Parham Health Care & Rehab Center

Inspectors wroteBased on resident interviews, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment remained free of accident hazards and to provide adequate supervision and safety measures to protect residents from the likelihood of accidents and hazards from permitting smoking in an undesignated courtyard that did not have a means to extinguish a fire. This resulted in the identification of immediate jeopardy and substandard quality of care and had the potential to affect residents on three of three units within the facility. The facility staff also failed to ensure that the fire extinguisher in the designated smoking area was an approved and inspected extinguisher.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for fifteen occurrences affecting one resident (Resident #201-R201) in a survey sample of 14 residents.

Inspectors wroteBased on observation, family interview, staff interviews, and clinical record review, the facility staff failed to provide a provider ordered mechanically altered diet for one of forty-three sampled residents (R)119 resulting in harm. R119 developed pneumonia and required antibiotic treatment.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to maintain resident clinical records in a manner to ensure privacy and confidentiality of records, on two of three nursing units (Central and [NAME] wings).

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for one resident (Resident #201- R201) in a survey sample of 14 residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to follow infection control standards during medication administration on one of three units (west wing), involving four residents.

Inspectors wroteBased on observation, resident interviews, staff interviews and facility documentation review, the facility staff failed to provide a functional, sanitary and comfortable environment for residents on 3 of 3 units.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to notify the responsible party (RP) of a change in condition for one of forty-three residents (R) 119.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respond to grievances for one resident (Resident #121-R121) in a survey sample of 43 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respect resident's right to be free from misappropriation of property for one resident (Resident #121-R121) in a survey sample of 43 residents.

Inspectors wroteBased on observation, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement a person-centered comprehensive care plan (CCP) for one of forty -three residents, Resident (R) 119.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to protect the residents' right to be free from physical abuse by other residents for 11 of 48 residents in the survey sample, Residents #43, #12, #37, #40, #39, and #41, resulting in the identification of immediate jeopardy; and for Residents #48, #38, #24, #42, and #10.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care, services, and supervision for resident safety for six of 48 residents in the survey sample, Residents #32, #7, #40, and #26, resulting in the identification of immediate jeopardy; and for Residents #48, and #45.

Inspectors wroteBased on observation, family interview, staff interviews, and clinical record review, the facility staff failed to provide a provider ordered mechanically altered diet for one of forty-three sampled residents (R)119 resulting in harm. R119 developed pneumonia and required antibiotic treatment.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide a full-time, qualified social services worker to meet the resident's individual needs whenever needed.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with a focus on the outcomes of care, quality of life, and to correct quality deficiencies, which resulted in multiple residents residing on three of three units being victims of abuse.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to accommodate resident's choices and/or needs for eight of forty-three residents (R), R102, R116, R138, R139, R140, R141, R143 and R129.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to maintain resident clinical records in a manner to ensure privacy and confidentiality of records, on two of three nursing units (Central and [NAME] wings).

Inspectors wroteBased on observation, staff interview and facility documentation review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of three units and for failure to keep a homelike environment for 1 Resident (Resident # 142) in a survey sample of 43 residents.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct a thorough investigation into allegations of abuse and misappropriation involving four residents (Resident #26- R26, Resident #40- R40, Resident #48- R48, and Resident #33- R33), in a survey sample of forty-eight residents.

Inspectors wroteBased on resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure resident care and services were provided in accordance with accepted standards of care for five of 48 residents in the survey sample, (Residents #27, # 21, 32, 12, and #24)

Inspectors wroteBased on staff interview, clinical record review, and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for fifteen occurrences affecting one resident (Resident #201- R201) in a survey sample of 14 residents.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to follow infection control standards during medication administration on one of three units (west wing), involving four residents.

Inspectors wroteBased on resident interview, observation, staff interview, and facility document review, the facility staff failed to provide a clean environment in four of 88 resident rooms, rooms 77, 13, 11, 53, and 58.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one resident (Resident #33) in survey sample of forty-eight residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to notify the responsible party (RP) of a change in condition for one of forty-three residents (R) 119.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respond to grievances for one resident (Resident #121-R121) in a survey sample of 43 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respect resident's right to be free from misappropriation of property for one resident (Resident #121-R121) in a survey sample of 43 residents.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for reporting and conducting a thorough investigation for five residents (Resident #33, 48, 40, 26, and 33) in a survey sample of forty-eight residents.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to report an allegation of misappropriation to the required agencies in a timely manner involving three residents (Resident #33- R33, Resident #26-R26, and Resident #48-R48), in a survey sample of forty-eight residents.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop a comprehensive person-centered care plan for one (1 ) resident (Resident #27) in a survey sample of 48 residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to review and/or revise the care plan for two (2) of 48 residents in the survey sample, Residents #32 and #7.

