Parkwood Skilled Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to obtain a resident's admission physician orders, including current gastrostomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications) feeding orders and a complete medication list, for one resident admitted to the facility for a respite stay (Resident #2). During the resident's stay, the facility failed to transcribe a new physician's order for added g-tube water flushes and a change to g-tube feedings from bolus (single/specified dose given all at once) to continuous. These deficient practices resulted in the resident not receiving all prescribed medications, water flushes, or continuous g-tube feedings throughout the day. The sample was 3. The census was 83. Review of the facility's Admissions policy and procedure, last reviewed 10/30/24, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure orders for weight monitoring were completed as ordered. Concerns were noted in four of five residents identified by the facility as receiving dialysis services (Resident's #6, #9, #10 and #12). The resident sample was 11. The census was 85. Review of the facility's Physician's Orders policy, revised 4/16/2024, showed:-The purpose of the policy is to transcribe and follow physician orders accurately;-Orders received by the physician are to be followed as prescribed. In the event that a resident refuses, documentation must be completed and the physician must be notified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left one resident's topical gel and inhaler in the resident's room (Resident #6). The resident had not been assessed as safe to self-administer medications and did not have an order to self-administer medications. The sample was 7. The census was 86. Review of the facility's Self-Administration of Medication policy, dated 6/1/2018, showed:-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards when staff failed to follow physician orders when staff provided wound care for one resident (Resident #5). The sample was 7. The census was 86. Review of the facility's Physician Orders policy, dated revised October 2023, showed when a Physician gives orders on any resident, nursing staff will have the orders written in the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) of the medical record of the resident. Nursing staff will follow through with any order(s) that were provided by the physician in the time frame given by the physician. 1. Review of Resident #5's medical record, showed:-Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's responsible party regarding the resident's pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) and when the resident's pressure wound condition deteriorated. The facility also failed to notify the resident's responsible party regarding new medications ordered for the resident's behaviors (Resident # 2). The sample was five. The census was 89. Review of the facility's Change in Condition Policy, revised 8/13/25, showed:-The facility provides medical care to all the residents in this community with all their varied diagnosis and medical conditions. If a resident has a change in condition at any time during their stay at the facility, the nurse will be made aware immediately and call the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) was assessed and monitored by performing accurate skin assessments on admission and weekly (Resident #2). The sample size was five. The census was 89. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting policy, undated, showed:-Purpose: To prevent Pressure ulcers by identifying residents at risk; To treat an identified pressure ulcer as soon as possible and initiate treatment.-Policy and Procedure: The Braden scale is used as an instrument to identify skin at risk for breakdown. The Braden scale is done upon admission and quarterly. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy by not reporting an allegation of abuse for one of four sampled residents (Resident #1). Resident #1 reported an abuse allegation to staff, and the facility failed to notify the regulatory authority as required by their policy and state/federal regulations. The facility census was 84. Review of the facility's undated Abuse Policy and Procedures/Investigation Protocols showed the following:-The facility is committed to protecting residents from mistreatment, neglect, abuse and misappropriation of resident property. -This facility has adopted the guidelines of the Department of Health and Senior Services, as well as Centers for Medicare and Medicaid Services (CMS), for defining abuse, reporting, investigating and responding to appropriate parties. