Parkview Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two sampled residents (Resident #5 and Resident #6) from physical abuse. On 3/14/26 at approximately 1:30 A.M. Resident #6 hit Resident #5 an unknown number of times. Resident #5 then threw his/her walker at Resident #6, which caused Resident #6 to fall to the ground. Resident #5 was transported to the hospital and treated for a chest bruise, abrasions, pain and Resident #6 had pain in his/her right hip out of 11 sampled residents. The facility census was 99 residents. On 3/23/26, the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 3/18/26. All staff received education prior to working their next shift. The deficiency was corrected on 3/18/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system operated as designed, failed to ensure call lights were within reach, and failed to ensure call lights were answered timely for six sampled residents (Resident #4, #10, #2, #8, #9, and #11) to maintain their activities of daily living (ADL) out of 11 sampled residents. The facility census was 99 residents. Review of the facility Call Lights; Accessibility and Timely Response Policy revised 1/1/26, showed:-It was the purpose of the policy to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer oxygen as ordered and to assess and monitor the oxygen saturation levels and respiratory status for one sampled resident (Resident #2) out of 11 sampled residents. The facility census was 99 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and behavioral health services per policy for three sampled residents (Residents #1, #2, and #3) who had a known history of substance abuse. The facility staff failed develop a plan of care related to behavioral health services for the use of illicit drug use needs based on the residents' Preadmission Screening and Resident Review (PASRR- DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source) and failed to assess and ensure the interventions for the resident were in place and implemented by facility staff after each behavior of illicit drug use. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the guardian in a timely manner when one resident (Resident #1) overdosed on fentanyl, received two doses of Narcan and was sent to the hospital on [DATE]. Six residents were selected for sample. The facility census was 101 residents. The Administrator was notified on 02/03/26 of the Past Non-Compliance which occurred on 02/01/26. The Director of Nursing (DON) educated floor staff on proper notification, location of emergency numbers, what information to leave on a voicemail, and to notify management when a guardian is contacted. The Social Services Director (SSD) was dedicated for follow up, auditing current contact information, and ongoing confirmation of emergency numbers at each care plan meeting and all admissions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure recommendations provided by the pest control technician were implemented and aggressive measures were taken to prevent or minimize the rodent infestation, potentially affecting any resident at the facility. Nine sampled resident rooms (Rooms 113, 123, 124, 129, 202, 204, 207, 214, and 230), occupied by 14 residents, out of 11 sampled resident rooms, had evidence of rodent activity. The facility census was 93 residents. Review of the facility Pest Control policy, revised May 2008, showed:-The facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents.-Garbage and trash aren't permitted to accumulate and are removed from the facility daily.-Maintenance Services shall assist, when appropriate and necessary, in providing pest control services. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to transcribe physician orders correctly for an opioid pain medication (controlled pain medication for moderate to severe pain) and failed to clarify the physician orders when the medication was not received by the pharmacy for one sampled resident (Resident #500) of out of 12 sampled residents. The facility census of 107 Residents. 1. Review of Resident #500's Face Sheet showed he/she admitted to the facility on [DATE] with a diagnosis of frost bite with necrosis (death of body tissue) to his/her left foot and non-pressure chronic wound (caused by prolonged pressure, arise from other factors like poor circulation, trauma, or infection) to his/her left foot. Review of the resident's hospital discharge instruction and summary dated 3/1/25 at 1:50 P.M. showed: -Had diagnosis to include frost bite to his/her left foot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of five sampled residents, was free from physical abuse. On [DATE], Resident #2 struck Resident #1 multiple times on the top of his/her head with a solid wood and metal cane, which resulted in Resident #1 sustaining a laceration to the left temple with four stitches, bruising to his/her left eye socket, defensive bruising on his/her left pinky, ring finger, and a laceration to his/her second knuckle to his/her right middle finger. Resident #1 was sent to the hospital for treatment and stated he/she was afraid of Resident #2. The facility census was 112 residents. The Administrator was notified on [DATE] at 9:31 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on documentation, interview and policy review, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ)excessively low weekend staff. This deficient practice had the potential to allow 112 residents not to receive the care and services required.

Inspectors wroteBased on document review, interview, and facility policy review, the facility failed to ensure eight hours per day of Registered Nurse (RN) coverage. Specifically, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ), the lack of RN coverage for three out of four quarters (first, second and fourth quarter of 2024). This deficient practice had the potential to allow 112 residents not to receive the care and services required.