Inspectors wroteBased on observation, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident received ADL (activity of daily living) assistance for one (1) resident (Resident #31) in a survey sample of 48 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to appropriately assess and monitor a resident following a fall with injury for one resident (Resident #20-R20) in a survey sample of forty-eight residents.

Inspectors wroteBased on staff interview and clinical record review the facility nursing staff failed to complete a provider ordered treatment to a pressure ulcer for one of forty-three sampled residents, Resident (R)102.

Inspectors wroteBased on staff interviews and facility document review, it was determined that the facility staff failed to complete annual performance evaluations for two of the five C.N.A.s (certified nursing assistants) records.

Inspectors wroteBased on observation, staff interviews, and facility document review, the facility staff failed to consistently follow menus for resident meals for one of forty-three sampled residents, Resident (R)119.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility document review, the facility failed to ensure a complete and accurate medical record in accordance with accepted professional standards for 2 (two) of 48 residents in the survey sample (Resident #27, #26).

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to ensure the Quality Assessment and Performance Improvement Committee consisted of the minimum required members for three of five meetings (1/9/25, 7/29/25, and 11/25/25; no meeting sign-in sheet for April 2025).

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an operational call bell system and in instances of repeated outages of their call system, the facility staff failed to ensure residents had a means to call for assistance from the bedside and bathroom where the call would go directly to a staff member or central location for residents, affecting multiple residents on one of three units at various times. During the survey, a resident on the central unit did not have an operational call bell and the resident had no alternate means to call for assistance.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure the corridors had firmly secured handrails on one of three units.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement their policy on smoking for one of forty-three residents, Resident (R)131.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide the required Resident's Rights training for one employee in a survey sample of six employee records.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide required abuse training for one employee in a survey sample of six employee records.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide the required Quality Assurance and Performance Improvement training for one employee in a survey sample of six employee records reviewed.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide required infection control training for one employee in a survey sample of six employee records.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide the required compliance and ethics training for one employee in a survey sample of six employee records.

Inspectors wroteBased on observations and staff and resident interviews, the facility staff failed to ensure the residents' right to a safe, clean, comfortable, homelike environment for the entire facility and for Residents #128, #103, and #109 in a survey sample of 21 Residents. The following observations were made during the survey period: On 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. On 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways. On 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing.8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. [...]

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an safe replacement for failing closet doors and insect pest prevention and control program concerns for 1 Resident (Resident #124) in a survey sample of 28 Residents.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to maintain an effective pest control program for 3 out of 3 units,. 1. For the facility, on 8/27/25 at 10:30 AM and 8/29/25 at 9:00 Am there was a strong urine odor in hallway past the lobby. 2. For the facility, on 8/27 through 8/29/25 flies were observed throughout the facility in resident rooms and in the hallways. 3. For the facility, on 8/29/25 at 9:00am observed breakfast trays being served with plastic utensils. An interview was conducted at approximately 9:10 AM with the Dietary Manager Employee #3 who stated due to callouts they opted to use plastic ware to save time on dish washing. 4. For the facility, on 8/27/25 through 8/29/25 observed wall mounted hand sanitizer units either missing or loose on the wall. Missing tiles in hallways or in resident rooms 12, 34; [...]

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to a dependent Resident (Resident #123) in a survey sample of 28 Residents.

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents.

Inspectors wroteBased on observations, staff interviews, resident interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to ensure the environment remained safe for residents and was free from hazards for one (1) resident (Resident #61) and potentially other residents, in a survey sample of 57 residents, resulting in a finding of Immediate Jeopardy. Unrelated to the IJ, the facility staff failed to ensure that the exhaust pipe from the generator was in good repair.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases for one (1) resident (Resident #61) in a survey sample of 57 residents, resulting in a finding of immediate Jeopardy.

