Park Terrace Rehabilitation Center

Inspectors wroteBased on resident interview, staff interview, medical record review, review of resident admission agreements, review of facility job descriptions, review of facility self-reported incidents (SRIs), review of facility corrective action plan, and review of facility policy, the facility failed to provide care and services to residents in accordance with professional standards of practice, the comprehensive assessment of each resident, and physician orders. This failure resulted in multiple residents not receiving prescribed medications, treatments, or care interventions, thereby potentially placing all residents residing in the facility at risk. The facility census was 89.

Inspectors wroteBased on resident interview, staff interview, electronic medical record (EMR) review, review of the Medication Administration Record (MAR), review of the Treatment Administration Record (TAR), review of staff time punches, review of facility policies, and review of the facility's Self-Reported Incident (SRI) #271289, the facility failed to protect residents from neglect when it failed to ensure staff providing resident care were able to safely perform their duties and failed to intervene when Licensed Practical Nurse (LPN) #100 was reported by staff and residents to be exhibiting behaviors consistent with being under the influence of an unknown substance while providing resident care on 02/22/26. [...]

Inspectors wroteBased on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), review of the Treatment Administration Record (TAR), staff interview, and review of facility documentation, the facility failed to ensure residents received necessary care and services in accordance with professional standards of nursing practice and physician orders. Specifically, the facility failed to ensure physician-ordered medications, treatments, assessments, monitoring, and interventions were implemented as ordered for 10 residents (#9, #12, #15, #24, #34, #43, #75, #77, #85, and #89). The facility's failure included, but was not limited to, failure to complete physician-ordered pain assessments; failure to administer ordered medications and tube feedings; failure to perform percutaneous endoscopic gastrostomy (PEG) tube monitoring and flushes; [...]

Inspectors wroteBased on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), staff interview, and review of facility documentation, the facility failed to provide routine and emergency medications and biologicals to meet the needs of each resident in accordance with physician orders and professional standards of practice. This affected nine (#9, #12, #15, #24, #34, #43, #75, #77, and #89) of ten residents reviewed for medication administration. The facility census was 89.

Inspectors wroteBased on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), staff interview, and review of facility documentation, the facility failed to ensure residents were free from significant medication errors. Specifically, the facility failed to administer numerous physician-ordered medications, including antihypertensives, anticoagulants, antiepileptics, psychotropic medications, insulin, and respiratory medications, as prescribed for 10 (#9, #12, #15, #24, #34, #43, #75, #77, #85, and #89) of 10 residents reviewed for medication administration. The facility census was 89.

Inspectors wroteBased on electronic medical record (EMR) review, review of the Medication Administration Record (MAR), staff interview, and review of facility documentation, the facility failed to ensure a resident receiving enteral nutrition received tube feeding and associated care in accordance with physician orders and professional standards of nursing practice. Specifically, the facility failed to administer physician-ordered tube feedings and required percutaneous endoscopic gastrostomy (PEG) tube flushes for one of one resident (#15) reviewed for tube feeding management. The facility census was 89.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, resident interview, staff interview, surveillance video review, facility Self-Reported Incident review, review of the facility investigation, review of staff schedules, and review of facility policy, the facility failed to ensure an allegation of abuse was reported timely. This affected one (#10) of three residents reviewed for abuse and had the ability to affect 23 residents (#33, #35, #36, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58, #59, #60) who reside in the secured behavioral unit. Facility census was 83.

Inspectors wroteBased on closed medical record review, staff interviews, review of staff witness statements, review of the hospital notes, and review of the facility policy, the facility failed to ensure bed rails were properly installed. This resulted in Actual harm to Resident #89 when on 10/11/25 the facility applied bed rail broke off during resident care, causing the resident to roll out of bed, be lowered to the floor by staff, and maneuvered onto a Hoyer pad. Consequently, Resident #89 sustained a displaced fracture of the right humeral neck (upper arm). This affected one (#89) of three residents reviewed for falls. The facility census was 86.

