Orchard Park Health Care & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 5 residents (Residents 1, 2, 3, 4 & 10) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect 5 of 5 residents' rights to Medicare benefits. The facility disenrolled five (Residents 1, 2, 3, 4 & 10) beneficiaries from Medicare Managed Health Plans without their request, consent, knowledge and/or complete understanding. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the circumstances under which the facility could assist a beneficiary with a plan change, and the need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement an effective discharge planning process that focused on residents' discharge goals and preparation of residents for discharge and failed to develop and implement comprehensive discharge care plans for 4 of 5 residents (Residents 2, 4, 3 & 5) reviewed for discharge planning. These failures placed residents at risk of a diminished quality of life, depleting valuable Medicare coverage days, unnecessarily extended length of stay and/or feeling they were being held against their will.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 7 of 8 Residents (Residents 8, 12, 18, 1, 15, 22 & 9) who were unable to perform Activities of Daily Living (ADLs-including oral care, grooming, personal hygiene, toileting, and good nutrition) received the care and services they required. This failure placed residents at risk for unmet care needs, skin breakdown, infections, and undignified quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the required care planned supervision to prevent accidents for 4 of 5 sample residents (Resident 1, 14, 13 & 20) reviewed for accidents/hazards. The facility failed to assess safety risks, provide adequate resident supervision, develop/implement/revise fall and elopement care plans (CP), and conduct thorough accident investigations to determine the circumstances of resident accidents and revise CPs to prevent reoccurrence for 2 of 2 residents (Resident 1 & 14) reviewed for falls and 2 of 3 residents (Resident 13 & 20) reviewed for elopement. These failures placed the residents at a potential risk of harm related to avoidable incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff to provide necessary care and services for 7 of 8 Residents (8, 12, 18, 1, 15, 22, & 9) reviewed for Activities of Daily Living (ADL). The facility had insufficient staff to ensure residents received assistance with showers and nail care in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and negative outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate dementia related care and services were provided to 4 of 4 residents (Residents 14, 7, 16, & 13) reviewed for dementia related behaviors. The failure to develop and/or implement resident-centered dementia care plans (CP) with purposeful diversional activities and behavioral interventions to address resident's care needs who had dementia with behavioral disturbances, exit-seeking behaviors, and/or required 1:1 supervision. These failures placed the residents at risk for a diminished quality of life/quality of care, decline in mood, increased social isolation, boredom induced restlessness/anxiety/behaviors, and accidents/hazards (falls, elopement, and resident-to-resident altercations).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social service interventions that addressed refusal of care for 4 of 4 residents (Resident 12, 3, 15, 7) reviewed for care and services. Failure to have a process for resident refusals, identify, and find ways to support residents' needs related to refusals placed residents at risk for unmet care needs, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure [it] was administered in a manner that used resources effectively and efficiently to attain or maintain the residents highest practical physical, mental, and psychosocial well-being, and maintain substantial compliance with state and federal regulations.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for 2 of 3 residents (Resident 6, 24) reviewed for resident-to-resident abuse. Resident 6 and 24 experienced physical abuse when they were hit by Resident 7. Resident 6 experienced verbal abuse when they were called disparaging remarks by Resident 7. Resident 6 experienced psychological harm, evidenced by verbalizations of fear, when the facility failed to provide adequate supervision, effective interventions to assure safety, and evaluate the effectiveness of current interventions to prevent further abuse. These failure placed the residents at risk of abuse, experiencing fear, intimidation, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 6 sample residents (Residents 9, 14 & 15) received wheelchair positioning and bowel care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure two residents (Residents 9 & 14) received services related to positioning and one resident (Resident 15) reviewed for bowel management, had an appropriate bowel care plan (CP) and received the medications for bowel management they were ordered to receive. These failures placed Residents 9 & 14 at risk for skin breakdown, accidents/hazards, uncomfortable positioning, and placed Resident 15 at risk for skin breakdown, infections, constipation, other significant negative outcomes related to untreated constipation, and diminished quality of care/quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted daily and updated at the beginning of each shift to reflect any staff absences, total number of staff each shift, and total number of actual hours worked for 3 of 3 months (July 2026, June 2026, May 2026) reviewed. In addition, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months. These failures caused the facility's staffing information to be unavailable to review for residents, visitors, staff, and the State Agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent abuse of 1 of 6 residents (Resident 7) reviewed for resident to resident altercations. Resident 7 experienced psychological harm, evidenced by change in social behaviors, isolating to their room and expressed changes in a trauma assessment, when the facility failed to provide adequate supervision, effective interventions to assure safety, and evaluate the effectiveness of current interventions to prevent further abuse. In addition, staff failed to adequately monitor and prevent Resident 151 from expressing aggressive behavior towards residents. These failures placed residents at risk for sexual and physical abuse, psychological harm, feeling uncomfortable and unsafe.