Inspectors wrote2. The facility's staff failed to identify Resident #156's pressure ulcer prior to progression to a Stage 3 and they failed to provide care and services to promote pressure ulcer healing that resulted in harm. Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. [...]

Inspectors wrote4. Comfortable and safe temperature on the Central Unit: a. Resident #43 complained of not being comfortable because of coldness on 4/17/25. Resident #43 was originally admitted to the facility 11/14/2024 after an acute care hospital stay. The current diagnoses included Parkinson's disease, heart failure and dementia with depression and anxiety. The quarterly MDS with an assessment reference date (ARD) of 2/21/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #43's cognitive abilities for daily decision making were moderately impaired. On 4/17/25 at 11:35 AM an interview was conducted with Resident #43. He was observed lying on his bed complaining of a toothache and wrapped in a robe. The only linens on the resident's bed was sheets and a light bedspread. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility's staff failed to provide meals at regular times and in accordance with resident needs, preferences and requests on three out of three units. The facility staff failed to offer and provide snacks at bedtime and failed to serve meals timely.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public throughout the facility.

Inspectors wroteBased on observation, interview, and clinical record review the facility staff failed to maintain an effective pest control program for the facility.

Inspectors wroteBased on resident interview, staff interview, and review of facility documentation, the facility's staff failed to act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility reported in three out of three months.

Inspectors wroteBased on staff interviews, and a clinical record review, the facility staff failed to notify the Physician and/or Designee of refusals of care and services for two (2) of 57 residents (Resident #43 and 116), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure medications were administered according to professional standards for 1 of 57 residents (Resident #43), in the survey sample.

Inspectors wroteBased on interviews, clinical record review and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 2 Residents (#77, & #147) in a survey sample of 57 Residents.

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 57 residents (Resident 43), in the survey sample.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents received dialysis and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 Resident (#64) in a survey sample of 57 Residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to ensure that a resident who exhibited behavioral health symptoms received clinically appropriate services for one (1) of 57 residents (Resident #43), in the survey sample.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 1 Resident (#64) in a survey sample of 57 Residents.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to safely store drugs and biological in one of three medication rooms and in the Infection Preventionist refrigerator.

Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to ensure meals served were palatable to consume by 2 of 57 residents (Resident #55, & #41) in the survey sample.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to maintain all mechanical and electrical equipment in safe operating condition for the facility.

Inspectors wrote2. Resident #41 was originally admitted to the facility [DATE]. The resident's current diagnoses included blindness, chronic back pain and migraines. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #41's cognitive abilities for daily decision making were intact. Resident #41's had a care plan problem with a revision date of [DATE] which stated he had an ADL self-care performance deficit related to blindness, and chronic health conditions. The goal stated the resident would maintain his current level of functioning through the review date, [DATE]. The interventions included requires minimal assistance with bathing/showers, and requires set up/supervision with dressing. [...]

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (Resident # 56) in a survey sample of 57 Residents. For Resident # 56, the facility staff failed to provide a bed that was an adequate size for someone 74 inches tall.

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review, the facility staff failed to promote self determination through support of choice for one (1) Resident (Resident # 75) in a survey sample of 57 Residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused, (Residents #167, Male 1, Male 2, and Female 1, #77, #50, and #56) in a survey sample size of 57 residents.

Inspectors wroteBased on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse at the hands of Residents, and staff members. The facility further failed to report the abuse to the state agency accurately and timely, failed to fully investigate the abuse, failed to protect new victims from abuse, and further failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1, and #77) in a survey sample size of 57 residents.

Inspectors wroteBased on interviews, clinical record review and facility documentation, the facility staff failed to implement the abuse policy and report an allegation of abuse for one (1) resident (Resident #77) in a survey sample of 57 Residents.

Inspectors wroteBased on observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate, prevent, and correct repeated willful abuse at the hands of Resident #86. The facility further failed to report the abuse to the state agency accurately and timely, and failed to implement their abuse and neglect policies for multiple known Residents who were abused. (Residents #167, Male 1, Male 2, and Female 1) in a survey sample size of 57 residents.

Inspectors wroteBased on the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 57 residents (Resident #156), in the survey sample.

