Oakwood Care and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance and performance improvement (QAPI) committee failed to identify and address concerns related to abuse, neglect and dementia care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to keep residents free from abuse for six (#15, #14, #9, #8, #19 and #20) of 11 residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to:-Protect Resident #15 from physical abuse by Resident #13 on 11/29/25; -Protect Resident #15 from physical abuse by Resident #16 on 1/6/26; -Protect Resident #15 from physical abuse by Resident #17 on 1/17/26; -Protect Resident #14 from physical abuse by Resident #13 on 11/20/25;-Protect Resident #14 from physical abuse by Resident #8 on 1/2/26;-Protect Resident #9 from physical abuse by Resident #10 on 2/5/26; -Protect Resident #9 from physical abuse by Resident #18 on 2/19/26;-Protect Resident #8 from physical abuse by Resident #9 on 2/15/26; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical physical, mental, and psychological well-being for nine (#15, #14, #9, #8, #13, #17, #10, #24 and #25) of 11 residents reviewed for dementia care out of 25 sample residents. Specifically, the facility failed to develop and implement effective person-centered dementia management interventions to prevent Residents #15, #14, #9, #8, #13, #17, #10, #24 and #25 from wandering into other residents' rooms and/or engaging in resident-to-resident altercations.

Inspectors wroteBased on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention. Specifically, the facility failed to ensure contracted and agency staff met training requirements, including timely reporting of suspected abuse.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to conduct a thorough investigation into an allegation of physical abuse of a resident by staff for one (#23) of three residents reviewed out of 25 sample residents. Specifically, the facility failed to conduct a thorough investigation in order to assess all facts of Resident #23's allegation of abuse by certified nurse aide (CNA).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL), received the necessary services to maintain good personal hygiene for one (#4) of five residents out of 25 sample residents. Specifically, the facility failed to ensure Resident #4 received timely incontinence care.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in three of five units. Specifically, the facility failed to:-Ensure common hallways were free from odors and clutter;-Maintain clean floors in the residents' rooms, hallways and secure unit dining room; and, -Ensure resident rooms and common hallways were in good repair.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents and their representatives had a right to participate in the development and implementation of their person-centered plan of care for two (#10 and #15) of 12 residents out of 19 sample residents. Specifically, the facility failed to ensure residents' representatives had the opportunity to attend quarterly care conferences for Resident #10 and Resident #15. I. Resident #10 A. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included dementia with behavioral disturbance, transient ischemic attack (TIA - a temporary blockage of blood to the brain), cerebral infarction (blood clot blocks blood to the artery), chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus with hyperglycemia (high blood sugar), anxiety disorder and depression. [...]

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's representative when there was a significant change in the resident's condition for one (#10) of four residents out of 19 sample residents. Specifically, the facility failed to notify the designated representative for Resident #10 when he had swelling on his face, was seen by a dentist emergently, had edema in his legs, loose stools and bruising on his knee.

Inspectors wroteBased on interviews and record review the facility failed to ensure two (#1 and #8) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #1 and Resident #8.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#53) of nine residents reviewed for services to maintain highest practicable quality of life out of 46 sample residents. Specifically, the facility failed to ensure Resident #53 received timely incontinence care and repositioning.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#53) of one resident out of 46 sample residents. Specifically, the facility failed to: Provide a meaningful activities program for Resident #53; and, -Ensure Resident #53's activity participation was accurately documented.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of three certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #7 and CNA #11.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene assisting residents with eating; and,-Ensure staff handled residents' drinkware in a sanitary manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year for two out of three CNAs reviewed. Specifically, the facility failed to:-Ensure a system was in place to track the CNAs training to ensure they met the annual training requirements; and,-Ensure CNA #7 and CNA #11 received the required 12 hours of training per year.