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe one resident's treatment orders in the medical record when the resident was readmitted to the hospital (Resident #1) and failed to accurately document completed wound treatments or treatment refusals by the resident on the Treatment Administration Record (TAR) for three residents (Residents #1, #4 and #2). The sample was 4. The census was 82. Review of the facility's Documenting/Implementing Doctors Orders policy, dated revised February 2025, showed:-Documentation: record all orders in the residents' chart. Review of the facility's Documentation policy, dated revised February 2025, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity when staff spoke to one resident in a disrespectful manner regarding the resident's hygiene and failed to provide care to promote his/her dignity (Resident #9), staff failed to provide one resident with grooming and feeding assistance (Resident #168) and staff entered one resident's room without knocking (Resident #34). In addition, staff failed to wear name badges to identify themselves to residents. The sample was 17. The census was 67. Review of the facility's Resident's Rights, provided to residents upon admission, showed the right to be treated with respect and dignity. Review of the facility's undated Resident Privacy/Dignity/Customer Service policy, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day, and the facility failed to ensure resident funds in excess of $100.00 (or $50.00 for Medicaid residents), were held in an interest-bearing account. This affected 40 residents whose funds were handled by the facility. The census was 76. 1. During a group interview on 8/29/24 at 10:04 A.M., seven residents, whom the facility identified as cognitively intact, said requests for personal funds are limited to $20.00. If a resident wants more than $20.00, they have to wait. During an interview on 8/29/24 at 11:03 A.M., the Business Office Manager (BOM) said she handles requests for cash made by residents who have funds held by the facility. She usually only does $20.00 for cash withdrawals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms and medical equipment and resident common areas were clean and homelike, affecting 13 of 17 sampled (Residents #9, #24, #43, #69, #32, #55, #27, #2, #50, #4, #269, #47 and #45). The facility also failed to ensure the 200 veranda hallway had clean floors. The census was 67. Review of the facility's housekeeping disinfecting cleaning schedule, revised 2/24/23, showed: -Housekeeping staff is responsible for the cleaning and disinfection of resident's room. Staff have responsibilities that are scheduled on a daily, weekly, and monthly basis. Housekeepers are responsible for every resident room on their halls which includes suites, gardens and terrace; -Disinfects bathrooms toilet and rails. Wipe sink and clean mirrors with Spic and Span. [...]

Inspectors wroteBased on interview and record review, the facility to develop a policy for and complete background checks for all newly hired employees, to include the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for thee of five newly hired employees sampled. The census was 67. Review of the facility's Policy on Background Checks, revised 8/29/24, showed: -The facility will conduct background checks on all employees before they start working at the facility; -Upon hire background checks will be completed two days prior to the employee start date; -Human Resources (HR) will conduct an annual Family Care Safety screening and quarterly Employee Disqualification List (EDL) screening; -The policy failed to identify which background checks will be completed prior to hire; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal hygiene. Resident #9 was not provided care after having a bowel movement and getting that bowel movement on his/her hands. In addition, the resident was not checked for incontinence or cleaned, resulting in the resident's brief being saturated through his/her pants (Resident #9). One resident was not provided showers or hair washing for an extended period of time and the hair care that was provided was not sufficient to cleanse the hair, resulting in the resident's hair becoming matted in a hard thick clump (Resident #32). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individual activities designed to meet the interests of and to support the psychosocial well-being of each resident, in accordance with needs and preferences for three residents (Residents #32, #9, and #55). The census was 67. 1. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Dependent on assistance for mobility; -Somewhat important to resident to have books, newspapers, and magazines to read; -Somewhat important to resident to go outside to get fresh air when the weather is good; -Somewhat important to resident to participate in religious services or practices; -Very important to resident to listen to music he/she likes; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The census was 67. Review of the facility's Facility Assessment Tool, updated 11/2/23, showed: -Facility resources needed to provide competent support and care for the resident population every day and during emergencies included: -Therapy services (e.g., activities professionals); -In addition to nursing staff, other staff needed for behavioral healthcare and services included Activity Director; -Staff training/education and competencies: Upon hire, all staff go through formal orientation for education and competency testing; -No documentation regarding the training requirement for a qualified Activity Director. