Parkside Manor

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain resident dignity, when staff entered resident rooms without knocking and/or failed to identify themselves prior to entering the room affecting two sampled residents (Resident #53 and #12), failed to answer a call light in a timely manner which resulted in one of three sampled residents (Resident #12) being incontinent and discussed the bowel habits of one resident (Resident #43) while they provided care for another resident (Resident #12). The facility census was 79.1. Review of the facility's Resident Rights policy, undated, showed each resident shall be treated with consideration, respectfully, and a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a comfortable and homelike environment. The facility census was 79.1. Review of the facility's policy titled, Environmental, undated, showed floors and tabletops will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Observation on 06/15/26 at 10:20 A.M. and 1:32 P.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. Observation on 06/16/26 at 7:45 A.M. and 4:00 P.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. Observation on 06/17/26 at 8:52 A.M., showed the hallway outside the conference room with a strong foul odor. The carpet had an irregularly shaped dark stain. 3. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for three (Resident #1, #9 and #58) of five sampled residents. The facility census was 79.1. Review of the facility's policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. The care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide transportation to outside activities for one resident (Resident #51) out of one sampled resident whose wheelchair would not fit in transport van. The facility census was 79.1. Review of the facility policy titled Residents Rights, undated, showed each resident shall be permitted to participate, as well as not participate, in activities of social, religious or community groups at his/her discretion, both within the facility, as well as outside the facility, unless contraindicated for reasons documented by the physician in the resident's medical record. 2. [...]

Inspectors wroteBased on record review and interview, facility staff failed to have systems in place to prevent misappropriation for one resident (Resident #15) of three sampled residents', when the resident's $360.00 cash was not located in the facility safe. The facility census was 79 residents.1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/17, showed each resident of the facility would be free from misappropriation of property.2. Review of the facility's policy titled, Protection of Residents Funds, undated, showed the facility shall furnish the Resident with a written receipt for all expenditures and deposits regarding any of the Resident's funds deposited with the Facility. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of misappropriation of $360 for one resident (Residents #15) of 39 sampled residents to the State Agency. The facility census was 79.1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/17, showed the nursing home administrator or designee will report to the State Agency per state and federal requirements. The facility shall report misappropriation to the State Agency no later than 24 hours after the allegation is made. The facility will comply with the seven-step approach to abuse and neglect, which include: Reporting and Response; Screening; Training; Prevention; Identification; Investigation and Protection. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%) out of 30 opportunities observed, five errors occurred, resulting in a 16.67% error rate, which affected four residents (Resident #32, # 34, #43, and #71) of seven sampled residents. The facility census was 79. 1. Review of the facility's policy titled Medication Errors and Drug Reactions, undated, showed staff are directed to report all medication errors immediately to the physician, Director of Nursing (DON) and administrator. The policy did not contain a medication error definition. Review of the facility's policy titled Medication Administration Guidelines, undated, showed it is important that the residents receive their medication on a timely basis. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Housekeeper B witnessed Certified Nurse Aide (CNA) A hug and kiss the resident on the mouth. The facility census was 76. The administrator was notified on 03/31/26 of Past Non-Compliance which occurred on 03/30/26. On 03/30/26, the administrator suspended CNA A, investigated the allegation, notified the required parties and agencies, in-serviced staff on the facility's abuse and neglect policy, and terminated CNA A on 03/31/26. 1. Review of the facility's Abuse and Neglect Policy, dated 11/2017, showed the purpose is to ensure each resident will be free from abuse. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate hand hygiene infection control practices during perineal care for one residents (Resident's #1) out of two sampled residents; staff failed to follow Enhanced Barrier Precautions (EBP), (the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms), for two residents (Resident #1 and #2) out of two sampled residents; and staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen in a manner to prevent the spread of bacteria for three residents (Resident #1, #3 and #4) out of three sampled residents. The facility census was 80.