Inspectors wroteBased on observation, interview, document review and record review, the facility failed to ensure a Certified Dietary Manager (CDM) or other qualified professional was employed by the facility to manage the dietary department when a Registered Dietitian was not employed full-time. Failure to meet this requirement placed all 112 residents receiving foods served by the facility at risk for dissatisfaction with meals, malnutrition and/or a food-borne illness.

Inspectors wroteBased on observation, interview, Food and Drug Administration (FDA) Food Code and policy review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. This had the potential to 112 of 112 residents who ate food from the kitchen and placed these residents at risk for a food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure refuse and garbage was disposed of properly when the lid to the dumpster was not kept closed. This had the potential to increase the risk of rodents and other pests which could affect all 112 residents who resided at the facility.

Inspectors wroteBased on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) plan was developed containing the process the facility will follow to guide the care and services provided to residents and measure improvement. This deficient practice had the potential to not capture the efforts made in measuring the care and services for 112 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the grievances voiced repeatedly by the resident council were addressed and resolution presented to the council regarding food palatability, staff to resident interactions, pest control, and call light response. These failures had the potential to create feelings of dissatisfaction and helplessness among the eight residents who participated in Resident Council (R96, R2, R48, R88, R87, R109, R106, and R17) out of a census of 112 residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from physical or verbal abuse by another resident for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and reporting of all alleged violations to the state survey agency (SSA) for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure allegations of resident-to-resident abuse were investigated for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents (Resident (R)65, R97, and R86) out of a total sample of 27 residents. The deficient practice increased the risk of staff administering narcotic medication that had already been administered to residents which increased the risk of adverse effects.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to properly label insulin pens with resident name and opened date and discard expired insulin pens, keep food, personal items and makeup separate from medications for two of six medication carts. The deficient practice could result in altered effectiveness of the medication, worsening of resident's symptoms

Inspectors wroteBased on observation, interview, document review and record review, the facility failed to assure food was palatable and served at appetizing temperatures for 10 of 10 residents (R2, R22, R101, R63, R70, R40, R31, R65, R97 and R94) reviewed for food concerns out of a sample of 27. Additionally, review of Review of Resident Council Meeting Minutes revealed complaints related to food palatability from five of five months of minutes reviewed. Failure to serve palatable and appetizing foods placed all residents residing in the facility at risk for weight loss.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to inform the 29 residents, R315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117, and/or their representatives who signed the binding arbitration agreement out of a census of 112 in writing they were not required to enter into a binding arbitration agreement as a condition of admission. This failure placed these 29 residents at risk of signing the agreement involuntarily.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to inform the 29 residents and/or their representatives (Resident (R)315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117) who signed the binding arbitration agreement out of a census of 112 in writing of the right to selection of neutral arbitrator agreed upon by both parties. This failure placed these 29 residents at risk of misunderstanding the process for selection of an arbitrator.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure five of five residents (Resident (R) 85, R70, R107, R34, and R95) residents reviewed for immunizations out of a total sample of 27 were assessed for eligibility, educated on the risks and benefits, and offered pneumococcal vaccination. This failure placed all eligible residents who wished to receive the vaccine at risk for contracting pneumonia unnecessarily.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain a safe and comfortable environment for six rooms (Resident (R) 70, R56, R94, and R65, room [ROOM NUMBER], and room [ROOM NUMBER]) of 32 rooms observed in Initial Pool.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement pest control measures to prevent mouse infestation in the facility, which affected four of 27 sampled residents (Resident (R) 76, R2, R22, and R73) and the common areas of the facility. This failure had the potential to cause an increase in rodent activity, creating a potential for spread of infection and dissatisfaction with living arrangements among the residents.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure residents were allowed to exercise their rights to make choices important to them, the right to privacy, and the rights to have care provided in manner that supported each resident's autonomy. The affected three residents (Resident (R) 31, R22 and R19) in the sample of 27 residents.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure residents were provided the correct form or provided the form that included the potential additional costs that the resident might have to pay if they chose to continue to receive services, Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, for Medicare Part A Services when they were no longer covered or coverage was ending for three of three residents reviewed (Resident (R) 61, R110, and R114). This deficient practice had the potential to allow residents not to be provided the information about what services may not be covered by Medicare for residents to make an informed decision about receiving therapies.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the assessment accurately reflected weight and significant weight loss for one (Resident (R) 52) of 12 residents reviewed for nutrition. This failure placed R52 at risk of additional unplanned weight loss or malnutrition.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) level I screening for mental disorder was completed for one (Resident (R) 36) of 27 residents in the sample. This failure had the potential for R36 to reside in the facility without a determination by the State mental health authority as appropriate for admission.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop and implement interventions for safety for two (Resident (R) 2 and R32) of two residents reviewed for substance use disorders.

