Orchard Hill Rehabilitation and Healthcare Center

Inspectors wroteBased on medical record review, resident and staff interview, and the facility investigation record, it was determined that the facility staff failed to follow the physician's order or the resident's care plan to prevent a resident (Resident #25) from experiencing a fall that resulted in harm. This was evident for 1 (25) of 1 resident. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 3/6/2026 The findings Include On 4/16/2026 10:50AM, during the initial interview, Resident #25 stated that GNA #41 had dropped me on the floor and broke my ankle. The resident then showed their pink lower leg cast. [...]

Inspectors wroteBased on record review, responsible person interview, and staff interview, it was determined that the facility failed to ensure care plans were reviewed and revised at least quarterly and updated to reflect residents' current needs. This is evident for 6 (Residents #2, #3, #4, #6, #107, and #113) of 9 residents reviewed for care plan review and revision.

Inspectors wroteBased on interviews with facility staff and review of employee files, it was determined that the facility staff failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 5 (GNA #42, GNA #43, GNA #44, GNA #45, GNA #46) out of 5 GNA employee files reviewed during the facility's recertification survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed failed to ensure that medication was secured in the pharmacy issued bubble packs. This was evident in 4 out of 4 medication carts observed during the survey. The findings Include: On 4/22/26, during the medication storage observation, it was observed that in all 4 Medication carts there were a large number of pills and capsules, approximately 2-3 dozen per cart, that had come loose from the bubble packs that the pharmacy provided the resident's medication in. [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to stock appropriate personal protective equipment (PPE) near resident rooms that were on enhanced barrier precautions (EBP). This was found to be evident in 2 (station 1 and station 2) of 4 unit stations reviewed during the recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure the resident or representative were informed of the risks and benefits of a medication prior to initiation. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure residents were free from unnecessary medications by failing to ensure a PRN psychotropic medication was ordered with an adequate indication, supporting diagnosis, and within the required 14-day time-limited duration without documented clinical justification for extended use. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of the resident's enrollment and discontinuation in hospice services. This was evident for 1 (Resident #1) out of 1 residents reviewed for hospice during the facility's recertification survey.

Inspectors wroteBased on review of Minimum Data Set (MDS) assessment records, MDS validation reports, and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 2 (Resident #84, #106) of 2 residents reviewed for resident assessment.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents' clinical status. This is evident for 2 (Residents #1 and #3) of 2 residents reviewed for MDS accuracy.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure comprehensive care plans were developed and updated timely to reflect residents' current conditions. This is evident for 2 (Residents #1 and #3) of 2 residents reviewed for care planning.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined the facility failed to order and implement the treatment of a Stage 3 pressure ulcer timely. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the during the facility 's annual recertification survey.

Inspectors wroteBased on medical record review, observations, and interviews, it was determined that the facility failed to provide additional nourishment for a resident as ordered by a physician. This was found to be evident in 1 (Resident #55) of 40 residents reviewed during the recertification survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined the facility failed to ensure that a resident's primary care provider(s) assessed and monitored his/her pressure ulcer. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the facility 's annual recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that the pharmacist performed an accurate medication regimen review and identify a medication without a matching diagnosis. This is evident for 1 (Resident #2) of 2 residents reviewed for medication regimen review.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure medications were ordered with an adequate indication and supporting diagnosis and failed to ensure appropriate parameters for a psychotropic medication ordered on an as-needed basis, resulting in an unnecessary medication. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and medical record review, it was determined that the facility failed to maintain and document accurate medical records. This was found to be evident in 1 (Resident #44) of 1 resident reviewed for dialysis during the recertification survey.

Inspectors wroteBased on interviews with facility staff, review of employee files, and review of pertinent documentation, it was determined that the facility failed to ensure the nurses' aides had continuing education that included dementia management training and addressed areas of weakness as determined in nurse aides' performance reviews. This was found to be evident for 2 (GNA #44 and GNA #45) of 5 GNA employee files reviewed during the facility's recertification survey.

Inspectors wroteBased on review of facility documentation and staff interview, it was determined the facility failed to provide documentation that allegations of neglect were thoroughly investigated. This was evident for 1 (#3) of 5 residents reviewed for facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased interview and observed smell of resident's room, the facility failed to provide bedpan or change resident as requested. This was evident for 1 out of 1 resident reviewed.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (#3) of 9 residents reviewed during a complaint survey.

Inspectors wroteBased on interview and medical record review, the facility failed to make an appointment for Resident # 6. that was to see an outside physician. This was evident for 1 out of 1 resident reviewed.