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment for residents, staff, and visitors. Staff failed to ensure carpet in shared hallways maintained a pleasant odor, and air vents remained free from excessive build-up of a black unknown substance. The facility's census was 71.1. Review of the facility's Housekeeping Department-Seven Step Cleaning Procedure policy, undated, showed the resident room cleaning procedure should be used for all resident rooms to maintain cleanliness and to promote infection control. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to notify one resident's (Resident #1) physician when the resident said he/she did not want to live anymore. The facility census was 77. 1. Review of the facility's Suicide Threats policy, undated, showed: -Resident suicide threats shall be taken seriously and addressed appropriately; -Staff shall report any resident threats immediately to the charge nurse; -The charge nurse shall immediately assess the situation and shall notify the director of nursing of such threats; -After assessing the resident in more detail, the charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician; -Staff shall document details of the situation objectively in the resident's medical record. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required time frame for one (Resident #1) of one sampled resident. The facility's census was 77. 1. Review of the RAI manual version 3.0 RAI Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary showed an admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission. 2. Review of Resident #1's Entry Tracking Record MDS, showed the resident admitted to the facility on [DATE]. Review of the resident's electronic health record did not contain a completed MDS or submitted admission assessment within the required time frame. Review showed the admission assessment included a due date of 04/02/25. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered baseline care plan to meet the resident's medical, nursing, mental and psychosocial needs for one resident (Resident #1). The facility's census was 77. 1. Review a baseline care plan showed staff are directed to complete the baseline care plan within 48 hours of admission. After completion, print and file following community protocols 2. Review of Resident #1's medical record showed staff documented the resident was admitted to the facility on [DATE]. Review showed the record did not contain a baseline care plan. During an interview on 04/05/25 at 7:42 P.M., the Assistant Director of Nursing (ADON) said he/she loaded the baseline care plan template into the Electronic Health Record when the resident was admitted . [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to take appropriate action when one resident (Resident #1) threatened suicide. The facility census was 77. 1. Review of the facility's Suicide Threats policy, undated, showed: -Resident suicide threats shall be taken seriously and addressed appropriately; -Staff shall report any resident threats immediately to the charge nurse; -The charge nurse shall immediately assess the situation and shall notify the director of nursing of such threats; -A staff member shall remain with the resident until the charge nurse arrives to evaluate the resident; -After assessing the resident in more detail, the charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician; [...]

Inspectors wrotePlease see Event ID 8CNK12 exit date 02/13/2025 Based on observation, interview and record review, facility staff failed to notify one resident's (Resident #24) representative when the resident's toilet came unsecured from the floor and tipped and required a room change. Facility staff failed to notify two resident's (Resident #24 and #32) physician in a timely manner when the resident had a skin injury. The facility census was 73.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of care, when staff failed to follow physician's orders regarding water flushes during medication administration for one resident (Resident #12) with a Percutaneous endoscopic gastrostomy (PEG) tube and one resident (Resident #38) with a Gastrostomy Tube (G-Tube), (tube inserted through the stomach used for administration of food, fluids, and medications). The facility census was 66. 1. Review of the facility's policy for Medication, Administration by Naso-Gastric or Gastrostomy Tube, undated, showed staff are directed as follows: -Wash hands; -Verify the recipient with physician orders and medication administration record; -Check residual, if less then 100 milliliters (ml) return to stomach and flush with amount of water as ordered; -Give medication only by gravity; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide adequate nursing staff on night shift, in accordance with their Facility Assessment based on the care needs of the residents. The facility's census was 66. 1. Review of the facility's Facility Assessment, dated 07/02/24, showed facility staff documented for an average daily census of 65-70 residents, the staffing requirements needed on the night shift to meet the care needs of their residents are as follows: -Two Licensed Nurses (one on each nurses' station); -Five to eight Certified Nursing Assistants (CNAs). 