Inspectors wroteBased on observation and interview, the facility failed to post the location of the survey results and place the binder in identifiable location. This failure prevented residents, family members, and visitors from exercising their right to review past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of their right to establish an advanced directive (AD, a document specifying who should make medical decisions for you when you an incapacitated) for 3 of 3 sampled residents (Residents 6, 11 and 141) reviewed for AD. This failure placed residents at risk of not having someone to make medical decisions when incapacitated, inability to direct medical care, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures regarding identifying, reporting and investigating incidents of resident-to-resident abuse for 2 of 6 sampled residents (Residents 114 and 150) reviewed for abuse. These failures placed residents at risk for further abuse, psychological harm and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident/resident's representative and Ombudsman in writing of the reason for the transfer/discharge to the hospital and provide written bed hold notice at the time of transfer to the hospital for 4 of 5 sampled residents (Residents 7, 157, 155, and 8 ) reviewed for discharge/hospitalization. These failures placed the residents at risk for lacking knowledge regarding their transfer, discharge rights, the right to hold their bed while in the hospital, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident quarterly, admission, and discharge Minimum Data Sets assessments (MDS) were completed within 14 days of the assessment reference date (ARD) as required for 11 of 11sampled Residents (Residents 46, 55, 70, 73, 99, 5, 118, 121, 128, 142 and 153) reviewed for resident assessments. Failure to timely complete MDS assessments placed residents at risk for a delay in identification of care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were timely revised and/or care conferences held timely for 6 of 23 sampled residents (Residents 123, 12, 11, 7, 128, and 141) reviewed for revision of care plan. This failure placed residents at risk of having inaccurate plans of care, inability to have input in plan of care, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to have sufficient staff to ensure residents received care according to their individualized care plans for 2 of 2 sampled residents (Resident 7 and 102) reviewed for abuse. This failure placed residents at risk for accidents, abuse and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) recommendations were implemented in a timely manner for 3 of 5 sampled residents (Residents 150, 1, and 122) reviewed for unnecessary medications. This failure placed the residents at risk for possible adverse complications due to the delay in follow-up/implementation of pharmacy recommendations and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (February, March and April 2026) reviewed for Infection Control. These failures placed residents and staff at risk for communicable diseases and infections, unidentified outbreaks, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed implement policies and procedures to ensure each staff member and resident was offered and received education for the Covid-19 vaccine. This failure placed the residents and staff at risk for lack of knowledge of the risks and benefits of the vaccine and increased risk for Covid-19 infection/complications.