Inspectors wroteBased on observation, staff interview, and facility policy the facility failed to ensure call lights were functioning properly. This affected two (#7 and #55) of ten residents reviewed for call lights. The facility census was 86.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure comfortable room temperatures. This affected three (#49, #57, and #95) of ten residents reviewed reviewed for room temperatures. The facility census was 86.

Inspectors wroteBased on review of facility policy, review of personnel files, and staff interview, the facility failed to ensure background checks were completed for one employee (Licensed Practical Nurse #607) of seven employees files reviewed. This had the potential to affect all residents. The facility census was 86.

Inspectors wroteBased on medical record review, staff and resident interview, review of employee timecards, review of facility Self Reported Incident, review of facility investigations, and review of facility policy, the facility failed to thoroughly and accurately investigate alleged occurrences of abuse and misappropriation of medications. This affected two (#21 and #88) of four residents reviewed for abuse prohibition and one Self Reported Incident (#256925) in a facility census of 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were suctioned per order. This affected one (#91) resident reviewed for respiratory therapy. The facility census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain blood pressures to monitor the ordered parameters for administering medication for one (#91) of three residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure accurate and timely documentation in the medical record. This affected two (#87 and #91) of three residents reviewed for accurate documentation. The facility census was 86.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of a facility investigation, resident and staff interview, review of a facility policy, and review of facility corrective action documents, the facility failed to ensure a resident was free from verbal abuse. This affected one (#5) of three residents reviewed for abuse. The facility census was 86.

Inspectors wroteBased on observation, medical record review, review of hospital documentation, staff interview, and facility policy, the facility failed to ensure wound treatments and dressing applications were applied in accordance with physician orders. This affected one (#7) of three residents reviewed for wound care and treatment services in a facility census of 86.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to provide timely interventions to prevent urinary incontinence. This affected one (#22) of three residents reviewed for incontinence care and services in a facility census of 86.

Inspectors wroteBased on observation, medical record review, review of hospital documents, staff interview, and facility policy, the facility failed to ensure peripherally inserted central catheters (PICC) were maintained in accordance with physician orders and dressing changes were completed using appropriate appropriate technique. This affected two (#7 and #8) of two residents reviewed for PICC line care and treatment in a facility census of 86.

Inspectors wroteBased on review of the facility incident and accident log, review of the Electronic Information Dissemination and Collection (EIDC - system used by facilities to report incidents to the State Survey Agency [SSA]) system, review of the facility Self-Reported Incidents (SRI), staff interview and review of the facility policy, the facility failed to report an incident of resident elopement to the SSA for Resident #3 and further failed to ensure allegations of abuse were thoroughly investigated for four (#26, #28, #30, and #31) residents reviewed for abuse. The facility census was 87.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were completed. This affected one (#53) of one resident reviewed for baseline care plans. The facility census was 87.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure person-centered care plans were completed. This affected one (#3) of four residents reviewed for care plans. The facility census was 87.

Inspectors wroteBased on review of the facility incident and accident log, staff interview, medical record review and review of the facility policy, the facility failed to provide adequate supervision to prevent resident elopement and further failed to timely implement interventions to ensure resident safety following an incident of elopement. This affected one (#3) of one resident reviewed for elopement. The facility census was 87.

Inspectors wroteBased on observation, medical record review, review of a fire and rescue run report, review of hospital documentation, review of narcotic/controlled drug records, staff interviews, interview with the pharmacist, and review of the policy on controlled substances, the facility failed to ensure Resident #86 was free from a significant mediation error, failed to report missing Fentanyl medication patches, failed to accurately assess the resident, and failed to immediately investigate and implement immediate interventions to ensure an accurate system was in place for monitoring Fentanyl patch placement. [...]

Inspectors wroteBased on medical record review, resident and staff interview, review of staff schedules, review of dialysis schedules, review of resident treatment tracker information, review of staff postings, review of shower schedules and shower sheets, review of the Facility Assessment, and policy review, the facility failed to ensure adequate staffing to meet the needs of the residents. This had the potential to affect all 89 residents in the facility. The facility census was 89.