2. Review of the facility's Nursing Staff schedule, dated 12/12/24 through 12/17/24 showed: -12/12/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; -12/13/24: One-Licensed Nurse and Four-CNAs scheduled to work the shift; -12/14/24: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 66. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated October 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Tuesday 10/01/24; -Saturday 10/05/24; -Sunday 10/06/24; -Thursday 10/10/24; -Friday 10/11/24; -Saturday 10/12/24; -Sunday 10/13/24; -Monday 10/14/24; -Tuesday 10/15/24; -Friday 10/18/24; -Saturday 10/19/24; -Sunday 10/20/24; -Tuesday 10/22/24; -Thursday 10/24/24; -Friday 10/25/24; -Saturday 10/26/24; -Sunday 10/27/24; -Tuesday 10/29/24; -Wednesday 10/30/24. 3. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three Nurse Aide's ((NA) NA A, NA C, and NA E) of five sampled staff completed the nurse aide training program within four months of his/her employment in the facility. The census was 66. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of the facility's employee file, undated, showed NA A's hire date as 12/07/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of the facility's employee file, undated, showed NA C's hire date as 07/25/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 12/18/24 at 4:45 A.M., NA C said he/she was told he/she needed to be certified within 90 days of hire. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not alert staff and visitors of one resident (Resident #8) out of four sampled residents who required EBP, when staff failed to place an EBP sign by the resident's room. Facility staff failed to place appropriate personal protective equipment (PPE) in close proximity for three (Resident #8, #12, and #38) of four sampled residents. Facility staff failed to use appropriate PPE for four (Resident #8, #12, #18, and #38) of four sampled residents who required EBP. The facility's census was 66. 1. Review of the Facility's Enhanced Barrier Precautions to Infection Control Guidance, dated 3/2024, showed: -Who required EBP; -Residents known to be infected or colonized with multidrug resistant organism (MDRO); [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 66. 1. Review of the facility's policies showed the facility did not provide a policy for Antibiotic Stewardship. 2. Review of the facility's antibiotic stewardship program showed facility staff did not track antibiotic trends. During an interview on 12/19/24 at 2:34 P.M., Infection Preventionist said he/she is responsible for the antibiotic stewardship program within the facility. He/She said he/she documents antibiotic usage for each resident in the facilities electronic medical record, but does not have a system in place currently to trend and monitor the usage. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to notify one resident's (Resident #24) representative and physician as per policy when the resident's toilet came unsecured from the floor and tipped and required a room change. Facility staff failed to notify one resident's (Resident #32) physician in a timely manner when the resident had a skin injury. The facility census was 73. 1. Review of the facility's Event Investigation policy, undated, showed: -The purpose was to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed and to identify any injuries after a resident sustains an event. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of daily activities designed to meet the resident's interests for four residents (Residents #1, #55, #67 and #270) out of five sampled residents who reside on the Memory Care Unit (MCU). The facility's census was 66. 1. Review of the facility's policies, showed the facility did not provide a policy for activities. 2. Review of the facility's activity calendar in MCU, dated November 2024, showed: -Saturday, 11/02/24: Did not contain documentation of an activity; -Sunday, 11/03/24: Activity cart available; -Saturday, 11/09/24: Activity cart available; -Sunday, 11/10/24: Activity cart available; -Saturday, 11/16/24: Activity cart available; -Sunday, 11/17/24: Activity cart available; -Saturday, 11/23/24: Activity cart available; -Sunday, 11/24/24: Activity cart available; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to have a system in place for ongoing communication with the dialysis clinic for one resident (Resident #20) of one resident who received dialysis. The facility census was 66. 1. Review of the facility's Dialysis, Care of a Resident Receiving policy, undated, showed communication between the facility and Dialysis Unit as follows: -The Dialysis Communication Record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after, any dialysis, any labs completed, medication given, follow up information and any new physician orders; [...]

Inspectors wroteBased on interview and record review, facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and local hospice provider for two residents (Resident #2 and #44) out of three sampled residents who received hospice services. The facility census was 66. 1. Review of the Facility's Nursing Facility Hospice Services Agreement, dated 1/2016, showed: -The Hospice and Facility representatives shall document and keep written records for all such communications and shall document that the services provided by the parties hereunder have been furnished in accordance with the terms of this agreement; -The medical records shall consist of at least progress notes and clinical notes describing all inpatient services and events. [...]