Inspectors wroteBased on interview and record review, the facility failed to issue Notification of Medicare (federal health insurance program for people age [AGE] or older) Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 2 of 3 sampled residents (Residents 27 and161) reviewed for beneficiary notices. This failure placed the residents and/or their representatives at risk of not being fully informed and losing their right to an appeals process.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe environment to ensure reasonable care and protection of resident's personal property from loss or theft for 1 of 3 sampled residents (Resident 2) reviewed for environment. Failure to ensure a cell phone was protected and/or replaced when reported missing placed a resident at risk for lack of ability to easily communicate with others outside of the facility, loneliness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from chemical restraints for 1 of 6 sampled residents (Resident 65) reviewed for behavioral-emotional and unnecessary medications. The failure to evaluate and document a clinical rational for use of a psychotropic medication and ensure adequate indications for the use of the medications placed residents at risk for decline in activities of daily living, potential adverse consequences, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely complete the admission minimum data set assessment (MDS) within 14 days of admission for 1 of 24 sampled residents (Resident 114) reviewed for MDS. This failure placed the residents at risk for unmet care needs, inaccurate medical record data, and poor clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment for a significant change in condition for 1 of 23 sampled residents (Resident 123) whose assessments were reviewed. Failure to identify Resident 123's need for a significant change assessment related to decline in health and who received hospice services (supportive care for people in the final phase of a terminal illness, focusing on comfort and quality of life) placed the resident at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure minimum data set assessments (MDS) were completed accurately for 2 of 23 sampled residents (Residents 8 and 85) reviewed for resident assessments. Failure to accurately complete MDS assessments placed residents at risk for a delay in identification of care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessments were accurately completed for 3 of 8 sampled residents (Residents 13, 14, and 150) reviewed for PASRR and unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to formulate baseline care plans within 48 hours of admitting to the facility for 1 of 23 sampled residents (Resident 159) reviewed for position and mobility. This failure placed residents at risk of delays in services, avoidable pain, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were accurate and reflected resident care needs for 2 of 23 sampled residents (Residents 103 and 2) reviewed for care plans. Failure to ensure Resident 103's fluid restriction and Resident 2's hard of hearing status were included in their plans of care placed residents at risk of fluid overload, avoidable discomfort, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to monitor actual pressure injuries or prevent new pressure injuries for 1 of 3 sampled residents (Resident 1) reviewed for pressure injuries. This failure placed the residents at risk for new or worsening pressure injuries and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure falls were investigated and future falls prevented and smoking assessments and interventions were in place for 1 of 6 sampled residents (Residents 85) and failed to protect residents from eloping (exiting the facility without the required supervision) and anti-elopement devices were in place for 1 of 6 sampled residents (Resident 14) reviewed for accidents. These failures placed residents at risk of significant injury and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure fluid restrictions were implemented for 2 of 4 sampled residents (Residents 103 and 2) reviewed for nutrition. This failure placed residents at risk of fluid overload, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered/documented in accordance with provider's orders for 2 of 3 sampled residents (Residents 9 and 4) reviewed for tube feeding. These failures placed the residents at risk for inadequate nutrition and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have a contract with the dialysis (a process of filtering the toxins out of the blood) facility regarding dialysis care and services for 2 of 3 sampled residents (Residents 103 and 2) reviewed for dialysis. This failure placed residents at risk of avoidable complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the psychosocial needs for 1 of 6 sampled residents (Residents 128) reviewed for abuse. This failure placed the residents at risk of unmet psychosocial needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide nonpharmacological interventions (NPI, nonmedicated methods to reduce pain, e.g. massage, heat, repositioning) prior to providing as needed (PRN) pain medications for 1 of 5 sampled residents (Resident 16) reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide prompt dental care services and ensure a care plan reflected current dental status for 1 of 3 sampled residents (Residents 85) reviewed for dental. This failure placed the residents at risk for continued dental problems, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide food that accommodated a documented food allergy for 1 of 3 residents (Resident 1) reviewed for dietary services. Resident 1 experienced harm when the resident was served food which contained an ingredient to which they were allergic, and the resident required medical intervention and monitoring. This failure placed other residents at risk for allergic reaction and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received necessary care and services for 1 of 3 residents (Resident 2) reviewed for quality of care when Resident 2 experienced a delay in care and developed a skin rash. This failure placed residents at risk of unmet care needs, discomfort, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents (Resident 1) reviewed for a significant medication error. This failure placed Resident 1 at risk of medical complications and unintended adverse reactions, and placed other residents at risk for medication errors and unmet needs, when they were discharged with medications that were prescribed to two other residents of the facility, along with their own medications.

Inspectors wroteBased on interview and record review, the facility failed to report to the State Survey Agency within 24 hours an unwitnessed fall, and failed to log the incident in the facility's reporting log, for 2 of 3 sample residents (Resident 1 and Resident 2) reviewed for falls. This failure placed residents at risk of incidents not being reported and placed residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a restorative nursing program was initiated for 1 of 1 residents (Resident 1) reviewed for range of motion (ROM) and mobility. This failure placed the resident at risk for decreased ROM, worsening contractures (a tightening/shortening or muscles, tendons, or ligaments causing a rigid, abnormal, and typically fixed positioning of joints), decreased independence, and a diminished quality of life. The facility had corrected the above deficiency prior to the complaint survey, and it is constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement an individualized comprehensive care plan, for 1 of 3 sampled residents (Resident 1) reviewed for Pressure Injuries (PI's- localized skin and underlying tissue damage from prolonged pressure). This failure placed residents at risk of developing PI's, pain, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to promote pressure injury (PI- localized skin and underlying tissue damage from prolonged pressure) prevention and healing, for 1 of 3 residents (Resident 1) reviewed for PIs. This failure placed residents at risk of developing new or worsening PIs, pain, infection and loss of limb

