Old Southwest Health and Rehabilitation

Inspectors wroteBased on observation, staff interview and facility document review the facility staff failed to ensure licensed nursing staff have the competencies and skill sets necessary to provide care for the residents.

Inspectors wroteBased on staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program met the needs of the facility as evidenced by repeated deficiencies in the areas of: Resident Rights, Resident Transfers, Quality of Life, Quality of Care, Pharmacy Services, Infection Control, and Staff Training Requirements.

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to ensure that a resident and/or resident representative had an opportunity to develop an advanced directive for three of three residents sampled, resident #101, resident # 103, and resident # 104.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that written transfer notices included the required information when provided to five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126).

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to have written evidence of providing the bed hold policy to the resident and/or the resident representative when the resident was transferred for five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126).

Inspectors wroteBased on observations, resident and staff interview, clinical record review and facility document review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming/bathing for three of 24 residents in the survey sample, resident # 101, resident # 103 and resident # 104.

Inspectors wroteBased on staff interview, clinical record review, and facility document review the facility staff failed to follow physician's orders for 4 of 24 residents, Resident #110, Resident #112, Resident #113, and Resident #104.

Inspectors wroteBased on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained at a level to decrease the risk for injuries.

Inspectors wroteBased on staff interview, facility document review and during a medication pass and pour observation the facility staff failed to follow established infection control procedures during finger stick blood glucose monitoring for 1 of 4 observations.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to maintain an effective training program for existing staff consistent with their expected roles.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 24 residents, Resident #118.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 24 residents, Resident #115.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for the administration of medications for 2 of 24 residents, Resident #123, and Resident #110.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure physician ordered equipment (splint) was in place to ensure the resident maintained and/or improved their highest level of range of motion (ROM) and mobility for 1 of 3 current residents in the survey sample. Resident #118.

Inspectors wroteBased on staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 2 of 24 residents, Resident #123, #113 and failed to ensure the nursing staff correctly implemented the facility schedule control medication monitoring system for 5 of 5 medication carts.

Inspectors wroteBased on staff interviews, medical record review and facility document review, the facility staff failed to act on pharmacy recommendations for one of three residents in the survey sample, resident # 101.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review the facility staff failed to ensure 1 of 24 residents was free from unnecessary medications, Resident #110.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 24 resident was free of significant medication error, Resident #110.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 4 sampled residents (Resident #122).

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to ensure a medical provider was promptly notified of critical lab values for one (1) of four (4) residents sampled for laboratory review (Resident #114).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to file laboratory results in the clinical record for 1 of 4 sampled residents (Resident #122).

Inspectors wroteBased on staff interviews, facility document review, and clinical record reviews, the facility staff failed to maintain a complete and/or accurate clinical record for three (3) of 24 sampled current residents (Resident #114, Resident #110, and Resident #101).

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure one (1) of three (3) residents sampled for pneumococcal vaccination review were provided the pneumococcal vaccine (Resident #119).

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure 2 of 3 residents was offered a 2023-2024 Covid-19 vaccine, Resident #109, and Resident #119.

Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to ensure 1 resident (Resident #9) was free of significant medication errors. For Resident #9, the significant medication error resulted in a transfer to a higher level of care for an anaphylactic reaction on two separate occasions, two months apart.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that their quality program implemented a corrective action plan following an initial medication error which resulted in a resident (Resident #9) requiring transfer and treatment at an acute care hospital. After the failure of the facility's quality program to adequately address the initial medication error, Resident #9 was subsequently provided the same incorrect medication which resulted in the resident again requiring transfer and treatment at an acute care hospital.

Inspectors wroteBased on observation, staff interview and facility document review the facility staff failed to ensure licensed nursing staff have the competencies and skill sets necessary to provide care for the residents.