Inspectors wroteBased on review of complaints, interviews, and documentation review it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 6 of 9 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff and resident interviews, observation of staffing boards, and review of staffing schedules. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify the Resident's physician when the Resident's BiPap was not administered (Resident #5). This was evident for 1 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility reported incidents, record review, and interview, it was determined the facility failed to report an injury of unknown origin within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident's representative within 48 hours of admission to the facility (Resident #3). This was evident for 1 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation, medical record review and interview, it was determined the facility failed to follow professional standards of practice when administering medications (Resident #5). This was evident for 1 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint review, medical record review and interview, it was determined the facility staff failed to provide needed activities of daily living (ADL) for residents totally dependent on bathing assistance (Resident #3, #13). This was evident for 2 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment and care in accordance with professional standards of practice (Resident #5 and #11). This was evident for 2 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#12) of 3 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended and discard medications/biologicals when expired. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #6 and #12). This was evident for 2 of 16 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation and interview, it was determined the facility staff failed to maintain accurate nursing staffing data. This was evident during a complaint survey and was evident for 18 of 18 days reviewed.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1) ensure food items were labeled, 2) ensure food items were discarded appropriately, 3) ensure the freezer was maintained free from ice accumulation, 4) ensure the device utilized for dispensing of juice was not stored on the kitchen floor, 5) ensure safe storage of cleaning chemicals and 6) ensure consistent required temperature levels for dishwashing sanitization. These deficient practices have the potential to affect all facility residents. On 3/10/25 beginning at 8:00 AM the surveyor conducted an initial tour of the facility's kitchen. On 3/10/25 at 8:12 AM the surveyor observed a metal container in the reach in refrigerator with the following label present: Monday Sauces/Gravies Homemade prep/opened on 3/3/25 1:25 PM, use by 3/5/25 1:25 PM. [...]

Inspectors wroteBased on a review of the resident medical records and interview with facility staff, it was determined that the facility failed to ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This was evident for 4 (Resident #14, #31, #52, and #100) out of 4 residents reviewed for administration of narcotic medication during this recertification/complaint survey.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure the kitchen steam table was maintained in safe operating condition. This was evident for one out of one steam tables observed to be in operation during the surveyor's initial tour of the facility's kitchen during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews with facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive and ensure that a current copy of residents' advanced directives was in the residents' medical record. This was evident for 1 (Resident #56) of 3 residents reviewed for advanced directives during the recertification/complaint survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility staff failed to notify a provider and/or resident representative of a significant weight loss for a resident. This was evident for 1 (Resident #113) of 47 residents reviewed for the facility's recertification/complaint survey.

Inspectors wroteBased on observation, resident interview, and staff interview it was determined that the facility staff failed to ensure showers maintained proper temperatures. This was evident for 1 out of 4 nursing units observed during the recertification/complaint survey.

Inspectors wroteBased on review of a facility reported incident, record review and interview it was determined the facility failed to ensure a resident (#120) was free from misappropriation of their personal funds. This was evident for 1 out of 2 facility reported incidents (#MD00212032) reviewed for misappropriation/personal property during the facility's recertification/complaint survey.

Inspectors wroteBased on review of a facility reported incident, record review and interview it was determined the facility failed to ensure the implementation of the abuse, neglect, exploitation and misappropriation policy and procedures. This was evident for 1 out of 2 facility reported incidents (#MD00212032) reviewed for misappropriation/personal property during the facility's recertification/complaint survey.

Inspectors wroteBased on record review and interviews with facility staff, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of the resident's enrollment and discontinuation in hospice. This was evident for 1 (Resident #33) of 2 residents reviewed for hospice during the recertification/complaint survey.

Inspectors wroteBased on interview with residents, review of medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of the Minimum Data Set (MDS). This was evident for 3 (Resident #55, Resident #104, Resident #37) of 28 residents reviewed for care plan during this recertification/complaint survey.

Inspectors wroteBased on observation, interview, and medical record review it was determined the facility failed to ensure medical orders were followed for the provision of thickened liquids. This was evident for 1 (Resident #46) out of 1 residents reviewed for hydration during the facility's recertification/complaint survey.

Inspectors wroteBased on medical record review and staff and resident interviews, it was determined that the facility failed to monitor/access residents related to potentially leading to smoking accidents. This was evident in 5 (Resident # 37, #44, #61, #93, and #100) of 5 residents reviewed for smoking during this recertification/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to monitor and timely address a significant weight loss for a resident. This was evident for 1 (Resident #113) of 3 residents reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interviews with residents and staff, it was determined that the facility staff failed to obtain/monitor pre and post-dialysis body weights. This is evident for 1 (Resident # 220) of the 1 resident reviewed for dialysis services during the recertification/complaint survey.

Inspectors wroteBased on observation it was determined that the facility staff failed to post staffing information in an easily accessible location. This was evident for 4 out of the 7 days of the recertification/complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure medications are kept in a secure location. This was evident for 1 out of the 4 nursing units observed during the recertification/complaint survey.