Inspectors wroteBased on interview and record review, the facility failed to ensure rehabilitative services were provided as determined by physician order for 1 of 3 residents (Resident 1) reviewed for rehabilitation services. This failure placed residents at risk for delayed progress towards goals, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment when the fire alarm panel malfunctioned, and fire watch was not performed as directed. The failure to perform fire watch, in the absence of a functioning fire alarm system, would likely cause a delayed response if a fire were to occur, which placed residents at risk for smoke inhalation, burns, displacement from their homes, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and treatment of an ileostomy (an opening in the body for the discharge of body wastes into a collection bag) was consistent to protect skin integrity for 1 of 3 sampled residents (Resident 1) reviewed for colostomy/ileostomy care. This failure placed the resident at risk for skin breakdown, discomfort, and diminished quality of life.

Inspectors wrote<Elopement> Review of a facility's policy titled, Elopements (when a resident identified as wandering leaves the facility without staff knowledge or authorization) - Resident Behavior and Facility Practices, dated 02/21/2025 showed when a resident who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Review showed monitoring and managing residents at risk for elopement and unsafe wandering showed the effectiveness of interventions would be evaluated and changes made as needed. The procedure for locating missing residents would be followed to include alert personnel using facility approved protocol. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly and timely investigate falls and/or injuries and implement interventions to prevent repeat falls for 4 of 6 sampled residents (Resident 14, 110, 21 and 29) reviewed for abuse / neglect. These failures placed the residents at risk for repeated falls, avoidable injuries and diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure an accurate assessments for 2 of 4 sampled residents (Resident 15 and 40) reviewed for dental conditions, 1 of 4 sampled residents (Resident 67) reviewed for respiratory care and 1 of 1 sampled residents (Resident 14) reviewed for restraints. These failures placed the residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care consistent with physician orders for oxygen (O2) therapy for 2 of 4 sampled residents (Residents 65 and 97) reviewed for respiratory care. This failure placed the residents at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medication requiring refrigeration in the medication refrigerator and to discard expired equipment and/or supplies in 1 of 2 medication rooms (East medication room) when reviewed for medication storage and labeling. These failures placed residents at potential risk for receiving medications contaminated by food items and/or for receiving compromised or ineffective supplies that had expired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food services which met resident preferences for 5 of 8 sampled residents (Residents 91, 21, 89, 16, and 80) when reviewed for food. This failure placed residents at risk of decreased mood, feelings of hunger, avoidable weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report an infectious disease outbreak to the local health department (LHD) as required for 1 of 1 Covid-19 outbreak (Resident 377 and 20) when reviewed for infection control. The facility failed to implement infection control practices for surveillance of current infections for 2 of 3 months (03/2025 and 04/2025) when reviewed for infection control. The facility failed to complete timely ordered labs for a possible infection for Resident 378. These failures placed the residents at risk for communicable diseases, clinical complications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each staff member received training related to resident abuse, dementia management and had continuing competencies for certified nurse aides on a yearly basis for 2 of 5 staff members (Staff S and T), reviewed for training. These failures placed residents at risk for potential abuse, lack of dementia care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 1 of 2 sampled residents (Resident 40) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for adverse side effects (ASE) related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents (Resident 107) when reviewed for unnecessary medication use. Failure to conduct/obtain an initial/baseline abnormal involuntary movement (AIM) assessment for the use of an antipsychotic medication (a psychoactive medication that affects a person's mental status) and identify potential involuntary movement placed Resident 107 at risk of unidentified presence and severity of AIM ASE, medical complications, and a diminished quality of life.