Inspectors wroteBased on observation, resident interview, and staff interview, facility staff failed to ensure residents received services according to expressed preferences as evidenced by resident reports that the dining room is open only 1 meal per day, showers and bathing services are not provided per expectation, and staff is enforcing a curfew. During a Resident Council meeting on 3/27/2024, residents informed surveyors that the only meal served in the Dining Room was lunch. Breakfast and dinner were served in resident rooms. Residents stated that many would prefer to eat in the dining room for those meals. One resident stated that there were not enough chairs for ambulatory residents to eat in the dining room when they wanted to do so. [...]

Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, and facility document review, facility staff failed to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish or emotional distress as evidenced by discovery of multiple deficient care areas at a pattern level scope. During an on-site standard and complaint survey, surveyors discovered patterns of deficient practice in multiple care areas. In the area of Resident Rights, surveyors cited seven deficient practices. In the area of quality of life, surveyors found three deficient practices including a pattern of failure to provide ADL care (activity of daily life care) to dependent residents. In the area of Quality of Care, surveyors found three deficient practices including in pain management and a pattern of failure to provide quality of care. [...]

Inspectors wroteBased on staff interview, employee record review, and facility document review, the facility staff failed to implement their policy regarding new hires for 5 of 5 new hires. New hire #1, 2, 3, 4, and 5.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that written transfer notices included the required information when provided to five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126).

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to have written evidence of providing the bed hold policy to the resident and/or the resident representative when the resident was transferred for five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126).

Inspectors wroteBased on observations, interviews, clinical record review, and facility document review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming/bathing for five (5) of 21 sampled residents (Resident #1, Resident #52, Resident #59, Resident #62, and Resident #66).

Inspectors wroteBased on resident interviews, staff interviews, clinical records review, and facility documents review, the facility staff failed to follow medical provider orders for 10 of 21 sampled residents (Resident #8, Resident #13, Resident #28, Resident #44, Resident #46, Resident #59, Resident #66, Resident #72, Resident #79, and Resident #235). 1. The facility staff failed to provide Resident #72's medication (Pancrelipase) as ordered by the medical provider. Resident #72's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/29/24, was signed as completed on 1/31/24. Resident #72 was assessed as being able to make self understood and as able to understand others. Resident #72's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained at a level to decrease the risk for injuries.

Inspectors wroteBased on resident interviews, staff interviews, facility document review, and clinical record review, the facility staff failed to ensure sufficient nursing staff as evidenced by (a) on the morning of 3/25/24 there was a delay in medication administration for one (1) of four (4) resident medication carts and (b) on 3/26/24 some medications were not administered when a nurse allegedly left their shift early.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete a performance review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 4 of 21 residents. (Residents #11, #28) and failed to ensure the nursing staff correctly implemented the facility's scheduled/controlled medication monitoring system for 3 of 4 medication carts.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to act on pharmacist recommendations for five (5) of five (5) residents selected for medication regimen view (Resident #11, Resident #32, Resident #36, Resident #57, and Resident #62).

Inspectors wroteBased on observation and staff interview, the facility staff failed to follow established infection control guidelines, the surveyor observed dirty linen in the floor for 1 of 21 residents, Resident #11.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, facility staff failed to ensure that each resident was offered Covid-19 vaccinations for 5 of 5 residents reviewed (Residents #1, #11, #25, #46, and #32). The surveyor reviewed infection control policies and records with the assistant director of nursing on 3/26/2024. The surveyor chose 5 current residents from the initial pool for review. Per clinical records, none of the records contained information about offering or receiving Covid-19 vaccination for the current (2023-2024) or vaccination information in the clinical record. Facility employees were unable to locate records that vaccines were offered to the 5 residents. The issue was reported to administrative staff during a summary meeting on 3/26/2024.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to maintain an effective training program for new and existing staff consistent with their expected roles.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of effective communication training for direct care staff.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of staff education on the rights of the resident for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of staff education regarding activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, abuse prevention, procedures for reporting abuse, and dementia management for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of staff training that outlines and informs staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of 12 hours of in-service training for nurse aides.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of behavioral health training for staff.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to treat 1 of 21 residents with dignity and respect, Resident #10.