Inspectors wroteBased on observations and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to maintain residents' dignity and ensure residents were provided equal access to incontinence care supplies.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the transfer or discharge was documented accurately in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (#2) of three residents reviewed for discharge out of 12 sample residents. Specifically, for Resident #2, the facility failed to: -Ensure the resident's discharge summary included the resident's need for two transfer poles; -Ensure the resident's discharge care plan included the resident's medical equipment needs, specifically the two transfer poles -Document communication and responses from the referral sources to confirm the resident's discharge needs; and, -Ensure the resident's discharge date documented in the physician's orders was accurate and the physician's order was obtained timely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#9) of five residents reviewed for medications errors out of 12 sample residents. Specifically the facility failed to ensure Resident #9 was administered Farxiga (for chronic kidney disease and diabetes mellitus type 2) per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#1, #8, #7 and #27) of 11 residents reviewed for abuse out of 28 sample residents were kept free from abuse. Resident #2 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. Resident #2's care plan documented he had potential to demonstrate physically and verbally aggressive behaviors due to his diagnosis of dementia. The resident had exhibited aggression toward staff and other residents. On 11/3/24, Resident #8 reported to staff that his roommate, Resident #2, had hit him. Resident #8 was assessed and found to have a bruise under his right eye. [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste and temperature. Specifically, the facility failed to ensure the residents' food was palatable in temperature. I. Facility policy and procedure The Timely Meal Service and Food Temperature policy, undated, was provided by the nursing home administrator (NHA) on 1/30/25 at 4:00 p.m. It read in pertinent part, Food will be delivered promptly to ensure safe, palatable and high-quality food served at the proper temperature. Food will be served at preferable temperatures (hot foods hot and cold foods cold) as discerned by the patients/residents and customary practice (not to be confused with proper holding temperatures). II. Resident interviews Resident #28 was interviewed on 1/27/25 at 11:47 a.m. [...]

Inspectors wroteBased on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and in three of five nourishment rooms. Specifically, the facility failed to ensure safe and appropriate storage of food items in the kitchen and three of five nourishment room refrigerators.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification agency in accordance with state law for two (#2 and #24) of 11 residents reviewed for abuse out of 28 sample residents. Specifically, the facility failed to report incidents of potential verbal and physical abuse involving Resident #2 and Resident #24 to the State Survey Agency (SSA).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#2) of five residents reviewed for mood and behavior out of 28 sample residents. Specifically, the facility failed to a implement person-centered care plan upon admission to address Resident #2's history of physical aggression towards others in order to prevent physical altercations with other residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of six units. Specifically, the facility failed to ensure facility staff followed enhanced barrier precautions (EBP) when performing high contact activity with Resident #12, who had a suprapubic catheter and stage 4 (damage extending through all skin layers, reaching underlying muscle, tendon or bone, often with exposed tissue and high risk of infection) pressure wounds.

Inspectors wroteBased on interviews and record review, the facility failed to ensure four (#79, #60, #31, #13) of four residents reviewed for abuse out of 48 sample residents were kept from mental and verbal abuse, contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. I. Staff to resident mental and verbal abuse A. In interviews with Resident #79, she stated the activities director (AD) was mean to her, spoke to her rudely, raised her voice at her, and made her feel belittled and like a scolded child on 4/3/24. Resident #79 was upset and was tearful as she recalled the incident. Although three staff who witnessed the incident promptly reported it to the nursing home administrator (NHA), the facility failed for several hours to initiate an investigation or implement corrective actions to protect Resident #79 from further abuse. B. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for three (#93, #40 and #57) of four residents out of 49 sample residents. Specifically, the facility failed to arrange optometry services timely for Resident #93, #40 and #57.

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively address the care and treatment needs of residents in the secured dementia care unit for the residents to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being and provide person-centered care for ten (#84, #78, #71, #89, # 8, #97, #90, #69, #41 and #52) of 18 residents residing on the secured unit out of 49 sample residents. Specifically, the facility failed to: -Provide a consistent and engaging activity program that was meaningful for Resident #84, #78, #71, #89, # 8, #97, #90 and #69, all of whom resided in the secure unit; -Offer and provide Resident #84, #78, #71, #89, # 8, #97, #90, #69, #41 and #52 unrestricted access to supplies and items for independent activities; -Interact in a safe, non-confrontational and appropriate manner with Resident #71; [...]