Inspectors wroteResident 14 Review of the EHR showed Resident 14 was admitted to the facility on [DATE] with diagnoses to include dementia (impaired memory and judgment), chronic obstructive pulmonary disease (COPD, a condition which blocks airflow that makes it difficult to breath), hypotension (low blood pressure), and depression. Resident 14 was unable to make their needs known. Review of a provider order, dated 01/21/2025, showed an antidepressant was prescribed. Review of June 2025 medication administration record showed Resident 14 was administered an antidepressant medication three times a day and a second antidepressant medication for appetite stimulation. Review of a Level I PASARR, dated 01/21/2025, showed Resident 14 had indications for serious mental illness. No Level II referral was completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement individualized comprehensive care plans related to oxygen therapy and oral/dental status for 3 of 23 sampled residents (Residents 67, 40, and 90) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs placed residents at risk of unmet care needs and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 3 of 23 residents (Residents 44, 14, and 90) when reviewed for quality of care. The facility failed to follow provider ordered boots (used to protect the heel and alleviate pressure) to heels every shift (Resident 44), to follow provider parameters (Resident 14), and to obtain orders to care for a central line/central venous catheter (CVC, flexible tube inserted into a large vein used to deliver fluids/nutrition (Resident 90). These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an individualized activity plan for 1 of 1 sampled resident (Resident 97) reviewed for activities. This failure placed the resident at risk for boredom, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for the treatment of non-pressure skin injuries for 2 of 3 sampled residents (Residents 44 and 65) when reviewed for non-pressure skin conditions. Additionally, the facility failed to develop a collaborative comprehensive care plan involving Hospice (specialized care for people who are nearing the end of their life) service for 1 of 2 sampled residents (Resident 67) when reviewed for Hospice and end of life. These failures placed the residents at risk for unmet care needs, poor clinical outcomes, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assist residents obtain new glasses for 1 of 2 sampled residents (Resident 63) when reviewed for communication/sensory. This failure placed the resident at risk of being unable to participate in activities, social isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide routine dental care for 1 of 4 sampled residents (Resident 40) reviewed for dental care. This failure placed the residents at risk for difficulty eating, dental pain, unintended weight loss and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance and follow up on an appointment for dental care services for 2 of 4 sampled residents (Residents 15 and 90) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary activities of daily living care and services for 2 of 3 sample residents (Residents 1 and 2) reviewed for bathing. The failure to bathe residents as per their bathing care plans placed residents at risk for hygiene issues and for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, report, and investigate allegations of neglect for 2 of 5 residents (Residents 1 and 4) reviewed for abuse and neglect. This failure placed the residents at risk for ongoing neglect, unmet needs, unmanaged pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to manage pain, in accordance with professional standards, and failed to administer ordered pain medications in a timely manner for 2 of 2 sampled residents (Residents 1 and 4) reviewed for pain management. This failure placed the residents at risk for unmanaged and increased levels of pain, interrupted sleep, decreased ability to participate in daily activities, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents consistently received restorative care (movement of joints to maintain range of motion) to maintain or prevent declines in mobility and services to improve mobility for 3 of 5 sampled residents (Residents 7, 10 & 85) reviewed for range of motion (ROM)/mobility. Resident 7 experienced harm when they had an avoidable decline in range of motion where their splints could not be applied without risking skin breakdown due to ankle contractures. Resident 10 experienced harm when they had an avoidable decline in bilateral ROM when passive ROM was not implemented. This failure placed the residents at increased risk of decreased motion, contractures, decreased mobility and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have a written transfer agreement with at least one area hospital approved for participation in Medicare/Medicaid programs. This failure placed residents at risk for delayed transfers and timely admissions to the hospital when medically appropriate.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker when reviewed for qualifications of social worker. This failure placed residents at risk of not having access to medically related social services, inability to coordinate care, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe homelike environment for 2 of 4 halls (East B and [NAME] B) reviewed for environment. This failure placed residents at risk for lack of privacy, unsanitary conditions and diminished quality of life.

Inspectors wroteResident 62 Review of the EHR showed Resident 62 was admitted on [DATE] with diagnoses that included anxiety and depression. Review of the quarterly MDS assessment, dated 08/08/2024, showed Resident 62 was cognitively intact and able to make needs known. <Investigation One> During an interview on 08/22/2024 at 10:07 AM, Resident 62 alleged that they had been verbally assaulted by a staff member, had requested the staff leave their room twice, and that during the alleged incident the staff member had gotten spit in Resident 62's eye. Review of the incident investigation report showed a statement dated 08/19/2024 by the alleged perpetrator that they confronted Resident 62 in their room and 3 witnesses were present. Two of the staff witness statements did not include any statement on the alleged incident itself, only the events surrounding it. [...]