Inspectors wroteBased on observation, review of medical records, and interviews with residents and staff, it was determined that the facility failed to ensure that residents received necessary and/or recommended dental services in a timely manner. This was evident for 1 (Resident #61) of 2 residents reviewed for dental services during the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to 1) ensure contracted services for wound care were timely documented in the medical record and 2) failed to ensure the resident's medical record was no longer accessible by a provider once that provider was no longer involved in the care of the resident. This was evident for 3 (Resident #121, #119, #270) of 47 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on review of the facility records and interview with facility staff, it was determined that the facility failed to monitor and track antibiotic usage. This was evident by 1) the delayed start of the antibiotic and 2) a resident receiving an extra dose. This was found to be true for 1 (Resident #94) out of 3 residents reviewed for antibiotic use during the recertification/complaint survey.

Inspectors wroteBased on review of facility reported incidents, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to keep residents who required either extensive assistance or total dependence with turning and repositioning in bed free from falling out of bed while providing activities of daily living (ADL) care, resulting in actual harm to Resident #33 and Resident #17. The failure of the facility staff to protect a resident from a fall resulted in a hematoma for Resident #33 and bilateral femur fractures for Resident #17. This was evident for 2 (#33, #17) of 39 residents reviewed for facility reported incidents.

Inspectors wroteBased on medical record review and interview, the facility staff failed to administer medications and treatments as ordered by the physician (Resident #5, #22, #47, #56). This was evident for 4 of 61 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify the resident's physician and/or resident's representative when the resident had a change in condition (Resident #9 and #47). This was evident for 2 of 38 complaint residents reviewed during a complaint survey.

Inspectors wroteBased on review of a facility reported incident, medical record review, and staff interview, it was determined the facility failed to protect a resident from inappropriate sexual contact from a geriatric nursing assistance (GNA) (Resident #21). This was evident for 1 of 39 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on reviews of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3 (#17, #3, #10) of 39 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on documentation review and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation or mistreatment for residents (Resident #3, #6, #10 and #43). This was evident for 4 of 39 residents reviewed for facility reported incidents during an annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#59, #24) of 61 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a facility reported incident, record review, and staff interview it was determined that facility staff failed to update care plans when there were changes in resident needs and failed to have evidence of care plan meetings. This was evident for 2 (#10, #4) of 61 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #22). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide respiratory care treatment for residents (Resident #47 and #4). This was evident for 2 of 3 residents reviewed for respiratory care services.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #47). This was evident for 1 of XX residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #27). This was evident for 1 of 61 residents reviewed during a complaint survey.

Inspectors wroteBased on administrative and medical record reviews and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #9 and #22). This was evident for 2 of 61 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility staff failed to maintain the resident call bell system in working order. This was evident for 1 of 14 resident rooms on the Unit 3 nursing unit which affected 2 (#10, #35) of 37 residents that resided on Unit 3 during a complaint survey.

Inspectors wroteBased on observations of the facility's kitchen food services, and staff interview it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified while observing the facility's dish washing machine in operation.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to promote self determination for Residents (#67, #69, # 112 and #113). This was evident for 4 of 10 residents reviewed for choices and 4 of 58 residents reviewed during the survey process.

Inspectors wroteBased on facility documentation and interview, the facility staff failed to provide evidence that the facility had purchased a surety bond to assure the security of all the residents' personal funds deposited with the facility. This was evident during the investigation of facility tasks during an annual survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed staff to provide residents and/or their representative (RP) with the proper paper documentation of the facilities bed hold policy (Resident #29, #40, #57, #82 and #89). This was evident for 5 out of 5 residents reviewed for discharge during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure the care plan meeting occurred to review and revise the care plan after the quarterly Minimum Data Set assessment (Residents #1, #13) and the facility staff failed to review and revise care plans for Residents ( #89 and #53) to reflect accurate and appropriate interventions. This was evident for 4 of 6 residents selected for review of care planning and 5 of 58 residents selected for review during the annual survey process.

Inspectors wroteBased on review of resident medical records and interviews with residents and facility staff, it was determined that the facility failed to ensure that residents received treatment and care to promote the highest practable well being as evidenced: by failures to follow physician orders, to follow up on dieticians' recommendations and abnormal labs, and to adequately assess residents for fall risks. This was evident for 6 of 58 residents (Residents #38, #80, #210, #260, #470, and #472) that were reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered by the physician in a timely manner for Residents (#53, #57); failed to provide Resident #69 with supplement as ordered; failed to hold milk for Resident #210 as recommended by dietician ;failed to ensure Resident #213 received foods of preference and failed to provide Resident #261 with a therapeutic diet. This was evident for 6 of 8 residents reviewed for Nutrition and 6 of 58 residents selected for review during the survey process.