Inspectors wroteBased of review of personnel records, review of staff training, and staff interview, the facility failed to ensure certified nurse aides (CNAs) received no less than 12 hours of annual in-service training. This affected five (#107, #115, #134, #130, and #107) of five CNAs reviewed and had the potential to affect all 89 residents. The facility census was 89.

Inspectors wroteBased on medical record review, review of a self-reported incident (SRI), review of hospital documentation, review of a fire and rescue report, review of dialysis resident tracking records, review of the Facility Assessment, review of daily posted staffing documentation, review of personnel job descriptions, and staff interview, the administration team failed to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility failed to ensure measures were in place to prevent a medication overdose and investigation and put follow-up interventions in place to be prevent recurrence, failed to ensure allegations of staff-to-resident verbal abuse were thoroughly investigated, failed to ensure medical records were accurate, and failed to ensure adequate staffing to meeting resident needs for [...]

Inspectors wroteBased on review of a self-reported incident (SRI), review of staff timecards, review of staff employment status documentation, staff interview, and review of a facility policy, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated. This affected one (#22) of three residents reviewed for allegations of abuse. The census was 89.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident residing on a secured behavioral unit met the criteria for admission to the secured unit. This affected one (#90) of three residents reviewed for placement on the secured unit. The facility identified 22 residents as residing on the secured unit. The facility census was 89.

Inspectors wroteBased on review of the medical record, staff interview, resident representative review, and policy review, the facility failed to ensure a notice of transfer or discharge was provided to residents. This affected two (#90 and #9) of three residents reviewed for transfer and discharge notices. The facility census was 89.

Inspectors wroteBased on review of the medical record, staff interview, resident representative review, and policy review, the facility failed to ensure a bed hold notice was provided to residents. This affected two (#90 and #9) of three residents reviewed for bed hold notices. The facility census was 89.

Inspectors wroteBased on resident interview, medical record review, review of shower schedules, review of shower documents, staff interview, and review of the facility policy, the facility failed to ensure showers were provided to residents who required assistance with showers. This affected three (#9, #34, and #88) of three residents reviewed for showers. The facility census was 89.

Inspectors wroteBased on medical record review, staff schedules, resident and staff interviews, and policy review, the facility failed to ensure residents on a mechanical ventilator received adequate care to decrease their need for ventilator dependence (wean from the ventilator). This affected one (#34) resident identified to require mechanical ventilation. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were ordered with instructions for the correct indication of use. This affected one (#83) of three residents reviewed for medications. The census was 89.

Inspectors wroteBased on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure residents were screened for therapy services, and failed to ensure therapy staff pursued authorization to provide therapy services. This affected two (#9 and #68) of three residents reviewed for therapy services. The facility census was 89.

Inspectors wroteBased on review of the medical record, staff and resident interview, and policy review, the facility failed to ensure accurate documentation was in the medical record and failed to ensure the medical record reflected care and services provided. This affected three (#21, #74, and #42) of nine residents reviewed for accuracy of the medical record. The facility census was 89.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the nursing staffing information was printed and posted daily. This affected all 89 residents in the facility. The census was 89.

Inspectors wroteBased on staff interview and facility document review, the facility failed to ensure there was Registered Nurse (RN) coverage eight consecutive hours, seven days a week for 17 days during the timeframe from 02/01/25 through 03/13/25. This had the potential to affect all 91 residents. The census was 91.

Inspectors wroteBased on personnel file review, staff interview, and policy review, the facility failed to provide dementia management and resident abuse prevention education for five Certified Nurse Aides (CNAs) (#9, #24, #27, #34, and #35 of five staff reviewed for training. This had the potential to affect all 91 residents in the facility.

Inspectors wroteBased on observation, medical record review, staff and resident interview, and facility policy review, the facility failed to ensure residents who were assessed by the facility to require supervision while smoking were supervised by staff when they went out to smoke, failed to ensure residents did not keep their smoking materials in their possession, failed to ensure residents smoked in the designated smoking area of the facility, and failed to ensure resident smoking evaluations were accurate. This affected four (#79, #70, #39, and #244) of six sampled residents reviewed for accidents in a facility census of 91.