Inspectors wroteBased on interviews and record review, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for four (#57, #40, #93 and #84) of four residents reviewed for dental services out of 49 sample residents. Specifically, the facility failed to ensure: -Resident #57 was provided follow-up dental services recommended by the dentist; -Resident #40 was provided dentures in a timely manner; -Dental services were offered to Resident #93; and, -Refer Resident #84 to a dental specialist as recommended by the facility dentist for follow up on the resident's dental issues.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate; -Ensure housekeeping staff performed hand hygiene appropriately when performed; -Ensure housekeeping staff properly used a disinfectant chemical when cleaning resident rooms and bathrooms; -Ensure tracking, offering and administration of the COVID-19 vaccination; -Follow infection control practices during wound care; and, -Ensure proper hand hygiene was conducted during medication administration.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#63, #68, #84, #3 and #31) of five residents reviewed for immunizations out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #63, #68, #84, #3 and #31's electronic medical record (EMR) was up to date with their vaccination history; and, -Determine which pneumococcal vaccine was given to Resident #63, #68, #84, #3 and #31 and determine if additional doses were needed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from multiple environmental concerns observed during tours of the facility.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure resident choices for two (#87 and #57) of three residents reviewed for activities of daily living out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #87 and #57 received showers consistently according to their choice of frequency; and, -Ensure Resident #87 and #57's preferences were included in their plan of care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents for one (#93) resident out of 49 sample residents. Specifically, the facility failed to ensure Resident #93's living space was comfortable to him by having access to fresh outside air.

Inspectors wroteBased on interviews and record review, the facility failed to initiate and complete a thorough investigation of alleged violations and take appropriate corrective action following the investigation. Particularly relevant when the allegation was verified for one (#79) of four residents reviewed for abuse out of 48 sample residents to alleviate after effects contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. Specifically, the facility failed to, for Resident #79: -Complete thorough investigations of the alleged violation of mental and verbal abuse that included sufficient evidence to allow the nursing home administrator (NHA) to determine what actions were necessary to protect the resident from further abuse that contributed to residents experiencing, among other emotions, anxiety, fear, and humiliation; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#60) of six residents reviewed for services to maintain highest practicable quality of life out of 49 sample residents. Specifically, the facility failed to provide bathing/showering assistance, grooming for nail care, assistance to change and put on clean clothing.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#87) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 49 sample residents. Specifically, the facility failed to assess and document Resident #87's blood pressure consistently prior to administering blood pressure medications.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#13 and #83) of two residents reviewed for catheter care out of 49 sample residents. Specifically, the facility failed to ensure there were orders for catheter care and maintenance for Resident #13 and #83.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#87) of five residents reviewed for psychotropic medications out of 49 sample residents. Specifically, the facility failed to attempt a gradual dose reduction (GDR) for Resident #87's use of antidepressant medication, sedative medication and antipsychotic medication or provide substantial documentation by the prescribing physician on why a GDR of the resident's medication was contraindicated.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication refrigerators and one medication cart. Specifically, the facility failed to; -Ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator; -Ensure medications were not left in a medication cup on top of the medication cart when not in direct line of sight with the nurse; and, -Ensure that the medication cart was locked when not in direct line of sight of the nurse.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#57 and #87) of two residents reviewed for pain out of 49 sample residents. Specifically, the facility failed to: -Offer person-centered non-pharmacological pain interventions for Resident #57; and, -Follow physician orders for pain parameters when administering as needed pain medications for Resident #57 and Resident #87.

Inspectors wroteBased on interviews, record review, and observations, the facility failed to protect six of nine residents reviewed out of 22 sample residents (#14, #20, #21, #15, #16, and #17) from incidents of resident-to-resident abuse and neglect. A. Record review revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care (secure) unit that protected residents from repeated incidents of resident-to-resident abuse. Residents #14, #20, #16, #17, and #21 resided in the facility's secure unit, along with 20 other residents. Residents #14, 21, #16, #17, and #21 were cognitively impaired and all had the potential for aggressive behavior toward other residents and/or staff. Residents #14 and #20 were known to wander into other residents' rooms. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents. Specifically, the facility failed to ensure staff were not using their personal cell phones while providing incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of three residents reviewed for professional standard out of 22 sample residents. Specifically, the facility failed to ensure Resident #10 received the care and services to treat a surgical wound and prevent the development of severe cellulitis (skin infection). Resident #10 was admitted on [DATE], readmitted on [DATE] and discharged on 4/5/23. Resident #10 had a diagnosis of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, dementia, need for assistance with personal care and gastro-esophageal reflux disease (GERD). Resident #10 had a dermatological surgical procedure on 3/30/23 to remove a cancer lesion from her left upper arm. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#15 and #10) of three residents reviewed out of 18 sample residents. Resident #15 admitted on [DATE] with chronic pain and neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection). According to record review and interviews, the facility failed to ensure the Resident #15's Oxycodone pain medication was available on three separate occasions resulting in increased pain. Additionally, the facility failed to administer Resident #10 the correct pain medication per physician order after a surgical procedure.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on [DATE] the resident had increasing wandering, agitation and physically aggressive behaviors. Due to the facility failures, Resident #14 wandered into other residents' rooms. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide medically related social services to two (#12 and #15) of two residents reviewed out of 22 sample residents. Specifically, the facility failed to assist Resident #12 in making a dental extraction appointment timely after she reported pain and the dentist recommended extractions resulting in infection. Resident #12 was seen by the mobile dentist at the facility on 3/2/23. The mobile dentist recommended sending a referral to a dentist in the community for five tooth extractions. At this time the resident was in pain. The facility did not obtain consent from the resident until 4/4/23 to send the referral. The facility failed to schedule an appointment for Resident #12's teeth extractions for four and a half months. [...]