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to ensure three of three portable compressed oxygen cylinders were safely stored in a secure device. The deficient practice had the potential for severe physical harm if the pressurized cylinder was to be knocked over and explode. In addition, the facility failed to ensure respiratory equipment was kept in a clean and sanitary manner for one of three residents (Resident (R) R58) reviewed for oxygen usage in the sample of 27. Failure to provide clean oxygen tubing and oxygen filter increased the risk for respiratory problems related to contaminated equipment.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and signed by the physician for two of five sampled residents (Resident (R)19 and R60). This deficient practice had the potential to allow residents to continue to receive medications with irregularities that the physician has not furnished a rational.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of one resident (R)50) in the sample of 27 revealed the resident's preference for a sandwich to be add to the lunch and dinner meals was not being honored. The failure to ensure that a resident's food preferences were honored could result in the resident loosing weight.

Inspectors wroteBased on observation, interviews, and facility policy, the facility failed to implement infection prevention strategies to prevent cross-contamination during the medication pass for three of five residents (Resident (R) 94, R316, and R18) observed during the medication pass out of a total sample of 27. This failure had the potential to spread infectious diseases to all residents. The facility census was 112 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 32) of one resident review for antibiotic use in the sample of 27 had a duration of antibiotic therapy specified and antibiotic use did not continue without medical necessity. This failure placed R32 at risk of antibiotic resistance or unnecessary adverse effects of the medication.

Inspectors wroteBased on record review, interview and policy review, the facility failed to provide the personalized dialysis contract for one of one resident (Resident (R)31) who received dialysis from the facility. This deficient practice had the potential to affect all residents who receive dialysis from this facility to receive agreed on services.

Inspectors wroteBased on interview and record review, the facility failed to provide a written discharge notice to one sampled resident (Resident #2) and/or his/her guardian upon emergency discharge from the facility out of five sampled residents. The facility census was 101 residents. Review of the facility's policy titled Transfer or Discharge Notice dated March 2021 showed residents and/or representatives were notified in writing, and in a language and format they understood, at least 30 days prior to a transfer or discharge. 1. Review of Resident #2's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/24 showed the resident was discharged on 10/9/24 and the resident's discharge was unplanned. Review of a nurse's note dated 10/9/24 at 3:14 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit one sampled resident (Resident #2) for re-admission to the facility out of five sampled residents. The facility census was 101 residents. Review of the facility's policy titled Bed-Hold and Returns dated March 2022 showed: -A resident would be permitted to return to an available bed in the location of the facility that he or she previously resided in. -If there was not an available bed in that part, the resident would be given the option to take the available bed in another distinct part of the facility and return to the previous distinct part when a bed were to become available. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the physical abuse of three sampled residents (Resident #4, #5 and #6). On 11/2/24 Family Member A entered the facility visibly and verbally upset stating to call 911 as he/she had been robbed. Receptionist A let Family Member A into the building. Family Member A began down the hall. Certified Nurse Aide (CNA) A followed Family Member A to ask why 911 should be called. Before CNA A could get an answer, Family Member A entered Resident #1 and Resident #2's room. Family Member A then went to Resident #1's side of the room struck Resident #3 and Resident #1 in the face and mouth area. Then Family Member A went to the bedside of Resident #2 where the resident was sleeping and struck Resident #2 in the face. [...]