Inspectors wroteBased on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for two (2) Residents (Residents #86, and #143) in a sample of 57 residents.

Inspectors wroteBased on clinical record review, staff interview and facility documentation review, the facility staff failed to develop and implement a comprehensive person-centered care plan consistent with resident needs for one (1) of 57 residents in the survey sample.

Inspectors wroteBased on observation, a clinical record review and staff interviews, the facility staff failed to provide foot care for 1 of 57 residents (Resident #116), in the survey sample.

Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while requiring use of an indwelling catheter for two (2) of 57 residents (Resident #124, and #50), in a survey sample of 57 Residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure adequate nutrition to prevent weight loss for one (1) Resident (#56) in a survey sample of 57 Residents.

Inspectors wroteBased on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure the resident received the physician ordered milliliters (ml) of oxygen for one (1) of 57 residents (Resident #271), in the survey sample.

Inspectors wroteBased on observations, resident interview, staff interview, and review of the clinical record, the facility staff failed to assess and attempt to use alternatives prior to the use of bedrails for one (1) of 57 residents (Resident #156), in the survey sample.

Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided at the facility were available.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure the resident's mattress was compatible for the bedframe for 1 of 57 residents (Resident #119), in the survey sample.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility nursing staff failed to treat residents with dignity and respect for one of four residents in the survey sample and per the resident council.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation review, the facility staff failed to inform the resident representative, when there was a change in condition for one resident in a survey sample of four residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure the residents right to a clean, comfortable, and homelike environment, for four (4) residents (Residents #4, #2,# 7, and #8) in a survey sample of eight (8) residents.

Inspectors wroteBased on staff interview, facility documentation, and clinical record review, the facility staff failed to provide routine medications to one resident (Resident #6) in a survey sample of eight (8) residents.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure one resident (Resident # 4) of eight (8) residents in the survey sample was free of significant medication errors. For Resident # 4, the facility staff failed to ensure the medication, Medrol, was available for administration as per physician's orders.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for the facility in general.

Inspectors wroteBased on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program so the facility is free of pests.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise the care plan for one resident (Resident #6) of eight (8) residents in the survey sample. For Resident #6, the facility staff failed to review and revise the care plan after a significant weight loss from July 2022 to October 2022.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure care and services met professional standards of quality for 1 resident (Resident #2 ) in a survey sample of eight (8) residents. For Resident #2, the facility staff failed to follow physician's orders to weigh Resident #2 three times per week due to a diagnosis of congestive heart failure (CHF). On 09/13/2023 at approximately 12:00 p.m., an interview was conducted with Resident #2 who was asked about her diagnosis of CHF. She stated she was diagnosed when she was in her 40's and has had to watch her diet and weight frequently and watch for swelling of her legs and feet. When asked how many times per week she is supposed to be weighed she stated 3 times per week. [...]

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents received the necessary services to maintain good grooming, and personal hygiene for 1 resident (Resident #1) in a survey sample of eight (8) Residents.

Inspectors wroteBased on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to arrange transportation to medial appointments for 1 resident (Resident #5) in the survey sample of eight (8) residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to prevent a significant weight loss for one resident (Resident #6) of a survey sample of eight (8) residents.

Inspectors wroteBased on observations, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to prevent significant weight loss for Two Residents (Resident #105, and #110 ) in a survey sample of 58 Residents, resulting in harm for Resident #110.

Inspectors wroteBased on Resident interview, staff interview, facility documentation review, the facility staff failed to respond to Resident Council grievances.

Inspectors wroteBased on staff interview, facility documentation review, and in the course of a complaint investigation, the facility failed to ensure that an RN (Registered Nurse) was on duty 8 hours per day 7 days per week. The facility had no RN on duty on 3-1-22, 4-21-22, and 4-24-22.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 4 Residents (Resident #10, 100, 127, and 135), in a sample of 5 Residents reviewed for immunizations.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to offer COVID vaccination(s) for Residents who were not vaccinated against COVID-19, for 2 Residents (Resident #127 & #100), in a sample of 5 Residents reviewed for immunizations.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to notify the Resident Representative of a change in condition and room changes for one Resident (Resident #305) in a survey sample of 58 Residents.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #133) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #133, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #133 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill.