Inspectors wroteClass II Based on observation, interview, and record review, facility staff failed to provide a barrier for the glucometer (a device for monitoring blood sugars) supplies and failed to appropriately sanitize a multiple use glucometer between use for four residents (Resident #1, #2, #3, and #4) out of four sampled residents. The facility census was 67. 1. Review of the facility's policy titled, Blood Glucometer Disinfecting, dated 03/2015, showed the purpose is to prevent the spread of infection. Staff direction to: -Approved wipes with ten percent bleach or comparable product; -Provide a clean field in which to place the glucose meter (a paper towel works well for this); -Clean the blood glucose meter prior to using with approved wipes with ten percent bleach or comparable product, place on clean field and let air dry according to manufacturer's directions. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards when staff failed to document they administered medication and failed to document the reason the medication not administered for two residents (Resident #1 and #2) out of three sampled residents. The facility census was 68. 1. Review of the facility's medication administration guidelines, dated 03/2015, showed it is the purpose of the facility residents receive their medications on a timely basis and in accordance with established policies. Review showed the person administering the medication must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when staff failed to remove his/her arm from under him/her and the resident sustained an injury to his/her arm. The facility census was 72. 1. Review of the Electric Portable Patient Lift owner's operator and maintenance manual, undated, showed the guide recommends operators of the mechanical lift use two staff to perform the transfer. The use of one assistant is based on the evaluation of the health of the resident by the health care professional for each individual case. Review of the facility's Hydraulic Lift policy, undated, showed the policy is to enable one individual to lift and move a resident safely. [...]

Inspectors wroteBased on observation, interview, and record review Facility staff failed to maintain the pantry ceiling by not keeping the attic access and vent closed which has the potential to allow dirt and debris to come into contact with food items. Facility staff failed to provide a thermometer in the refrigerator on the secured unit to ensure temperatures did not enter the danger zone, failed to protect, label, and date stored food to prevent cross contamination and outdated use. Staff failed to maintain refrigerators and freezers in a clean sanitary manner to prevent the potential for cross-contamination. These failures had the potential to affect all residents. The facility census was 74. 1. The facility did not provide a policy for cleaning refrigerators and freezers, pantry wall and ceiling upkeep, or thermometers in cooling units. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff failed to sit down while feeding two residents (Resident #16, and #39), and when staff failed to close the door when providing care to one resident (Resident #59). The facility census was 74. 1. Review of the facility's policy titled, Patient [NAME] of Rights as provided by the Long Term Care (LTC) Ombudsman Program, not dated, showed that residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality, including privacy in treatment and care of personal needs. 2. Review of Resident #16's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/11/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from one staff member for eating. [...]

Inspectors wroteBased on observation and interview, facility staff failed to ensure resident's personal information was protected when they left the Medication Administration Records (MARs) open and unattended in public hallways and dining areas. The facility census was 74. 1. Review of the facility's Resident Rights Policy, undated, showed each resident will be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. Observation on 8/21/23 at 7:45 A.M., showed a medication cart unattended with a resident's information displayed on a computer screen in the dining room. Several residents sat in the dining room. Staff arrived with other residents and passed by the cart with the information displayed. Observation on 8/22/23 at 7:26 A.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three residents (Resident #23, #24 and #43) were appropriately screened for a mental disorder (MD) or intellectual disability (ID) after admission, when they failed to complete or obtain a Pre-admission Screening and Resident Review (PASRR). The facility census was 74. Level I PASRR is an initial screening completed prior to admission to the nursing facility. The purpose of the Level I pre-admission screening is to identity individuals who have or may have MD/ID or a related condition, who would then require a PASRR Level II evaluation and determination prior to admission to the facility. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to include in the plans cognitive state for one resident (Resident #11), code state for two residents (Resident #16 and #59), falls for one resident (Resident #55), pain for one resident (Resident #43), and Activities of Daily (ADL) for one resident (Resident #59). The facility census was 74. 1. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the staff were directed to do the following: -A comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for one resident (Resident #11) for nutrition, one resident (Resident #16) with risk for pressure ulcers, three residents (Resident #11, #59 and #64) who fell, and two residents (Resident #11 and #16) who had Activity of Daily Living (ADL) needs. The facility census was 74. 1. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the staff were directed to do the following: -A comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Date Set (MDS); -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; [...]