Inspectors wroteBased on medical record review, staff and resident interview, and facility policy review, the facility failed to ensure a bed hold notice was issued for two (#61 and #78) of three sampled residents reviewed for hospitalization in a facility census of 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the licensed nursing staff notified the physician of a resident's readmission to the facility and to obtain medication and/or treatment orders to direct staff how to care for one (#61) of 19 sampled residents in a facility census of 91.

Inspectors wroteBased on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set assessments were coded accurately for two (#38 and #65) of three residents reviewed for resident assessments in a facility census of 91.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure a resident received their tube feeding as ordered by the physician for one (#68) of three sampled residents reviewed for tube feeding in a facility census of 91.

Inspectors wroteBased on medical record review, resident and staff interview, and facility policy review, the facility failed to provide physician-ordered respiratory care and services for three (#4, #78, and #291) of four residents reviewed for respiratory care in a facility census of 91.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to provide coordination of treatment to ensure medications were administered as ordered for a dialysis resident. This affected one (#61) of two sampled residents reviewed for dialysis. The facility census was 91.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure pharmacy recommendations were implemented timely for one (#65) of five sampled residents reviewed for unnecessary medications. The facility census was 91.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure there was a medication error rate of five percent (%) or less. There were 10 errors out of 26 opportunities observed, which yielded a medication error rate of 38.5%, This affected two (#68 and #57) of two residents observed for medication administration.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure staff donned recommended personal protective equipment (PPE) in a room labeled as requiring enhanced barrier precautions (EPB) for one (Resident #6) of five residents reviewed for transmission-based precautions or EBP. The facility further failed to ensure staff performed proper hand hygiene and glove changes during the provision of incontinence care for one (Resident #190) of two residents reviewed for bladder and bowel incontinence. The facility census was 91.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure soiled linen was contained to prevent cross contamination with clean linen. This had the potential to affect all 88 residents receiving laundry services. The facility census was 88.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure wash clothes and towels were provided to residents. This had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on record review, observation, and resident and staff interview, the facility failed to ensure residents who were incontinent were provided with a supply of appropriately fitting incontinence garments and briefs. This affected 43 current residents (#2, #3, #5, #6, #7, #8, #10, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #26, #28, #29, #30, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #55, #69, #74, #76, #79, #81, #82, #86, #87, and #89) identified by the facility to require incontinence briefs. The facility census was 88.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure residents who required assistance with activities of daily living (ADL) were assisted with bathing as scheduled. This affected four (#1, #2, #5, and #6) of six residents reviewed for ADL. The facility census was 88.

Inspectors wroteBased on observations, medical record review, resident and staff interview, and facility staffing documentation, the facility failed to schedule sufficient nursing staff to ensure resident care and treatment was provided as indicated. This affected four residents (#1, #2, #5, and #6) and had the potential to additionally affect 32 residents (#3, #4, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #22, #23, #70, #72, #73, #74, #75, #76, #77, #79, #81, #82, #83, #84, #85, #86, #87, and #88). The facility census was 88.

Inspectors wroteBased on observation, staff interview, review of facility dietary spreadsheets and resident dietary order documentation, the facility failed to ensure dietary meal portions were provided as required. This affected 60 residents (#1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #17, #18, #20, #21, #22, #25, #26, #29, #30, #33, #35, #37, #43, #44, #46, #48, #49, #51, #53, #54, #55, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #68, #69, #70, #71, #73, #74, #75, #76, #77, #78, #79, #80, #83, #84, #85, #87, and #88) of 86 residents who were on a regular diet and 15 of the residents who were on a no concentrated sweets diet (NCS). The facility census was 88.

Inspectors wroteBased on observations, medical record review, and resident and staff interview the facility failed to ensure residents were provided with personal clothing and clothing was appropriately fitting. This affected one (#2) of six residents reviewed for clothing and personal affects in a facility census of 88.