Inspectors wroteBased on medical record review, it was determined the facility staff failed to address Consultant Pharmacy Drug Regimen Review in a timely manner for Residents (#29, #38, #53, #80, #82 and #98). This was evident for 6 of 6 residents reviewed for unnecessary medication and 6 of 58 residents selected for review during the survey sample.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents (Resident #38, #82, #84,# 89, #212, #213, #312, #460 and #463). This was evident for 9 of 58 residents reviewed in the annual survey.

Inspectors wroteBased on observation, review of employee health records and interview; the facility staff failed to: 1.) thoroughly screen for immunity to diseases and failed to offer the Hepatitis B vaccine to those newly hired employees (Employee #38, #39, #40, #41, #42). This is evident for 5 of 5 newly hired employees and 1 out of 58 residents reviewed during an annual survey; and 2.) failed to follow standard infection control practices regarding the food tray for Resident #35. This was evident for 1 of 1 breakfast tray observed.

Inspectors wroteBased on medical record review, observation, and interview, it was determined the facility staff failed to provide an environment to promote the highest dignity to Resident #213. This was evident for 1 of 1 resident reviewed for dignity and 1 of 58 residents reviewed during the survey sample.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to notify Resident #69's Responsible Party (RP) when a medication was discontinued. This was evident for 1 of 1 resident reviewed for notification of change and 1 of 58 resident reviewed during the annual survey process.

Inspectors wroteBased on medical record review, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 2 (Residents #89, and #106) of 2 residents reviewed that remained in the facility after termination of skilled services.

Inspectors wroteBased on observation on 6/25/21 at 11:49 AM, the facility staff failed to replace ripped and torn screens in rooms 209, 211, 213, and 215. This was evident for 4 out of 15 rooms observed for ripped screens.

Inspectors wroteBased on medical record review it was determined the facility staff failed to notify the Office of Health Care Quality (OHCQ) of an injury of unknown origin to Resident #69. This was evident for 1 of 58 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 1 (Resident #40) of 6 residents reviewed for hospitalization and 1 of 58 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that the resident, and/or their responsible party (RP), received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #29 #40, #57, #82 and #89). This was found to be evident for 5 out of 5 residents reviewed for hospitalization during an annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was exemplified for 2 (#40, #89) of 6 residents reviewed for hospitalization during the annual survey and 2 of 58 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #1, #54 and #111). This was evident for 3 out of 58 residents selected for review during the annual survey process.

Inspectors wroteBased on record review and staff interview it was determined that facility staff failed to develop and implement comprehensive care plans for residents (Resident #1 and #260). This was evident for 2 of 6 residents reveiwed for care plans and 2 of 58 residents selected for review during an annual survey.

Inspectors wroteBased on medical record review and observation, it was determined the facility staff failed to provide nursing care within the standards of practice for Residents #84 and #210. This was evident for 2 of 58 residents reviewed during the survey process.

Inspectors wroteBased on review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary (Resident #112). This was evident for 1 of 3 residents reviewed for closed records during an annual survey.

Inspectors wroteBased on medical record review, observation and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Residents #1, #69, #80, #212). This is evident for 4 of 9 residents reviewed for activities of daily living (ADL) care and 4 of 58 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #67, #77 and #260). This is evident for 3 of 5 residents reviewed for pressure ulcers and 3 of 58 residents reviewed during an annual survey.

Inspectors wroteBased on observation, medical record review and interview with a resident, it was determined that the facility failed to provide safety equipment for a resident that smokes. This was identified for Resident #70 during 1 of 3 smoking observations and 1 of 58 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess and intervene when Resident #53 was noted with a decrease in urinary continence. This was evident for 1 of 3 resident selected for review of urinary continence and 1 of 58 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to administer pain medication to newly admitted residents in a timely manner (Resident #261 and #470). This was evident for 2 out of 2 residents reviewed for pain management and 2 of 58 residents reviewed during an annual survey.

Inspectors wroteBased on interview and medical record review, it was determined the facility failed to maintain enough nursing staff to meet resident care needs in a timely manner for residents. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on medical record review, it was determined the facility staff failed to ensure that Resident #80 was free from unnecessary medications. This was evident for 1 of 5 residents selected for review of unnecessary medications and 1 of 58 residents selected for review during the annual survey process.

Inspectors wroteBased on record review and observation of medication administration, it was determined the facility staff failed to maintain an error rate below 5%. Observation of medication administration resulted in an error rate of 12.9%. This was evident for 2 of 3 (#210 and #84) residents observed and 4 of 31 opportunities for error.

Inspectors wroteBased upon observation, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care (Resident #1 and #69). This was evident for 2 of 2 residents reviewed for dental and 2 of 58 residents reviewed during an annual survey.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of registered nurses, licensed practical nurses, and certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. It was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for the first 5 days of the survey.