Inspectors wroteBased on interview and record review the facility staff failed to meet professional standards of practice when facility staff failed to complete post-dialysis assessments on one resident (Resident #24), failed to clarify a lorazepam (anti anxiety medication) order for one resident (Resident #64), failed to apply ace wraps as ordered for one resident (Resident #34), failed to complete weekly skin assessments, monthly weights, complete blood work and apply a sling as ordered for one resident (Resident #16), failed to obtain monthly weights as ordered and follow dietary orders for one resident (Resident #39), failed to obtain monthly weights for one resident (Resident #46), failed to complete blood work as ordered and complete neurological assessments for one resident (Resident #55), failed to complete neurological assessments after a fall for two residents (Resident #11 and #59), and [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist six dependent residents (Resident #11, #16, #34, #39, #43, and #61) with Activities of Daily Living (ADLs) (everyday tasks such as personal hygiene, eating and dressing with clean clothes). The facility census was 74. 1. Review of the facility's Daily Care Needs policy, dated March 2015, showed: -Before beginning care, check the bathing schedule and resident's care plan. Make note of special problems or special care needed by each resident. Resident care plans are individualized and give specific instructions on care; -Offer assistance or assist resident in brushing teeth; -After meals wash hands and face of residents and remove any food particles from residents' clothing; -Before the shift ends, check all residents to be sure they are clean, dry and comfortable. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for six residents (Resident #11, #16, #25, #39, #43 and Resident #58) and thirteen of thirteen residents who reside on the secured unit. The facility census was 74. 1. Review of the facility policy titled Resident Activities, dated March 2012, showed staff were directed to do the following: -Activities service will plan, organize, and carry out a program of activities to meet individual resident needs; -A calendar of events will be posted on the activity bulletin board to inform residents, visitors, and staff of scheduled activities; -An activity program is planned for each resident as a part of their total resident care by the Activity Director (AD); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure three residents they assessed as unsafe while smoking (Resident #21, #25, and #55 ) were supervised while they smoked, failed to properly store razors and hazardous chemicals, failed to maintain medication safety when staff left medication carts unlocked and unattended, left medication in resident rooms, and left medication on top of the medication carts, failed to properly propel three residents (Resident #46, #55 and #59) in wheelchairs and failed to properly perform mechanical lifts for two residents (Resident #6 and #21). The facility census was 74. 1. Review of the facility's Smoking-Resident Policy, dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure a medication error rate of less than 5%. Out of 43 opportunities observed, six errors occurred, resulting in a 13.95% error rate, which affected four residents (Resident #18, #31, #45, and #326) of seven sampled residents. The facility census was 74. 1. Review of the facility's Medication Errors and Drug Reactions policy, dated March 2015 showed staff are directed to report all medication errors immediately to the attending physician, Director of Nursing (DON) and Administrator. Further review of the policy showed it did not indicate the definition of a medication error. 2. Review of Resident #18's physician order sheet (POS), showed an order, dated 9/30/22, to administer Levothyroxine (a thyroid hormone) 25 microgram (mcg) between 6:00 A.M. and 7:00 A.M. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store and label medications in safe and effective manner in one of the two medication storage rooms, and four of the seven medication storage carts. The facility census was 74. 1. Review of the facility's policy titled Medications, Storage of, dated March 2015, showed staff are directed to do the following: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts; -All mobile medications carts must be under visual control of the staff at all times when not stored safely and securely; -Biologicals or medications requiring refrigeration must be kept in a separate, securely fasted refrigerator, at or near the nurse's station with in a locked medication room (Note: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during catheter care (a tube that enters the bladder) for one resident (Resident #66), during wound care for one resident (Resident #25), and during medication administration for one resident (Resident #45) with a gastrostomy tube (a tube that enters the stomach). [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow policies and procedures for resident immunizations against pneumococcal disease (an infection caused by the bacteria called Streptococcus pneumoniae, or pneumococcus) in accordance with national standards of practice and failed to assess and vaccinate eight sampled residents (Resident #11, #16, #21, #24, #25, #34, #43, and #55). The facility census was 74. 1. Review of the facility's Immunization policy, undated, showed: Pneumococcal Vaccination in Persons age [AGE] and older years, unless contraindicated will be administered according to the following guidelines when determining vaccination status: A. [...]