Inspectors wroteBased on medical record review and physician and staff interview, the facility failed to notify the physician regarding blood glucose monitoring following admission to the facility. This affected one (#1) of six residents reviewed for notification of physician in a facility census of 88.

Inspectors wroteBased on observation, medical record review, staff interview, review of facility staffing schedules, and facility wound treatment policy, the facility failed to ensure wound treatments were provided as ordered by the physician. This affected one (#3) of six residents reviewed for the application of wound treatments in a facility census of 88.

Inspectors wroteBased on observation, medical record review, staff interview, review of facility staffing schedules, and facility wound treatment policy, the facility failed to ensure pressure ulcer wound treatments were provided as ordered by the physician. This affected one (#3) of six residents reviewed for the application of wound treatments in a facility census of 88.

Inspectors wroteBased on observations, medical record review, resident and staff interview, and review of facility incontinence policy, the facility failed to provide residents with timely incontinence care and application of related and appropriate incontinence products. This affected one (#2) of three residents reviewed for incontinence care in a facility census of 88.

Inspectors wroteBased on observation, medical record review, physician and staff interview, and review of policy, the facility failed to ensure medications were administered as ordered by the physician. This affected two (#1 and #4) of four residents reviewed for medication administration. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were administered according to the physician orders to the residents without any significant medication errors. This affected one (#4) of four residents reviewed for medication administration. The facility census was 88.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure residents were provided with a bed of appropriate size and comfortable, intact mattress. This affected one (#1) of six residents observed for the provision of furniture and room furnishings. The facility census was 88.

Inspectors wroteBased on observation, interviews with facility staff and the nurse practitioner, review of open and closed medical records, review of skin assessments, review of wound assessment reports, review of physician orders, review of treatment administration records, and policy review, the facility failed to ensure a resident's skin impairment was timely identified and treatment provided. [...]

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to maintain an odor free and clean environment in the secured behavior unit. This had the potential to affect all 26 residents on the secured behavior unit (#19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44). Additionally, the facility failed to maintain a clean, sanitary environment. This affected one resident (#19) resident in the secured behavior unit. The facility census was 87.

Inspectors wroteBased on observations, medical record review, staff interviews, review of the facility's perineal care protocol and urinary incontinence clinical protocol, the facility failed to ensure timely incontinence care was provided and included the appropriate technique while providing care to a resident who was incontinent. This affected one (Resident #12) of three residents reviewed for incontinence care in a facility census of 87.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to administer medications as ordered and within scheduled time frames resulting in a medication error rate greater than five (5) percent (%). A total of three (3) medication errors were observed out of 25 opportunities for a medication error rate of 12%. This affected one (#12) of 10 residents observed during medication administration. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered and within prescribed time frames resulting in a significant medication error. This affected one (#12) of 10 residents observed during medication administration. The facility census was 88.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with timely incontinence care. This affected one (Resident #3) of three residents sampled for incontinence care. The facility census was 93.

Inspectors wroteBased on medical record review, observation, staff interview, review of the facility policy, and review of the manufacturer instructions, the facility failed to ensure blood sugar monitoring and associated insulin administration were implemented in accordance with physician orders. This affected one (Resident #4) of eight residents reviewed for medication administration. The facility census was 93.

Inspectors wroteBased on observation, medical record review, staff interview, review of the emergency cart checklist and review of facility policy, the facility failed to ensure necessary supplies and life sustaining equipment was available for staff to immediately respond to a medical emergency. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes when Resident #93, who had a tracheostomy, did not have suction catheters available at her bedside or on the emergency cart. The lack of equipment at bedside and on the emergency cart delayed the clearing of secretions to maintain a patent airway when Resident #93 experienced shortness of breath, loss of consciousness, loss of respirations, and loss of pulse. This affected one (#93) of four residents reviewed for tracheostomy care. [...]

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to administer medications within physician ordered parameters. This affected one (#6) of four residents reviewed for medication administration. The facility census was 92.