Inspectors wroteBased on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included facility and community based risk assessments, facility resources, types of staff medical practitioners needed, staff training and competency information, and contract and memorandum of understanding information for third party providers in normal and emergency situations.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, abuse and neglect, quality of life and quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for five of eight staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA), #13, CNA #14, CNA #15, CNA #9 and CNA #16.

Inspectors wroteBased on record review and interviews, the facility failed to report an allegation of potential abuse to the State Agency in accordance with State law for one (#15) resident of three residents reviewed for abuse out of 22 sample residents. Specifically, the facility leadership failed to report an allegation of verbal abuse of Resident #15 by facility a staff member to the facility administrator, local law enforcement or the State Agency.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to investigate an allegation of abuse for one (#15) of four residents reviewed for abuse out of 22 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse involving Resident #15.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#12) out of 22 sample residents. Specifically, the facility failed to contain an accurate representation of incontinence care and meals provided to Resident #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to provide three years worth of survey and investigation findings in a prominent location for public viewing.

Inspectors wroteBased on observations, record review and interviews, the facility failed to prevent development of pressure ulcers for two (#14 and #101) of four residents reviewed for pressure ulcers of 49 sample residents. Specifically, the facility failed to prevent avoidable pressure ulcers and to provide necessary services to promote healing and prevent new ulcers from developing. The facility failed to obtain physician orders for pressure ulcer prevention, to update the resident's care plan, to implement interventions, and to monitor the effectiveness of interventions for Residents #14 and #101. Due to the facility's failures, Residents #14 developed an unstageable pressure ulcer to her right ischium (the area of skin covering the lower hip bone) that worsened to a Stage 4. Resident #101 developed a deep tissue injury pressure ulcer to his right heel and unstageable pressure ulcer to his coccyx.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for three (#34, #62 and #4) four residents reviewed for accidents/hazards out of 49 sample residents. Specifically, the facility failed to prevent residents at risk for falls from having repeated falls, falls with injury, and major injury. Resident #34 experienced multiple falls while a resident of the facility. Resident #34 was assessed to have had poor balance, unsteady gait and poor safety awareness. The resident was blind and had severely impaired cognitive impairments, however, the resident's fall prevention care plan lacked any specific person centered interventions which would be appropriate for the blindness and the cognitive impairments. The facility failed to implement effective fall precautions. [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 15 of 62 resident rooms and on seven of eight hallways. Specifically, the facility failed to ensure: -Walls, ceilings, floors were repaired, painted and properly maintained; -To ensure oxygen concentrators were plugged into electrical outlet instead of a power strip; and, -Comfortable room temperature levels for all rooms in the facility located in the dementia nitunit and dining rooms.