Inspectors wroteBased on observation and interview, facility staff failed to maintain a clean, comfortable and homelike environment by failing to ensure resident areas were maintained and free of odors. In addition, residents were served meals with Styrofoam and plastic dinnerware. The facility census was 74. 1. Review of the facility's policies showed the facility did not provide a Housekeeping Policy, a Homelike Environment Policy, or a Facility Maintenance Policy. 2. Observation on 08/20/23 at 11:00 A.M., showed the building had an odor of urine. Observation on 08/21/23 at 8:00 A.M., showed the building had an odor of urine. Observation on 06/22/23 at 8:00 A.M., showed the building had an odor of urine. Observation on 08/23/23 at 7:30 A.M., showed the building had an odor of urine. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide the resident council with written actions, responses and rationales to their concerns. The facility census was 74. 1. Review of the facility's protocol titled, Grievance Protocol, undated, showed no direction for staff in regard providing a written response to the resident councils concerns. During an interview on 08/21/23 at 2:16 P.M., the members of the resident council said facility staff do not provide a written response to grievances. Further the council members said they rarely hear any response to concerns they share. During an interview on 08/23/23 at 2:16 P.M., the resident council president said he/she knows how to file a grievance. The Activity Director (AD) records notes at every monthly meeting and then the council talks about the improvements at the next meeting. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post Resident Rights in an area accessible to all residents and visitors. The facility census was 74. 1. Review of the facility's policies showed the facility did not provide a policy for the required postings. Observations from 8/20/23 at 11:00 A.M. through 8/23/23 at 10:00 A.M., showed the facility did not post resident rights in a form and manner accessible to all residents and visitors including on the secured unit. During an interview on 8/23/23 at 8:53 A.M., Certified Nurse Aide (CNA) said he/she did not know where the resident rights were posted but thinks they should be. During an interview on 8/23/23 at 10:08 A.M., Registered Nurse (RN) said the resident rights are posted by the double doors near the service entrance and front doors. He/She was not aware the resident rights were not posted. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Residents #21, #24, #50, and #64) out of five sampled residents. The facility census was 74. 1. Review of the facility's policy titled, Bed Hold, undated, showed staff are directed to provide a copy of the policy at the time of transfer to the hospital or leave. Review of the facility's admission Packet showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave and at the time of non-covered therapeutic leave. 2. Review of Resident #21's medical record showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. Facility staff failed to appropriately sanitize mechanically washed dishes to prevent cross-contamination. Facility staff also failed to allow dishes to air dry prior to stacking in storage. The facility census was 64. 1. Review of the facility's Receiving and Storage of Food policy, dated April 2006, showed: -The dietary manager is responsible for receiving and storing food and nonfood items; -All perishable items are stored in either refrigerators or freezers; -Keep all foods in clean, undamaged wrappers or packages; -Reseal open boxes effectively. Review showed the policy did not contain instruction to staff related to the labeling and dating of opened food items. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a clean, comfortable and homelike environment by failing to ensure resident areas were maintained, free of odor and pests, and resident linens were clean. Additionally, staff failed to allow residents to use their personal belongings as decorations in their rooms. The facility census was 64. 1. The facility did not provide a Housekeeping Policy, Pest Control Policy, or Facility Maintenance Policy. 2. Review of Resident #1's Significant Change Minimum Data set (MDS), a federally mandated assessment tool, dated 4/27/22, showed staff assessed the resident as Cognitively intact. Observation on 7/25/22 at 10:41 A.M., showed the resident's room had an area of chipped paint on the bathroom door. Observation on 7/26/22 at 2:43 P.M., showed the resident's room had an area of chipped paint on the bathroom door. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete required Nurse Aide (NA) Registry (a list of individuals with a previous incident involving abuse, neglect, or misappropriation of property) checks on for five out of ten sampled employees, prior to their starte date. The facility census was 64. 1. Review of the facility's New Hire Paperwork Checklist, undated, showed during pre-orientation, Certification/License Registry Check (Certified Nurse Aide (CNA), Nurse Verification, and other certifications if applicable, are checked. Review of the facility's Abuse Policy, undated, showed: -It is the policy of this facility to screen employees and volunteers prior to working with residents; -The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, for two residents (Resident #4 and Resident #60), and failed to accurately code one resident's (Resident #34's) MDS in regard to tracheotomy (a surgically created hole in the windpipe that provides an alternative airway for breathing) use while at the facility. Additionally, staff failed to accurately code the use of anticoagulants for one resident (Resident #48). The facility census was 64. 