Inspectors wroteBased on resident interview and staff interview, facility staff failed to promote the resident's right right to make choices about aspects of his or her life in the facility that are significant to the resident as evidenced by the resident and staff reports that the resident's right to leave the building is restricted for 1 of 21 residents in the survey sample.(Resident #1). Resident #1 was admitted to the facility with diagnoses which include, but are not limited to, acute and chronic respiratory failure, dysphagia, quadriplegia, chronic decubitus ulcer, and more. The resident utilizes a mechanical chair to ambulate. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. [...]

Inspectors wroteBased on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the resident representative of a change in condition requiring treatment for 1 of 21 residents (Resident #13) and failed to notify the medical provider of unavailable medications for 1 of 21 residents (Resident #72).

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a safe, clean, sanitary, and comfortable homelike environment for 2 of 21 current residents in the survey sample, Resident #14 and #52.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to conduct a comprehensive assessment in accordance with the timeframe of not less than once every twelve (12) months for 1 of 21 residents in the current survey sample, Resident #57 (R57).

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to accurately complete Minimum Data Set (MDS) assessments for one (1) of 21 sampled residents (Resident #62).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for 3 of 21 residents, Resident #10, #79, and #52.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to revise resident care plans and/or failed to include the resident in the care plan process for two (2) of 21 sampled residents (Resident #15 and Resident #62).

Inspectors wroteBased on staff interview, clinical record review, facility document review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for the administration of medications for 2 of 24 residents, Resident #123, and Resident #110.

Inspectors wroteBased on interviews, facility document review, and clinical record review, the facility staff failed to provide splints for one (1) of 21 sampled residents (Resident #62).

Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing program of activities designed to meet the interests, and the physical, mental, and psychosocial well-being for 1 of 21 current residents in the survey sample. Resident #52 (R52).

Inspectors wroteBased on interviews, facility document review, and clinical record review, the facility staff failed to provide care and/or treatment to address and/or prevent pressure wounds/area for one (1) of 21 sampled residents (Resident #62).

Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide services and/or treatment to prevent further decrease in range of motion, including the provision of equipment for limited range of motion for 1 of 21 current residents in the survey sample. Resident #52 (R52).

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to provide nutrition services to ensure the resident could maintain the highest practicable well-being for 1 of 21 residents in the survey sample (Resident #46). Resident #46 was admitted to the facility with diagnoses including, but not limited to, hypertension, gastroesophageal reflux, bacteremia, sepsis, gangrene of right foot, other disorders of the circulatory system, deep vein thrombosis, acquired absence of right leg above the knee, surgical aftercare. On the most recent Minimum Data Set assessment, the resident scored 12/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review on 3/27/2024 revealed weights upon return were 121.0 on 2/13 and 2/16, 124.8 on 2/16 and 2/23. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review facility staff failed to ensure residents' pain was managed according to goals and preferences for 1 of 21 residents. Resident #77.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review the facility staff failed to ensure 1 of 24 residents was free from unnecessary medications, Resident #110.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the provider reviewed the residents laboratory results for 1 of 21 residents, Resident #79.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure complete and/or accurate clinical records for three (3) of 21 sampled residents (Resident #46, Resident #59, and Resident #72).

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record reviews and facility document reviews, the facility staff failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of corrections for the standard recertification and abbreviated surveys dated 8/05/21 through 11/01/23, in order to maintain compliance as evidenced by repeated deficiencies in the areas of Resident Assessments, Quality of Care, Pharmacy Services, and Administration.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, facility staff failed to ensure that each resident was offered the influenza and pneumococcal vaccinations for 3 of 5 residents reviewed (Residents #25, #46, and #32). The surveyor reviewed infection control policies and records with the assistant director of nursing on 3/26/2024. The surveyor chose 5 current residents from the initial pool for review. Per clinical records, 1 resident refused the influenza and pneumococcal vaccines. One resident received the influenza vaccine, and the other three residents had no vaccination information in the clinical record. Facility employees were unable to locate records that vaccines were offered to the three residents without records. The issue was reported to administrative staff during a summary meeting on 3/26/2024.

Inspectors wroteBased on observation and staff interview, the facility staff failed to post, in a form and manner accessible to residents and resident representatives the mailing address and telephone number of the State Survey Agency.

Inspectors wroteBased on observation and staff interview, the facility staff failed to have readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility and failed to post a notice of the availability of such reports in areas of the facility that were prominent and accessible to the public.

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to ensure that a resident and/or resident representative had an opportunity to develop an advanced directive for three of three residents sampled, resident #101, resident # 103, and resident # 104.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 4 sampled residents (Resident #122).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to file laboratory results in the clinical record for 1 of 4 sampled residents (Resident #122).

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to properly label and store medications in 4 of 4 medications carts and for 1 of 33 resident's, Resident #30.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a clean, comfort homelike environment for 3 of 33 Residents (#15, #23, and #24) and in 2 of 2 shower rooms.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure the facility was free of accident hazards in 2 of 2 shower rooms.

Inspectors wroteBased on observation, staff interview, facility document review, clinical record review and during a medication pass and pour observation the facility staff failed to ensure that physician ordered medications were available for administration for 5 of 33 residents, Resident #1, Resident #10, Resident #31, Resident #32 and Resident #21.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a baseline care plan for 1 of 33 Residents, Resident #21.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop and implement a comprehensive care plan (CCP) for 1 of 33 Residents, Resident #21.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to review and revise the residents care plan for 1 of 33 Residents, Resident #26.

Inspectors wroteBased on staff interview, facility document review, clinical record review, and during a medication pass and pour observation the facility staff failed to follow standards of practice in regards to medication administration for 2 of 33 residents, Resident #19, and Resident #33.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provided pressure ulcer treatment for two of 33 residents in the survey sample, Resident # 18 and Resident # 25.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide foot care for a dependent care resident for 1 of 33 Residents, Resident #23.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure 1 of 33 residents (Resident #23) tube feeding was set on the rate that was ordered by the provider.

Inspectors wroteBased on staff interview, facility document review, clinical record review and a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5 %. There were 6 errors in 34 opportunities for a medication error rate of 17.6 %. These errors affected Resident #30, Resident #32, and Resident #33.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review the facility staff failed to ensure 2 of 33 residents were free of significant medication errors, Resident #30, and Resident #21.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to maintain a complete and accurate clinical record for 2 of 33 residents, Resident #20, and Resident #21.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review the facility staff failed to establish and follow an effective infection control program for 2 of 32 residents, Resident #12, and Resident #26.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the code status for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the clinical record contained conflicting documentation regarding the resident's code status.

Inspectors wroteBased on interviews and facility document review, the facility staff failed to report the investigation results of an alleged episode of neglect to the appropriate agencies within 5 working days of the incident for one (1) of 19 sampled current residents, Resident #59. The facility staff self-reported an allegation of neglect involving Resident #59 to the state survey agency (SA); the facility staff failed to report the investigation results to the SA.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to provide bed hold policy information to a resident or resident's representative for one (1) of 19 sampled current residents, Resident #13. Resident #13 had been admitted to a local hospital.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure the accuracy of MDS (minimum data set) assessments for 1 of 19 residents, Resident #42. For Resident #42, the facility staff failed to ensure the BIMS (brief interview for mental status) was completed

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to conduct a level 1 PASARR (pre-admission screening and resident review) for 1 of 19 residents in the survey sample (Resident #55). Resident #55 was admitted to the facility with diagnoses including bipolar disorder, psychotic disorder, major depression, respiratory failure, coronary artery disease, heart failure, hypertension, malnutrition, hypertension, and anemia. On the minimum data set assessment with assessment reference date 7/6/2022, the resident scored 3/15 on the Brief Interview for Mental Status and was assessed as without delirium, psychosis, or behavior affecting care. On 7/18/22, the surveyor was unable to locate a PASARR in the resident's clinical record. The surveyor was offered a demographic form which did include the questions asked on a level 1 PASARR. [...]