Inspectors wroteBased on interviews and record review the facility failed to prevent resident to resident altercations for six (#35, #59, #74, #99, #70 and #21) of six residents out of 49 residents reviewed. Specifically the facility failed to prevent resident to resident physical abuse altercations between: -Resident #35 and Resident #59; -Resident #74 and Resident #99; and, -Resident #21 and Resident #70.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#15, #95 and #53) of six residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, hygiene, dressing and grooming out of 49 sample residents. Specifically, the facility failed to provide each resident a dignified dining experience with timely feeding assistance, proper positioning, and adaptive equipment as recommended for Resident #15, #95 and #53.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the residents choice for three (#96, #90 and #67) of four residents reviewed for oxygen therapy out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #96, and Resident #90 had complete oxygen orders to include a prescribed liter flow rate; -Ensure Resident #96, and Resident #90 had a person-centered care plan focus for oxygen therapy based upon the resident's assessed needs; and, -Ensure Resident #67's continuous positive airway pressure (CPAP) was cleaned per manufacturer's recommendations.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for two of four medication rooms. Specifically, the facility failed to discard expired medical supplies and laboratory testing items.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens and one of two dining rooms. Specifically, the facility failed to: -Ensure food was served in a sanitary manner where staff did not handle resident ready to eat foods with bare unwashed hands; and, -Ensure staff performed proper hand hygiene prior to assisting a resident with their meal.

Inspectors wroteBased on record review and interviews the facility failed to ensure that the personal funds account were managed adequate for one (#39) of one resident reviewed for personal funds out of 49 sample residents. Specifically, the facility failed to ensure Resident #39 was aware of personal funds and was able to access his funds on the weekend.

Inspectors wroteBased on record review and interviews, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf for one (#39) of one reviewed for personal funds out of 49 sample residents. Specifically, the facility failed to ensure quarterly statements were provided for Resident #39.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate the appropriate relocation following facility-initiated transfer and discharge for one (#106) of two residents reviewed for discharge out of 49 sample residents. Specifically, the facility failed to ensure Resident #106 was provided: -An updated comprehensive care plan and discharge plan, when the facility issued a facility initiated discharge notice; and, -An effective discharge planning process that focused on the resident's discharge goals. The facility further failed to: -Consider the availability or lack of caregiver/support; and the resident's capacity and capability to perform required care, as part of the identification of discharge needs; -Ensure the resident was discharged to a safe location; [...]

Inspectors wroteBased on record review and staff reviews, the facility failed to provide notice of discharge to the resident representative and Office of the State Long-term Care Ombudsman at least 30 days before the resident's discharge for one (#106) of two reviewed for discharge out of 49 sample residents. Specifically, the facility failed to: -Ensure the resident was provided an appropriate discharge notice at least 30 days prior to actual discharge date ; -Ensure Resident #106 and the resident representative/medical power of attorney (MDPOA) was provided written notice of transfer/discharge in a language/format the resident could understand; -Ensure the resident and resident representative were fully informed of their appeal rights and how to request and file an appeal to the resident's discharge from the facility; [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to incorporate the recommendations from the PASARR (preadmission screening and resident review) level II determination and evaluation report into the assessment, care planning and transition of care for two (#62 and #21) or four residents reviewed for PASARR out of 49 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in Resident #62 and Resident #21's PASARR level II report; -Ensure the PASSAR recommendations were included in Resident #62 and Resident #21's medical record; and, -Ensure the PASSAR recommendations were included in Resident #62 and Resident #21's care plans.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper activities of daily living care (ADLs) for two (#21 and #25) of two residents reviewed for ADL care out of 49 sample residents. Specifically, the facility failed to: -Address Resident #21's request for incontinent care in a timely manner; and, -Implement an effective communication system for Resident #25.

Inspectors wroteBased on resident observations, record reviews, and interviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (#82) of two residents reviewed for urinary tract infections of 49 sample residents. Specifically, the facility failed to for Resident #82: -Provide timely nursing assessment of urinary status/condition when the resident experienced a change in condition consistent with a urinary tract infection; and, -Ensure the consistent nursing assessment and catheter care for a placed indwelling urinary catheter to ensure urinary health.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure behavior monitoring was conducted for target behaviors related to the use of a stimulant for one (#62) of five residents reviewed for unnecessary medications of 49 sample residents. Specifically, the facility failed to track and document binge and purge behaviors prior to and after starting a stimulant medication for Resident #62.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's cultural needs for one (#25) of one resident reviewed for nutrition out of 49 sample residents. Specifically, the facility failed to ensure reasonable efforts to meet the ethnic and cultural food needs of Resident #25.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#90) of two residents reviewed for hospice services out of 49 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure for Residents #90, a written plan of care included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff.