviews, the facility failed to ensure one of four sampled residents (R) #58 with a mental illness, had a Level I Pre-admission Screening and Record Review (PASARR) accurately completed prior to admission to determine the need for specialized services.