Inspectors wroteResident 67 Review of the EHR showed that Resident 67 was admitted on [DATE] with diagnoses that included protein-calorie malnutrition (not enough protein and calories being consumed, weakening the body), anorexia (fear of gaining weight leading to poor nutrition), and gastroesophageal reflux disease (the backflow of stomach acid or bile). Review of the annual MDS assessment, dated 05/16/2024, showed Resident 67 was cognitively intact and able to make needs known. Resident 67 smoked cigarettes daily. <Dental> Further review of the annual MDS showed that Resident 67 did not have any dental issues or dental care areas selected. Review on 08/24/2024 of Resident 67's care plan, initiated on 06/01/2022, showed Resident 67 was at risk for dental care problems. Review of the document titled, Oral Health Evaluation dated 09/19/2023, showed Resident 67 had 1-3 decayed or broken teeth. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed for four of five residents (Resident 83, 60, 93 and 20) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised to ensure needed interventions were in place, and accurately reflected residents' care needs and/or failed to provide care conferences in a timely manner for 5 out of 25 sampled residents (Resident 10, 78, 68, 25 and 62) reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the necessary interventions were in place to prevent further skin condition issues for one of 3 sampled residents (Resident 35) when reviewed for skin care. Additionally, the facility failed to ensure wound care and ADLs (activities of daily living) were enacted for 2 of 3 sampled residents (458 and 68) when reviewed for hospice care. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 3 of 5 sampled residents (Resident 93, 358 and 25) reviewed for bowel protocol. Furthermore, the facility lacked timely clinical interventions for 1 of 2 sampled residents (Resident 108) when reviewed for hospitalization. These failures placed the residents at risk for unmet needs, worsening condition, discomfort, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a safe dialysis program for 2 of 2 sampled residents (Residents 308 and 60) when reviewed for dialysis. Failure to accurately document, care plan, and communicate with the dialysis provider placed residents at risk of not receiving dialysis care as ordered and a diminished quality of life.

Inspectors wroteResident 83 Review of Resident 83's EHR showed the resident re-admitted on [DATE] with diagnoses to include heart and lung disease, anxiety, depression and bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The MDS further showed that the resident was able to make needs known. During an observation and interview on 08/22/2024 at 10:01 AM, Resident 83 sat on the side of their bed. Resident 83 stated they took pain medication related to back issues. Review of Resident 83's focus care plan dated 10/16/2023 showed the resident exhibited or was at risk for alterations in comfort related to chronic pain, lumbar (relating to the lower part of the back) fracture. Interventions included to medicate the resident as ordered for pain, monitor effectiveness and side effects. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of potential adverse side effects (ASE) related to the use of psychoactive (used for the treatment of certain mental health conditions) medications for 2 of 5 sampled residents (Resident's 460, and 25) and ensure an appropriate diagnosis was in place prior to the administration of an antipsychotic medication for 1 of 5 sampled residents (Resident 460) reviewed for unnecessary medication use. These failures placed the residents at risk for adverse side effects and medical complications and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the posted menu for 1 of 1 tray line observation (Lunch) when reviewed for kitchen. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food served at appetizing temperatures for 6 of 22 sampled residents (Residents 68, 7, 93, 20, 10, 62) and failed to resolve resident council grievances regarding unpalatable food for 3 of 3 months (June, July, and August 2024) when reviewed for palatable food. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food safely for 1 of 2 kitchen observations and failed to monitor resident food refrigerators for 2 of 2 sampled refrigerators (East and West). These failures placed residents at risk of consuming tainted food, foodborne illness, discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to implement transmission-based precautions for 5 of 22 residents (Residents 6, 458, 358, 466 and 93) also the facility failed to ensure staff followed current infection control guidelines for cleaning and disinfecting of the washing machines during use. These failures placed the residents at an increased risk for infections and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to have an antianxiety (a psychotropic medication that affect s a person's mental state) medication informed consent signed and in place prior to the resident receiving the medication for 1 of 5 sampled residents (Residents 60) reviewed for unnecessary medication use. Failure to obtain informed consents as required, placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident privacy was honored when providing topical medications for 2 of 4 sampled residents (Resident 62, and Resident 465) reviewed for medication administration, and failed to ensure a private location for personal phone calls and personal conversation for 1 of 2 sampled residents (Resident 25) reviewed for dignity. These failures placed residents at risk of not having personal space honored, feelings of institutionalization and a diminished quality of life

Inspectors wroteReview of the policy titled Grievance/Concern, dated 08/25/2021, showed that the facility would investigate the grievance, and that the person who filed the grievance should be notified of the status or resolution of the grievance within 72 hours. Resident 67 Review of the electronic health record (EHR) showed Resident 67 was admitted on [DATE]. Review of the MDS, dated [DATE], showed Resident 67 was cognitively intact and able to make needs known. During an interview on 08/23/2024 at 8:58 AM, Resident 67 stated they had a pair of black pants that went missing about 5 months ago and they filed a grievance that was still unresolved. Review of the facility's grievance log on 02/28/2024, showed Resident 67 had a missing clothes grievance with no resolution. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to resident or responsible party for 1 of 2 sampled residents, (Resident 358) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged .

Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 2 sampled residents, (Resident 358) reviewed for hospitalization. This failure placed the resident at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 22 sampled residents (Resident 460 and 68) reviewed for new admissions. Failure to ensure initial care plans were addressed for dementia and hospice care placed the residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation in a manner that meets professional standards of quality for 1 of 22 sampled residents (Resident 67) reviewed. This failure placed residents at risk for decreased quality of care, biases towards residents, and a diminished quality of life.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 sampled residents (Residents 458 and 358) when reviewed for pressure injuries. These failures placed the residents at risk for decreased comfort, infection, poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident spaces were free from accident hazards by not locking facility shower rooms where shaving supplies were stored for 3 of 4 sampled shower rooms (East A Hall, East B Hall and [NAME] C Hall) when reviewed for accidents. This failure placed residents at risk for accessing shaving supplies, increased injury risk, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a clear system in place to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders and/or to monitor and address nutritional needs for 3 of 4 sampled residents (Residents 60, 92, and 67) reviewed for nutrition and/or dialysis (the process of removing excess water, waste, and toxins from the blood). These failures placed the residents at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 6 sampled residents (Residents 60 and 78) reviewed for respiratory care. Failure to obtain and/or follow physician orders for oxygen (O2) therapy, care plan, ensure O2 tubing was appropriately maintained, regularly changed, and O2 concentrators (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's Medication Regimen Review (MRR) recommendations for 2 of 5 sampled residents (Resident 83 and 460) reviewed for unnecessary medication use. Failure to act on the pharmacist's recommendations placed the residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made out of twenty seven opportunities during medication administration for 1 of 5 sampled residents (Resident 465) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services to ensure residents could eat and drink for 1 of 4 sampled residents (Resident 308) reviewed for dental. This failure placed residents at risk of discomfort while eating, diminished nutritional intake, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assist residents with obtaining routine dental care for 1 of 4 sampled residents (Resident 67) reviewed for dental care. This failure placed residents at increased risk of pain, nutritional concerns, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident food preferences for 4 of 22 sampled residents (Residents 62, 67, 87, and 8) when reviewed for food preferences. This failure placed residents at risk of lack of nutritional intake, unintended weight loss, decline in condition, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 2 sampled residents (Resident 67) reviewed for rehabilitation. This failure placed the residents at a risk for decreased activities of daily living (ADL), decreased range of motion, preventable pain, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice for anti-hypertensive medication administration for 3 of 4 sampled residents (Residents 2, 3, and 6). These failures placed residents at risk of medical complications, and diminished quality of care.

Inspectors wroteBased on interview, and record review, the facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for 4 of 5 sampled residents (Residents 1, 2, 3 and 4) reviewed for skin and non pressure wound management. This failure placed residents at risk for unidentified wounds, wound decline, infection, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 4 of 5 sampled residents (Residents 1, 2, 3 and 5) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure of the facility to ensure physician orders with a supporting diagnosis, routine catheter care and monitoring was provided, placed the residents at risk for infections, skin breakdown, and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to initiate, document, investigate and/or resolve grievances for 3 of 4 sampled residents (Residents 2, 3 and 5) reviewed for grievances and missing property. This failure placed residents at risk for loss of clothing and property, having their complaints and concerns go un-addressed, feelings of unimportance, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to routinely provide dependent residents bathing assistance for 2 of 5 sampled residents (Residents 1 and 5) reviewed for activities of daily living. This failure placed residents at risk for poor hygiene, infection, a negative impact on mental health and dignity, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a readily available and adequate supply of bath linens (washcloths, towels) on four of four occupied wings of the facility (Wings A, B, C and D) reviewed for Safe/Clean/Comfortable/Homelike Environment. This failure placed residents at risk for longer wait times for care, inadequate hygiene, infection, diminished dignity, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow their process for nurses to document findings of weekly skin assessments, for three of three residents (Residents 2, 3 and 4) reviewed for pressure ulcer prevention. This failure placed residents at risk for undocumented skin impairments, lack of treatment, and inability for care staff to determine changes in skin condition, due to insufficient documentation.