Inspectors wroteBased on interview and record review, the facility failed to take corrective action which included physician notification, staff education, staff training and or staff in-services after physical abuse of three sampled residents (Resident #4, #5 and #6) out of seven sampled residents. The facility census was 105 residents. Review of the facility Abuse, Neglect, Exploitation or Misappropriation Prevention Program Policy dated 4/2024 showed: -Protect residents from abuse by anyone including visitors. -Provide orientation and training programs that include topics such as abuse prevention, identification and reporting abuse. -Establish and implement a Quality Assurance Performance Improvement (QAPI review and analysis of reports, allegations or findings of abuse). Review of the facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation Policy dated 4/2024 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the guardian, emergency contact and/or physician for one sampled resident (Resident #7) when on 10/30/24 the resident did not return to facility out of seven sampled residents. The facility census was 105 residents. Review of the facility Wandering and Elopement Policy dated 3/2019 showed: -If a resident is missing, initiate the elopement/missing resident emergency procedure. -Determine if the resident is out on an authorized leave or pass. -If the resident was not authorized to leave, initiate a search of the building and premises. -If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies. Review of the facility Leave of Absence Policy dated 4/1/22 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the call light system which resulted in one sampled resident's (Resident #2) call light not being answered for approximately 20 minutes out of four sampled residents. The facility census was 105 residents. Review of the facility Supporting Activities of Daily Living policy dated 3/2018 showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility Answering the Call Light policy dated 3/2021 showed: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #3) dignity was maintained when on 9/30/24 Certified Nursing Aide (CNA) B pulled the resident's pants down exposing his/her buttocks to other bystanders out of four sampled residents. The facility census was 105 residents. Review of the facility's Dignity policy dated 2/2021 showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -The facility culture support dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. -This begins with the initial admission and continues throughout the resident's facility stay. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate weight management for two sampled residents (Resident #8 and Resident #10), who had Percutaneous Endoscopic Gastrostomy (PEG) tubes (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate), with weight discrepancies out of 10 sampled residents. The facility census was 101 residents. Review of the facility's policy titled Weight Assessment and Intervention dated March 2022 showed: -Residents are weighed upon admission and at intervals established by the interdisciplinary team. -Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. -If the weight is verified, nursing will immediately notify the dietician in writing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician's orders to ensure the intake of tube feeding and fluids was completed, failed to ensure the flush bag was dated and labeled, and failed to ensure the tube feeding bag and flush bag were changed every 24 hours, for one sampled resident (Resident #10) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate) out of 10 sampled residents. The facility census was 101 residents. Review of the facility's policy titled Enteral (passing through the intestine) Feeding via Continuous Pump dated November 2018 showed: -In preparation staff would need to verify that there is a physician's order for this procedure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was operable and within reach for one sampled resident (Resident #1), who was bedbound and needed total assistance from staff for care, out of 10 sampled residents. The facility census was 101 residents. Review of the facility's Call light policy and procedure dated March 2021, showed: -The purpose was to ensure timely responses to the resident's requests and needs. -Be sure the call light is plugged in and functioning at all times. -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check these residents frequently. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to keep trash dumpster's closed; to change the deep fryer oil in a timely manner; failed to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to separate damaged foodstuff; to store food within acceptable temperature parameters; and to ensure the proper refrigeration of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped with a complete, functioning call light system throughout the facility to ensure the ability to meet the residents' needs in a timely manner. This deficient practice had the potential to affect all residents who resided in the facility. The facility census was 105 residents with a licensed capacity for 120 residents at the time of the survey. Record review of the facility's emergency preparedness plan in a binder entitled Emergency Operations Plan, obtained from the west nurse station and last revised on 1/7/22, on page #30 with the heading Power Outage, showed there was no policy or procedural plan for an alternate method (for example, bells, whistles, or flashlights) for residents to contact staff to have their needs met in the event of a power outage to the building. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) was completed and available for three sampled residents (Resident #79, #18, #64 ) out of 21 sampled residents. The facility census was 105 residents. The facility s PASRR Policy was requested several times and one was not provided by time of exit. 1. Record review of resident #79's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/23, showed: -The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were offered or provided as needed showers for three sampled residents (Resident #23, #304, and #204), and to return to a resident's room to assist them after turning out the call light for one sampled resident (Resident #23), out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Shower or Tub Bath, dated February 2018 showed: -Staff was to document the date and time the shower was performed. -Document the name and title of the individual who performed the shower. -Document all assessment data obtained during the shower. -Document how the resident tolerated the shower. -If the resident refused the shower, the reason why and the interventions taken. -Document the signature and title of the person recording the data. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The facility census was 105 residents. The facility policy for staffing of RN coverage for eight consecutive hours per days was requested and was not received by the end of the survey. 1. Record review of the worked staffing sheets on 4/24/23 at 11:31 A.M., showed there was no RN scheduled for eight consecutive hours for the weekend of Friday 4/14/23; Saturday 4/15/23; or Sunday 4/16/23. During an interview on 4/21/23 at 6:04 A.M., Licensed Practical Nurse (LPN) E said: -He/she worked the night shift 6:00 P.M., to 6:00 A.M. -Sometimes there was an RN working the night shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going nurses to verify the correct count of narcotics. The facility census was 105 residents. Record review of the facility's Controlled Substance policy dated April 2019 showed: -The facility complies with all laws, regulations and other requirements related to the handling, storage, disposal, and documentation of controlled medications. -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. -Controlled medications are counted at the end of each shift. -The nurse coming on duty and the nurse going off duty determine the count together. -Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing (DON) services immediately. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain Drug Regimen Review (DRR) reports and failed to ensure the reports were acted upon for three sampled residents (Residents #12, #24 and #35) out of five residents sampled for medication review. The facility census was 105 residents. Record review of the facility's Medication and Prescribing - Clinical Protocol policy dated as revised April 2018 showed: -The staff and physician would periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications. -There were no instructions regarding the completion of the DRR reports and acting upon them. 1. Record review of Resident #12's care plan dated as admission date 2/7/22 showed the resident: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication carts were locked when the nursing staff was not within sight of the cart; to ensure there were not loose pills in the medication cart drawers; and to ensure cleaning products were not in the same drawer as the residents' medications. The facility census was 105 residents. Record review of the facility's policy, Storage of Medications, dated November 2020 showed: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility were stored in locked compartments. -Only persons authorized to prepare and administer medications were to have access to locked medications. -The nursing staff was responsible for maintaining medication storage in a clean, safe and sanitary manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #35 and #58,) out of five residents sampled for vaccination review were offered the influenza (flu) vaccine and three sampled residents (Resident #35 #58, and #88) were offered a pneumococcal (pneumonia) vaccine. The facility census was 105 residents. Record review of the facility's flu vaccine policy dated March 2022 showed: -All residents who had no medical contraindications to the vaccine would be offered the flu vaccine annually. -The facility would provide pertinent information about the significant risks and benefits of vaccines to residents. -Between October 1st and March 31st each year, the flu vaccine would be offered to residents unless the vaccine was medically contraindicated or the resident was already immunized. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior & dementia training, abuse prevention, resident rights, care of the cognitively impaired resident, and training areas of weakness as determined in the Nurse aides' performance reviews for five out of five Certified Nursing Assistants (CNA). This had the potential to affect all residents. The facility census was 105 residents. The facility policy for staffing in-services and training was requested and was not received by the end of the survey. 1. Record review of the inservice/trainings dated April 2022 to April 2023 that were provided showed: -Abuse Policy presented by the Regional Social Services (RSS) dated 2/14/23 to all department heads, then the department heads in-serviced their department staff. -Handwashing on 4/20/23 did not show who presented the in-service. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat the residents with dignity by not ensuring two sampled residents, (Resident #23 and #72) genitals were covered up during cares and their Foley catheter bags were in a dignity bag when the residents were outside of their rooms out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Dignity, dated February 2021 showed: -Residents were to be treated with dignity and respect at all times. -Staff was to promote, maintain, and protect residents privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Record review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) was provided to the resident or their representative for one sampled resident (Resident #82) and to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Resident #82 and #21) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 105 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide notification to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the 30-day discharge notices for two sampled residents (Resident #11 and #43) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy on discharging the resident dated as revised December 2016 showed the policy did not address 30-day discharge notices or notifying the Ombudsman of 30-day discharge notices. Record review of the facility's undated 30-Day Notice policy showed the policy did not address notifying the Ombudsman of 30-day discharge notices. 1. Record review of Resident #11's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/23/23 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (document that specified health care and support needs and outlines how the facility met resident requirements) that included needs, goals, outcomes and preferences for one sampled resident (Resident #26) for use of oxygen and one sampled resident (Resident #44) for bowel and bladder routine out of 21 sampled residents. This practice had the potential to effect all residents. The facility census was 105 residents. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated, March 2022, showed: -A comprehensive, Person Centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were written parameters for when the staff should notify the physician and what to do when a resident's blood sugar was too high or too low for two sampled residents, (Resident #35 and Resident #88) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Nursing Care of the Older Adult with Diabetes Mellitus (diabetes - a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), dated November 2020 showed: -Use a glucometer (a small device that measures how much sugar is in a person's blood sample) for capillary blood sampling to measure correct blood glucose levels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have in place measures to effectively communicate with one sampled resident (Resident #88) whom English was not his/her primary language and did not provide activities for him/her in Spanish (his/her primary language) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Translation and /or Interpretation of Facility Services dated November 2020 showed: -The facility's language access program would ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. -When encountering LEP individuals, staff members would conduct the initial language assessment (e.g., I speak Cards and notify the staff person in charge of the language access program. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Urinalysis (a test of your urine to check for infection, kidney problems, or diabetes) after a physician ordered the test for one sampled resident (Resident #88) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Principles of Laboratory Specimen Collection, dated 4/1/22 showed: -A specimen collection was performed as ordered by a physician. -Contact the Unit Supervisor for questions or concerns regarding specimen collection. -Document in the progress notes any abnormalities associated with the collection process. 1. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a group of diseases that result in too much sugar in the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing and the oxygen humidifier were stored in a sanitary condition; and to change out the oxygen tubing per physicians' order for two sampled residents (Resident #18 and #64) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Oxygen Administration, dated 2022 showed: -Change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. -Change humidifier bottle when empty, every 72 hours, or per facility policy, or as recommended by the manufacturer. -Use only sterile water for humidification. -Change nebulizer tubing and delivery device every 72 hours or per facility policy and as needed if they become soiled or contaminated. -Keep delivery devices covered in plastic bag when not in use. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects of psychotropic (a type of psychiatric medication which was available on prescription to treat psychosis) medications for one sampled resident (Resident #26) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy, dated April, 2018, showed: -The physician and staff will identify situations in which a resident took medications associated with potentially significant medication-related problems such as allergies, drug to drug interactions drug-food interactions and adverse drug reactions. -The physician and staff will identify significant factors that may affect medication effectiveness and medication -related problems. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered labs and/or maintain lab results for two sampled residents (Resident #12 and #35) out of 21 sampled residents. The facility census was 105 residents. A policy regarding following physician's orders for labs was requested but not received. During an interview on 44/26/23 at 2:27 P.M., the Administrator said if a policy wasn't provided that was requested that they did not have it or it was in the computer and they did not find it. 1. Record review of Resident #12's care plan for the admission date of 2/7/22 showed the resident had a diagnosis of Convulsions (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). [...]