1. Review of the Centers for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) manual, dated [DATE], shows: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents' medical and nursing needs for three residents (Resident #33, #48, and #57) and failed to update care plans for two residents (Resident #31 and #52) who required supervision while smoking. The facility census was 64. 1. Review of the facility's care plan policy, dated March 2015, showed the following: - The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs) (everyday tasks), for six residents (Resident #3, #24, #31, #34, #42 and #52). The facility census was 64. 1. Review of the facility's Daily Care Needs policy, dated March 2015, showed: -Before beginning care, check the bathing schedule and resident's care plan. Make note of special problems or special care needed by each resident. Resident care plans are individualized and give specific instructions on care; -Offer assistance or assist resident in brushing teeth; -After meals wash hands and face of residents and remove any food particles from residents' clothing; -Before the shift ends, check all residents to be sure they are clean, dry and comfortable. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for seven residents (Resident #6, #19, #43, #46, #56, #57, and #59) in the Aspen Unit, a locked dementia hall. The facility census was 64. 1. Review of the facility's Activity Calendar, dated July 2022 showed: -July 4, 10 A.M. Aspen Activity: -July 6, 10 A.M. Aspen Activity; -July 11, 10 A.M. Aspen Activity -July 18, 10 A.M. Aspen Activity; -July 20, 10 A.M. Aspen Activity; -July 21, 10 A.M. Aspen Activity; -July 25, 10 A.M. Aspen Activity; -July 27, 10 A.M. Aspen Activity; -July 28, 10 A.M. Aspen Activity. Further review of the Activity Calendar showed staff did not document a planned Aspen Activity for July 1, 2, 3, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 19, 22, 23, 24, 26, 29, 30 or 31. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure three residents (Resident #22, #31 & #52) were supervised while they smoked, after the residents had been determined to be unsafe while smoking. Additionally, staff failed to propel one resident (Resident #52) in manner to prevent accidents, and failed to implement an intervention after one resident (Resident #46) became entrapped between his/her bed and wall. The facility census was 64. 1. Review of the facility's Smoking Policy, undated, showed: -Any smoking-related privileges, restrictions, and concerns (example, need for close monitoring) shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues; -The facility may impose smoking restrictions on residents at any time, if it is determined that the resident cannot smoke safely; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received Level 5 Minced and Moist (MM5) and pureed diets. The facility census was 64. 1. Review of the facility's Menus policy, undated, showed: -Menus are planned for a five week cycle twice yearly; -The original set of menus should be kept in the Dietary Service Manager's office with copies made for the staff to use; -Standardized recipes are available in the dietary department for the foods on the menu. 2. Review of the facility menus, dated 07/25/22 (Week 1, Day 2), showed the menus directed staff to provide the residents on MM5 diets with a #16 (two ounce) scoop of pureed bread and a #8 (four ounce) scoop of pureed frosted chocolate cake. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to wear facemasks appropriately throughout the facility to prevent the spread of Coronavirus Disease 2019 (COVID-19). Additionally, staff failed to provide perineal care in a manner to prevent infection for one resident (Resident #34). The facility census was 64. 1. Review of the Centers for Disease Control (CDC)'s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated 2/2/22 showed: -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting; [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards of quality when staff failed to provide consistent documentation in regard to residents' Physician Orders for Life-Sustaining Treatment (designed to improve patient care by creating a medical order form that records residents' treatment wishes so staff know what treatments the resident wants in the event of a medical emergency) for three residents (Resident #12, #25, and #57). The facility census was 64. 1. Review of the facility's Advance Directive Policy, dated March, 2015, showed the staff are directed to: -Upon admission, the social services designee (SSD) will inquire of the resident, and/or his/her family members, about the existence of any written advance directives.; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all facility residents. The facility census was 64. 1. Review of facility records showed they did not have a policy in regard to qualifications for the Activity Director (AD) position. During an interview on 7/28/22 at 3:12 P.M., the AD said a Corporate nurse asked him/her if he/she would be interested in the AD position in September of 2021, and he/she started as the AD that month. He/She said he/she held the position in the past, under a different administrator at the facility, but he/she had never been offered a class or formal training regarding activities. He/She said he/she had no idea a class or certification was required. During an interview on 7/28/22 at 4:44 P.M., the Administrator said the AD was not certified. [...]