Inspectors wroteBased on interview and record review, the facility failed to notify the medical provider and family/resident representative of newly identified injuries for one of three residents (Resident 4) reviewed for notification of changes. This failure placed the resident at risk for lack of medical provider oversight and treatment, related to the injuries, and lack of family involvement in care plan decisions.

Inspectors wroteBased on interview and record review the facility failed to investigate injuries of unknown origin, to identify root cause and rule out potential abuse and/or neglect, for one of three residents (Resident 4) reviewed for investigations. This failure placed the resident at risk for continued injuries and unidentified abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility did not provide bathing, according to the care plans, or resident preferences, for three of five residents who required assistance with bathing (Residents 2, 4 and 10), reviewed for activities of daily living. This failure placed the residents at risk for poor hygiene, skin impairments/rashes, infection, poor self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed maintain a safe homelike environment for 2 of 2 residents' bathrooms (Residents 85 and 68) reviewed for environment. The facility's failure to repair loose and broken toilets placed residents at risk for injury and decreased independence.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate incidents to rule out neglect for 1 of 2 residents (Resident 34) reviewed for Abuse/Neglect. This failure placed the resident at risk of lacking planned fall interventions, repeated falls, avoidable injury, and a diminished quality of life.

Inspectors wroteResident 95 Observation and interview on 10/22/2023 at 11:25 AM showed Resident 95 in bed in a hospital gown, their hair appeared dirty and tangled, and the resident was brushing at their hair saying please excuse my appearance. During an interview on 10/27/2023 at 12:25 PM, Resident 95 stated that they thought they had received one shower in the last month but couldn't remember and would love to have a shower. Review of Resident 95's MDS assessment dated [DATE] showed that choosing between bathing/ shower/bed bath was very important. Review of Resident 95's care plan showed they preferred a tub bath in the evenings. Review of Resident 95's Electronic Health Record (EHR) on 10/27/2023 showed no documented showers/baths during the month of October. The last documented shower showed a date of 09/29/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure placed residents at risk of unmet needs, decreased range of motion and mobility and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate was less than 5 percent (%). During observation of 26 opportunities for error, 3 of 3 Licensed Nurses (Staff G, P and EE) made three errors; an error rate of 11.54%. This failure placed residents at risk for not receiving medication timely and according to the physician orders.

Inspectors wroteBased on observation and interview, the facility failed to ensure professional standards were met during medication administration for 2 of 3 residents (Residents 62 and 73) reviewed during Medication Administration. Two staff (Staff G and P) left medications sitting at the residents' bedsides and did not ensure that the medications were taken by the residents prior to leaving their rooms. This failure placed residents at risk for not receiving their medications as ordered, untreated medical conditions, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to administer bowel medications in accordance with Physician's orders (POs) for 2 of 5 residents (Residents 34 and 75) and implement dressing changes per Physicians Orders for 1 of 6 residents (Resident 81). These failures placed residents at risk for pain/discomfort related to constipation, poor wound healing/infections related to wound care, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for one of two residents (Resident 65), reviewed for limited range of motion (ROM). This failure placed the residents at risk for decreased ROM, increased pain, and diminished quality of life.

Inspectors wroteResident 75 Review of Resident 75's EHR showed an order for oxycodone (a narcotic pain medication) every 8 hours as needed for pain with a start date of 09/22/2023. Review showed this pain medication was given 3 to 4 times a day for the past 24 days. Further review showed no documentation that non-pharmacological interventions were attempted prior to administering as needed oxycodone for the last 24 days. During an interview on 10/25/2023 at 9:03 AM, Staff P, Licensed Practical Nurse (LPN), stated that they were aware that non-pharmacological interventions for pain should be attempted before offering narcotic pain medications but Resident 75 just wants their pain meds. Staff P stated that Resident 75 had no physicians' orders to attempt non-pharmacological interventions for pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an outbreak of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) to the State Agency for two of two residents (Residents 1 and 2) reviewed for infection control. This failure placed residents, staff, and visitors at increased risk of contracting illness due to the facility's lack of regulatory oversight.