Inspectors wroteBased interview and record review, the facility failed to establish and maintain competencies and skill sets of facility nursing staff for four out four sampled nurses. The facility census was 62 residents. 1. Record review of four Licensed Nurses employment files on 1/19/21 showed no competencies sign offs could not be produced for verification. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -No competencies could be found for the nursing staff. -He/She started working for the facility in November 2020. -He/She had not provided any competencies or skills check offs since he/she started working for the facility. -He/She could not locate any nursing competencies or skills check offs prior to November 2020. -Training was poor prior to him/her working for the facility, and he/she had just started getting a training program developed. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure a Certified Nursing Assistant (CNA's) received the required 12 hours in-service education based on performance reviews annually for six CNAs out of six sampled. The facility census was 62 residents. 1. Record review on 1/19/21 of six CNAs employment file showed the required 12 hours in-service education hours competencies and/or skills sign offs could not be produced for verification. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -The required 12 hours of CNA in-service education records could not be produced for verification. -He/She started in working for the facility in November 2020. -He/She could not find documentation of any CNA inservice education or skills check-offs prior to November 2020. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 12 hours of in-service training for the licensed nurses on dementia and behavioral health needs for four licensed nurses of four sampled. The facility census was 62 residents. 1. Record review of four Licensed Nurses employment file showed the required 12 hours of in-service training on dementia and behavioral health needs verification could not be produced. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -He/She started working for the facility in November 2020. -He/She had not provided the required 12 hours in-service training on dementia and behavioral health needs for the nursing staff since he/she started working for the facility. -He/She could not locate any in-service training verification on dementia and behavioral health needs prior to November 2020. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 62 residents. Record review of the facility's Inventory Control of Controlled Substances policy dated 11/28/12 and revised on 11/26/17 showed: -Staff were to always participate in the counting of the controlled substances at the beginning and ending of your shift. -Have partner to assist in the count. -Sign name, time and date of completed count. 1. Record review of the facility's Controlled Drug Count sheet dated 11/9/20 - 11/20/20 showed: -The document did not identify which hall the narcotic count sheet was for. -Five out of 26 opportunities were not signed by either the oncoming or off going staff. [...]