Inspectors wroteBased on Resident interview, staff interview, clinical record review and facility document review the facility staff failed to follow professional standards of practice for the documentation of medications for 1 of 19 Residents, Resident #47. For Resident #47 the facility staff initialed a nebulizer treatment as being administered as ordered, when the resident was not receiving the treatment.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure care and services were provided to address the needs for 5 of 19 residents in the survey sample, Residents #3, #16, #39, #47, and #164. For Residents #3 and #16, the facility staff failed to obtain weekly weights as ordered by the physician. For Resident #39, the facility staff failed to obtain a dermatology consult, gastroenterology consult, a chest CT (computed tomography) scan, and an upper GI (gastrointestinal) x-ray as ordered by the physician. For Resident #47, the facility staff failed to administer the medication Pulmicort as ordered by the physician. Pulmicort is an inhaled steroid used in the treatment of chronic obstructive pulmonary disease. For Resident #164, the facility staff failed to obtain a weight ordered by the dietician.

Inspectors wroteBased on observation, staff and resident interviews, and facility document review the facility staff failed to provide supervision to prevent potentially avoidable accidents for 1 of 19 residents. (Resident #5) For Resident #5 the facility staff failed to provide supervision while the resident was smoking.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident who is fed by enteral means receives the provider ordered tube feeding nutrition and hydration and failed to address a significant weight loss for 2 of 19 residents in the survey sample, Residents #3 and #164. For Resident #3, the facility staff failed to provide tube feeding formula and water as ordered on 7/18/22. For Resident #164, facility staff failed to address a documented significant weight loss. 1. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Demyelinating Disease of Central Nervous System, Epilepsy, Dysphagia, Bipolar Disorder, Generalized Anxiety Disorder, Essential Hypertension, and Pseudobulbar Affect. [...]

Inspectors wroteBased on observation, Resident interview, staff interview and facility document review the facility staff failed to maintain respiratory equipment for 1 of 19 residents, Resident #47. For Resident #47 the facility staff failed to store the resident's respiratory equipment to prevent contamination.

Inspectors wroteBased on observations, staff and resident interviews, clinical record reviews, facility document reviews, and during a medication pass and pour the facility staff failed to ensure medications were available for 3 of 19 residents. (Resident #25, Resident #32, and Resident #3) For Resident #25, facility staff failed to ensure Azelastine HCl Solution 0.05% eye drops (used to treat allergic eye inflammation) were available for administration. For Resident #32 the facility staff failed to ensure the medications Fentanyl and pantoprazole were available for administration. For Resident #3, the facility staff failed to ensure Clonazepam, a benzodiazepine used to control certain types of seizures and relieve panic attacks, was available for administration on seven (7) separate occasions.

Inspectors wroteBased on interviews, facility document review, and clinical record review, it was determined the facility staff failed to ensure: (a) medical regimen reviews (MRRs) were completed and/or (b) medical regimen review (MRR) recommendations were addressed by a medical provider for three (3) of 19 sampled current residents, Resident #1, Resident #31, and Resident #59.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to safely store medications on 1 of 3 units (unit 1) and failed to secure a narcotic in 1 of 1-medication rooms. 1. The facility nursing staff failed to lock their medication cart when out of view and failed to secure a bottle of 325 mg Tylenol. 2. The facility staff failed to store liquid oxycodone, a Schedule II drug, in a separate and locked compartment within one (1) of one (1) medication storage units.