Inspectors wroteBased on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed to ensure assessments, care, and services were provided for a resident with a dialysis access port. This resulted in actual harm when Resident #100 was assessed with an elevated temperature and a decline in mental status. Resident #100 was transported to the hospital and required hospitalization and intervention to treat sepsis and dialysis line infection. This affected one (#100) of three residents reviewed for dialysis. The census was 68.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to administer medications as ordered by the physician. In total, two medication errors were observed out of 31 opportunities for a medication error rate of 6.45 percent (%). This affected one (#1) of four residents observed for medication administration. The facility census was 95.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store foods and maintain the kitchen in a safe and sanitary manner. This affected all 75 residents residing in the facility. The facility census was 75.

Inspectors wroteBased on observation, personnel file review, staff interview, policy review, and review of the tuberculosis control plan, the facility failed to complete two step tuberculosis testing on staff upon hire and failed to ensure the first step testing results were negative prior to direct resident contact and failed to ensure annual tuberculosis screening for all employees. This has the potential to affect all residents. Additionally, the facility failed to ensure body excretions were cleaned up timely. This affected one resident (#16) out of 23 residents who resided on the secured unit. In addition, the facility failed to ensure clean linens were transported in a sanitary manner. This affected nine residents (#02, #03, #04, #07, #16, #41, #54, #59 and #67) out of 23 residents residing on the secured behavior unit. The facility census was 75.

Inspectors wroteBased on observation, resident and staff interview and policy review, the facility failed to ensure a clean, sanitary and homelike environment. This affected 23 residents (#02, #03, #04, #07, #09, #11, #13, #16, #22, #26, #31, #32, #37, #40, #41, #42, #48, #53, #54, #59, #64, #67 and #69) residing on the secured behavior unit, 15 residents (#01, #10, #24, #27, #30, #35, #38, #39, #46, #52, #55, #66, #70, #77, and #81) residing on the secured memory care unit, and residents (#14 and #19) out of 75 residents who reside in the facility. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, pharmacy interview and policy review, the facility failed to ensure administration of pneumococcal vaccines. In addition, the facility failed to thoroughly document the administration of influenza vaccinations per facility policy. This affected four residents (#04, #13, #15 and #31) out of five residents reviewed for vaccination status. The facility census was 75.

Inspectors wroteBased on observation, staff interview, resident representative interview, and medical record review, the facility failed to maintain resident dignity by not trimming facial hair on a female resident. This affected one resident (#52) out of one resident reviewed for dignity. The facility census was 75.

Inspectors wroteBased on medical record review, staff and durable power of attorney interview, and policy review, the facility failed to ensure resident care conference were held with resident representatives as required. This affected one resident (#27) out of one resident reviewed for care planning. The facility census was 75.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure residents that required assistance with bathing were provided adequate care and services. This affected one resident (#19) out of three residents reviewed for activities of daily living. The facility identified 14 residents who required staff assistance with bathing. The facility census was 75.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to follow up on recommendations for wound care. This affected one resident (#16) out of two residents reviewed for non-pressure related skin conditions. The facility identified seven residents with non-pressure related skin conditions. The facility census was 75.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure pressure ulcer treatment was implemented. This affected two residents (#19 and #33) out of two residents reviewed for pressure ulcers. The facility census was 75.

Inspectors wroteBased on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place as ordered or care planned. This affected two residents (#16 and #46) out of three residents reviewed for falls. The facility identified 18 residents assessed at high risk for falls. In addition, the facility failed to ensure medications were secured. This affected one (#31) of one residents reviewed for self-administration of medications on the secured behavior unit. The facility identified 23 residents on the secured behavior unit who were assessed to be unsafe with self-administration of medications. The census was 75.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to ensure physician orders were in place for catheter care. This affected one resident (#16) out of one residents reviewed for catheter care. The facility identified two residents with indwelling catheters. The facility census was 75.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure physician orders were in place for colostomy care. This affected one resident (#16) out of one residents reviewed for colostomy care. The facility identified five residents with colostomies. The facility census was 75.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility assessment, the facility failed to ensure enough staff were available to provide activities of daily living care for dependent residents. This affected one resident (#19) out of three residents reviewed for activities of daily living. The facility census was 75.