Inspectors wrote5. Observation on 1/14/21 at 6:30 A.M., showed: -The Human Resource (HR) Director entered the facility through the double doors from the outside into the foyer. -He/She stood in line waiting to be screened for signs or symptoms of COVID. -There was a receptionist at the desk who was screening people. -There were new surgical masks on the receptionist's desk. -The HR Director stood in the foyer for more than ten minutes without a mask on. -There was one male resident sitting in a chair in the foyer looking out the doors. -The HR Director went into his/her office which was located directly behind the receptionist's desk without a mask on. Observation on 1/15/21 at 8:15 A.M., showed: -CMT A walking down the hall between the East and [NAME] Halls without his/her mask pulled up over his/her nose and mouth. -His/Her mask was down around his/her neck. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking the employee disqualification listing (EDL) and completing the Nurse Aide Registry Check within a timely manner and in accordance with state requirements prior to employing eight of ten employees sampled for the EDL screening and five of ten employees sampled for the Nurse Aide Registry screening. The facility census was 62 residents. Record review of the facility's Abuse Prevention and Reporting revised on 12/10/18, showed regarding pre-employment screening of potential employees: -The facility will not knowingly employ any individual convicted of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy Drug Regimen Reviews (DRR) were completed and in the resident's medical record monthly and failed to ensure the resident's physician responded to pharmacy recommendations and the response were documented in the resident's medical record for five sampled residents (Resident #42, #13, #41, #5, and #6) out of 19 sampled residents. The facility census was 62 residents. Record review of the facility's policy titled Pharmacist Medication Review dated 11/28/17 showed: -The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inhalers and medication vials were dated when opened; failed to ensure expired medications were removed from the medication delivery system; and failed to ensure medications carts are locked and not left unattended by staff when they were unlocked. The facility census was 62 residents. Record review of facilities Medication Storage policy dated 10/1/15 revised 7/2/19 showed: -Facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. -Once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guidelines, and failed to have a basic ingredient in stock that is called for in many recipes. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 62 residents with a licensed capacity for 120 residents. Record review of the undated Week at a Glance menus for weeks 1 through 4, provided by the DM, showed a variety of meals that met the nutritional needs of residents in accordance with established national guidelines. The lunch meal for week 2 that was supposed to be served was listed as chili mac with buttered peas and peaches with whipped topping. 1. Observations on 1/11/21 at 9:30 A.M. of the lunch meal preparation showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils and preparation equipment; failed to ensure plastic cutting boards were in good condition to avoid food safety hazards; failed to separate damaged food stuffs; and failed to keep a ceiling vent and floor fan free of lint to prevent food contamination. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 62 residents with a licensed capacity for 120. 1. Observations during the kitchen inspection on 1/11/21 between 8:51 A.M. and 1:15 P.M. showed the following: -A microwave had food splatters on the interior walls, top, and inside of door. -A toaster had an abundance of crumbs in the bottom. -A white cutting board was deeply scored to the point of plastic bits hanging off it. [...]