Inspectors wroteBased on observations, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise care plans for unplanned weight loss for Two Residents (Resident #105, and #110 ) in a survey sample of 58 Residents. 1. For Resident #105, the facility failed to specifically care plan Resident centered weight loss interventions. 2. For Resident #110, the facility staff failed to care plan weight loss interventions recommended by dietary, and failed to specifically care plan Resident centered weight loss interventions.

Inspectors wroteBased on staff interviews, record review, and in the course of a complaint investigation the facility staff failed to provide activities of daily living care to one resident, Resident #1400, in a sample of 17 residents.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary care and treatment as ordered by the physician to promote healing of a pressure wound for one Resident (Resident #28) in a sample size of 58 Residents. Specifically, the facility staff failed to: 1) Administer pressure wound treatments on 03/18/22, 03/19/22, 03/22/22, 03/24/22, 03/25/22, 03/28/22, 04/10/22, and 04/22/22 as ordered by the physician. 2) Apply an air mattress as ordered by the provider.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy as ordered by the physician for 1 Resident, Resident #118, in a survey sample of 58 Residents.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to label and store medications in accordance with currently accepted professional standards for 2 medication carts (Cart (1,2) and Cart (2,3) out of 9 medication carts.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed, for 2 Residents (Resident #105, and #110) in the survey sample of 58 residents, to provide follow preferences and/or drinks for hydration.

Inspectors wroteBased on observation, staff interviews, and facility documentation review the facility staff failed serve food in a sanitary manner for two out of six kitchen employees observed in the kitchen over the course of the survey.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one Resident, Resident #154, in a survey sample of 58 Residents.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to conduct COVID-19 testing in accordance with the CDC recommendations for 15 facility staff and two Residents (Resident #11 and #104) in a survey sample of 58 Residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to 1) have an accurate system to track the immunization status of all facility employees, and 2) failed to ensure 100% of facility staff were vaccinated, the facility vaccination rate was 92.9%. 1. The facility failed to include all staff members on the vaccination tracking, therefore rendering it as incomplete. 2. The facility staff vaccination rate for COVID-19 was 92.9%.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to mitigate an accident hazard during ADL care for 1 resident (Resident #39) of 57 residents in the survey sample resulting in harm. Resident #39 was coded as two person assistance when turning and repositioning in bed. During incontinence care provided by one staff person, the resident fell out of bed and fractured her shoulder.

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure 1 resident (Resident #260) of 57 residents in the survey sample was assessed to self administer medications. For Resident #260, a bottle of colace (for constipation) was observed on the over bed table.

Inspectors wroteBased on staff interview and record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to provide the resident's caregiver with written discharge instructions and prescriptions for medications for continuity of care. The facility staff failed to provide Resident #358's caregiver with written discharge instructions and prescriptions for medications for continuity of care.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility documentation, the facility staff failed to develop and implement comprehensive care plans for three residents (Resident #44, #23, #34) in a sample size of 57 residents. 1. For Resident #44, the facility staff failed to develop and implement care associated with contractures in bilateral hands. 2. For Resident #23, the facility staff failed to develop and implement care associated with contractures in bilateral arms and hands. 3. For Resident #34, the facility failed to develop and implement an individualized care plan that addresses contractures

Inspectors wroteBased on staff interview and record review, the facility staff failed for 1 resident (Resident 358) in the survey sample of 57 residents, to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done. For Resident #358, the facility staff failed to ensure that a written reconciliation of pre-discharge medications with the residents post discharge medications was done.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation the facility failed to act on pharmacy alerts to possible drug interactions for 1 Resident (Resident #260) in a survey sample of 10 Residents. For Resident # 260 the facility failed to act on pharmacy alerts of medications that were incompatible or known to alter the effects of Coumadin (a blood thinner).

Inspectors wroteBased on observations, family interview, staff interview, clinical record review, facility documentation, and facility policy review, the facility staff failed to provide timely dental services for one resident (Resident #115) in a sample of 57 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed, for 1 resident (Resident #17) in the survey sample of 57 residents, to administer medications in a manner to prevent the spread of infection. For Resident #17, the nurse (LPN C) failed to perform proper handwashing technique prior to preparing and administering medications.