Inspectors wroteBased on interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for three (3) of 19 sampled current residents, Resident #32, Resident, #42, and Resident #59. For Resident #59, the facility staff failed to document the results of monthly medication regime reviews (MRRs) completed by a pharmacist. For Resident #32, the facility staff failed to document that medications were administered as ordered. For Resident #42, the facility staff failed to document that medications were administered as ordered.

Inspectors wroteBased on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection for 1 of 30 residents in the survey sample, Resident #108.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to develop and implement a comprehensive care plan for 4 of 30 residents, Resident #32, Resident #10, Resident #31 and Resident #17.

Inspectors wroteBased on observations, staff interviews, resident interview, and the review of documents, it was determined the facility staff failed review and revise comprehensive care plans for four (4) of 30 residents (Resident #10, Resident #13, Resident #14, and Resident #33).

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that residents who was unable to carry out (ADLs) activities of daily living received the necessary care and services to maintain personal hygiene and grooming for 10 of 30. Residents #35, #40, #52, #208, #10, #31, #5, #7, #33, and #34.

Inspectors wroteBased on interviews, the review of documents, and in the course of a complaint investigation, it was determined the facility staff failed to ensure required care was provided to for 10 of 30 sampled residents (Resident #1, Resident #5, Resident #6, Resident #13, Resident #17, Resident #19, Resident #31, Resident #46, Resident #48, and Resident #52).

Inspectors wroteBased on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure a properly working call system for parts of two (2) of two (2) open units.

Inspectors wroteBased on staff interview, employee record review and facility document review the facility staff failed to implement facility abuse and neglect policy for 4 of 25 new hire employees, #16, #17, #18 and #19.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an injury of unknown source was reported for 1 of 30 residents in the survey sample, Resident #31.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an injury of unknown source was investigated for 1 of 30 residents in the survey sample, Resident #31.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to document basis for transfer in the residents clinical record for 1 of 30 residents, Resident #32.

Inspectors wroteBased on staff interview, clinical record review and the facility staff failed to ensure the accuracy of MDS (minimum data set) assessments for 1 of 30 residents, Resident #32.

Inspectors wrote2. For Resident #16, the facility staff failed to refer the resident for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination. Resident #16's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Bipolar Disorder Unspecified, Anxiety Disorder Unspecified, Mental Disorder not Otherwise Specified, and Unspecified Dementia with Behavioral Disturbance. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/28/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #16's clinical record included a Level 1 PASARR dated 10/10/19 indicating the recommendation for a Level II evaluation and determination, MI (mental illness) was checked under section 5 Recommendation. [...]

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to provide catheter services for 3 of 30 residents, Resident #32, Resident #48 and Resident #14.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and in the course of a complaint investigation the facility staff failed to ensure 1 of 30 residents received the necessary care and treatment in regards to a colostomy.

Inspectors wroteBased on interviews and the review of documents, it was determined the facility staff failed to address a weight loss for one (1) of 30 sampled residents (Resident #33).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to follow physician orders in regards to tube feedings for 2 of 30 residents, Residents #40 and #32.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to maintain respiratory equipment for 1 of 30 residents, Resident #19.

Inspectors wroteBased on interviews and the review of documents, it was determined the facility staff failed to provide a pain medication as ordered by the provider for one (1) of 30 sampled residents (Resident #34).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with the contracting dialysis center for 2 of 30 residents in the survey sample, Resident #46, and #49.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to identify and report medication irregularities for 1 of 30 residents, Resident #13.

Inspectors wroteBased on staff interview, clinical record review and in the course of a complaint investigation the facility staff failed to store and account for controlled medications for 1 of 30 residents, Resident #159.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain a physician ordered laboratory test for 1 of 30 residents, Resident #40.

Inspectors wroteBased on interviews and the review of documents, it was determined the facility staff failed to maintain complete and accurate clinical records for three (3) of 30 sampled residents (Resident #6, Resident #34, and Resident #49).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer the flu and pneumonia vaccine to 1 of 30 Residents, Resident #35.