Inspectors wroteBased on observation and interview, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests (for example, bed bugs, lice, roaches, ants, mosquitoes, flies/gnats, mice, and/or rats), and failed to maintain an effective pest control program with measures to eradicate those pests when present. The facility's census was 62 residents with a licensed capacity for 120 residents. 1. Observations during the dining room and kitchen inspections on 1/11/21 between 8:51 A.M. and 2:10 P.M. showed the following: -A roach was on the floor of the southeast dining room doorway to the Main Dining room and another one on the room's west wall. -Gnats were hovering about a full trash can in the southeast dining room by the Kitchen double doors and another one by the room's west wall outlet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's Foley catheter (a sterile tube placed in the bladder to drain urine) was in a dignity bag (a covering that can not be seen through that hides the urine of a Foley catheter) while the resident was in a public area and by not ensuring a resident was provided privacy during cares for one sampled resident, (Resident #37) out of 19 sampled residents. The facility census was 62 residents. Record review of the facility's Dignity policy dated 11/28/12 with a revision date 4/23/18 showed: -The facility shall promote care for the residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of a Resident to Resident altercation for one sampled resident (Resident #38) who was at risk for potential resident to resident abuse, and failed to thoroughly investigate an allegation of misappropriation of resident property for one closed record resident (Resident #101) out of 19 sampled residents and seven closed record reviews. The facility census was 62 residents. Record review of the facility's undated Incident/Accident Reports Policy showed: -Policy: The Incident/Accident Report should be completed for all unexplained bruises or abrasions, all accidents or incidents where there was injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or others, and resident-to-resident altercations. -Procedure: [...]