Inspectors wroteBased on observation, staff interview, medical record review, review of drug manufacturer's instructions, and policy review, the facility failed to ensure insulin medication was administered as ordered and without significant error. This affected one resident (#08) out of five residents observed during medication administration. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents had laboratory values obtained as ordered. This affected one resident (#27) out of five residents reviewed for unnecessary medication. The facility census was 75.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure meals were served to all residents. This affected one resident (#33) out of three residents reviewed for food. The facility census was 75.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure accurate and complete medical records. This affected two residents (#16 and #33) out of two resident records reviewed for complete and accurate medical records. The facility census was 75.

Inspectors wroteBased on personnel file review and staff interview, the facility failed to ensure annual performance evaluations were completed as required for State Tested Nursing Assistant (STNA) staff. This affected three out of seven STNA personnel files reviewed. This had the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect 83 residents who received food from the kitchen. The facility identified one Resident (#5) received no food by mouth and no food from the kitchen. The facility census was 84.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure a resident's call light was in reach, failed to ensure the water from a resident's bathroom sink was able to be utilized and failed to provide furnishings to meet the residents' needs and preferences. This affected five (#72, #75, #134, #135 and #182) of nine residents reviewed with environmental concerns. The facility census was 84.

Inspectors wroteBased on interview and observation, the facility failed to provide a comfortable and homelike environment. This affected six resident rooms (Resident #21, #23, #27, #49, #50 and #52) reviewed for environmental concerns. The facility census was 84.

Inspectors wroteBased on medical record review, observation, resident and staff interview, self-reported incident review and facility policy review, the facility failed to implement their abuse policy by not reporting to the State Survey Agency and completing thorough investigations regarding four allegations of physical abuse. This affected two residents (#24 and #79) and had the potential to affect 21 residents residing on the locked unit of Serenity Cove. The facility census was 84.

Inspectors wrote2. Review of Resident #79's medical record revealed an admission date of 04/09/19. Diagnoses included dementia with behavioral disturbances, type II diabetes, hypertension, chronic obstructive pulmonary disease, heart disease, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed Resident #79 was rarely or never understood. The resident had short and long term memory problems. Resident #79 was aware of the location of his room, staff names and faces as well as he was in a nursing home. Resident #79 was not able to recall the season. Resident #79 had disorganized thinking and displayed inattention during the review period. Resident #70 required extensive assistance with bed mobility, and dressing. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interview, self-reported incident review and facility policy review, the facility failed to thoroughly investigate four allegations of resident-to-resident abuse. This affected two residents (#24 and #79) and had the potential to affect 21 residents residing on the locked unit of Serenity Cove. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility's policy, the facility failed to review and revise the plan of care for Resident #24. This affected one (Resident #24) of 24 residents reviewed for care planning. The facility census was 84.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide scheduled showers to a resident (#73) who required assistance with bathing. The facility further failed to to provide assistance to a resident (#10) who was dependent on staff for eating. This affected two residents (#73 and #10 of three reviewed for Activities of Daily Living (ADLs). The facility census was 84.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility's policy, the facility failed to provide activities to meet the interests and psychosocial needs of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 84.

Inspectors wroteBased on medical record review, observation, resident and staff interview and facility policy review, the facility failed to provide the care and services necessary for wound care for Residents #1 and #134. This affected two (#1 and #134) of two residents reviewed for non-pressure wounds. The facility census was 84.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policies, the facility failed to ensure one Resident's (#8) smoking materials were kept secured. The facility also failed to ensure fall interventions were in place for one Resident (#10). This affected two residents of six reviewed for accidents and supervision. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to administer medication as ordered. This affected one Resident (#65) of five reviewed for medications. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to address pharmacy recommendations for one Resident (#38). The facility further failed to provide a rationale for the use of an antianxiety medication beyond 14 days for one Resident (#76). This affected two Residents (#38 and #76) of five reviewed for unnecessary medications. The facility census was 84.