Inspectors wroteBased on interview and record review the facility failed to provide a resident with a discharge notice with the right to appeal upon discharge from the facility, failed to ensure the resident was provided with a discharge plan, failed to allow the resident to return to the facility after his/her improper discharge, failed to notify the resident and family in writing the reason of the transfer to the hospital, and failed to notify the Ombudsman of the resident's discharge from the facility for one closed record resident (Resident #1) and one sampled resident (Resident#37) out of 19 sampled residents and seven closed records. The facility census was 62 residents. Record review of the facility's undated Discharge/Transfer of Resident policy showed: -The purpose was to provide safe departure from the facility and to provide for continuity of care and treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Bed Hold notification was provided to three sampled residents (Resident #42, #1, and # 37) or their responsible party for signature, upon discharge to the hospital out of 19 sampled residents and seven closed records. The facility census was 62 residents. Record review of the facility's Bed Hold Policy, revised on 9/16/17, showed the purpose was to ensure that the residents and/or resident representative are notified of the facility bed hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. The guideline showed the facility's bed hold policy applied to all residents. It showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure accurate documentation of the use of a Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle); failed to obtain a physician's order for a continuous blood glucose monitor for one sampled resident (Resident #13); failed to accurately transcribe physician's orders to include the proper use or diagnosis for a blood pressure medication, for one sampled resident (Resident #7); and failed to ensure a resident had an appointment with a psychiatrist in a timely manner and failed to obtain a physician's order when sending a resident to the hospital for one sampled resident (Resident #37) out of 19 sampled residents. The facility census was 62 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a written discharge summary and coordinate discharge planning with the resident's legal guardian for one closed record resident (Resident #107) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents. Record review of the facility's undated Discharge/Transfer of Resident policy showed: -Purpose: to provide safe departure from the facility, and to provide for continuity of care and treatment. -Explain the discharge procedure to the resident and family. -Provide additional health education or medication instruction information for the resident or family as indicated in lay terminology. -Ongoing resident/family conferences should address health education and potential discharge planning needs. [...]

Inspectors wrote2. Record review of Resident's #6 Facesheet showed he/she was admitted to the facility on [DATE] with following diagnosis: -Acquired absence of left leg below the knee. -Peripheral vascular disease (PVD - inadequate flow of blood to the extremities). -Essential hypertension (HTN- high blood pressure). Record review of the facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure, dated 11/28/12 and revised on 6/8/18, showed: -Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. -Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision to prevent accidents not ensuring a resident did not have smoking materials in his/her room for one sampled resident (Residents #46), failed to thoroughly document falls and complete a comprehensive fall investigation (which described/documented the resident's fall, interventions that were in place prior to the fall, immediate response to the fall, post fall interventions, notification of the resident's physician and responsible party, and analysis of the possible cause of the resident's fall) for one sampled resident (Residents #59) and one closed record resident (Resident #103) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents. Record review of the facility's Fall Prevention Program policy revised 11/21/17 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) had a valid physician's order indicating where and when the resident was to go for dialysis treatment and obtain orders directing staff to monitor the resident's dialysis central venous catheter (CVC - a flexible, long, plastic, Y-shaped tube that is threaded through your skin into a central vein in your neck, chest or groin - a connection between a vein and artery to provide access for dialysis treatment) for one sampled resident (Resident #34) out of 19 sampled residents. The facility census was 62 residents. Record review of the Dialysis Monitoring and Observation policy dated 11/28/12 revised 2/13/18 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medications for one sampled resident (Resident #13) out of 19 sampled residents. The facility census was 62 residents. Record review of the Pharmacist Medication Review policy dated 11/28/17 showed the Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility. -The consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. [...]

Inspectors wrote2. Record review of Resident #42's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pain, diabetes, dementia without behavioral disturbance, high blood pressure, anxiety disorder, obesity, vitamin deficiency, depression and other specified disorders of adult personality and behavior. Record review of the resident's MDS dated [DATE], showed: -The resident's BIMs was 15 out of 15 showing he/she had no cognitive incapacities. -The resident had no mood, behaviors or psychosis/delirium. -The resident needed extensive assistance with transfers and physical assistance with bathing needed, but no assistance noted with dressing grooming eating. -The resident was always incontinent. -The resident had no infections during the lookback period. -The resident was not taking any antibiotics during the lookback period. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visit and communication with hospice staff and failed to obtain pertinent documentation of the the delivery of hospice care services for one sampled resident (Resident #27) out 19 sampled residents. The facility census was 62 residents. Review of the facility Hospice Services Policy and Procedure revision on 11/17/17 showed: -Hospice services staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary environment in one non-resident room adjacent to a hallway and the Main Dining area by allowing ceiling tiles and walls to become dampened to the point of having a visible black substance appearing to be mold growth on them. This deficient practice had the potential to affect numerous residents, visitors, and staff who passed through, used, or worked in the two areas nearby. The facility census was 62 residents with a licensed capacity for 120. 1. Observations during the facility Life Safety Code room inspections with the Interim Maintenance Director (IMD) on 1/12/21 at 2:41 P.M. showed the following in the Conference room across from the Main Dining room: -One discolored 2 foot (ft) by 4 ft ceiling tile with numerous black splotches on it was sagging down from the ceiling tile grid. [...]