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 67. Review of the facility's Narcotic Count Change of Shift Policy, dated 1/4/23, showed: -Narcotics must be counted with the nurse or Certified Medication Technician (CMT) at the change of shift; The nurse and CMT must count the total number or cards and packages and note total on count sheet; Each care and package must be counted to ensure that the total number of narcotics is accurate and matches that total number of narcotics in the card or package; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals stored in a medication room refrigerator had a temperature log in one of two medication rooms observed. In addition, staff failed to keep a medication cart locked when left unattended. The census was 67. Review of the facility's Medication Storage policy dated, 6/1/18, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier; -Procedures: All medications are maintained within the temperature ranges noted in the United States Pharmacopoeia (USP, an organization that sets standard for health care products) and the Centers for Disease Control (CDC); Medications and biologicals are stored at their appropriated temperatures and humidity according to the USP guidelines for temperature ranges; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents food that is palatable and at a safe and appetizing temperature for two residents (Residents #24 and #45) and residents on the Veranda hall. The sample was 17. The census was 67. Review of the facility's meal service temperatures policy, revised January 2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: meals temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow hair restraint policies while preparing food, keep the kitchen equipment clean and floors free of trash and grime. This had the potential to affect all residents who eat from the facility kitchen. The census was 67. Review of the facility's food service policy, undated, showed: -The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes; -Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Review of the facility's dietary cleaning schedule, undated, showed: -Items to be cleaned: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis access sites and centrally inserted intravenous (IV) lines, urinary catheters, wounds requiring treatment, and tube feedings administered via a feeding tube surgically inserted into the stomach through the abdomen, for nine of nine residents sampled for EBP (Residents #68, #32, #269, #55, #16, #29, #62, #69, and #5). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for four residents (Residents #55, #32, #47, and #50). The facility identified 47 residents with side rails in use. The census was 67. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's pest control program was effective in preventing roaches, which affected eight of 17 sampled residents (Residents #45, #27, #2, #46, #43, #168, #34 and #67). The census was 67. Review of the facility's pest control policy, revised 4/22/23, showed: -Parkwood has a contract with CES Pest Control Company. CES will come out every 2 weeks to spray for bugs and use traps for both bugs and other pests. If additional spraying is needed Parkwood will call CES to come out and spray. A log book is in the front office for CES to sign whenever staff indicates a certain area needs attention for spraying. Any staff member can write a request in the log book for CES to spray or put down traps. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room, who did not have a physician order for self-administration or medications to be left at the bedside (Resident #27). The sample was 17. The census was 67. Review of the facility's Medication Administration policy, dated 6/1/18, showed: -Purpose: To administer oral medication in a safe, accurate, and effective manner; -Procedure: Administer medication and remain with the resident while medication is swallowed; Do not leave medications at bedside, unless specifically ordered by the prescriber. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/24, showed: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment was coded accurately to include a life expectancy of less than 6 months for all residents on hospice for one of one resident investigated for hospice (Resident #24). The census was 67. Review of Resident #24's medical record, showed the resident admitted to hospice on 5/10/24. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/21/24, showed: -Received hospice care; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No. During an interview on 8/27/24 at 1:00 P.M., the MDS Coordinator said she does not indicate a life expectancy of less than 6 months just because a resident is on hospice. It is only marked if the resident is actively dying. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments for the pre-admission screening and resident review (PASARR) program under Medicaid with the appropriate state-designated authority, to ensure that individuals with a mental disorder receive care and services in the most integrated setting appropriate to their needs for one of eight residents investigated for the preadmission screening. Of those eight, only one indicated a level II screening was required and the level II assessment for the resident was not completed (Resident #5). The census was 67. Review of Resident #5's medical record, showed: -The resident resided in a Medicaid certified bed; -A DA-124c form, dated 2/29/07, showed: -Section B: Level 1 screening criteria for serious mental illness; -Question #4: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of three of 17 sampled residents (Residents #9, #45, and #2). The census was 67. Review of the facility's Care Planning Policy and Procedure, dated 1/17/20, showed: -Objective: The facility's standard is to perform quality of care that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices; -A care plan will be developed upon admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and apply a Tubi grip (elastic tubular dressing that reduces swelling) to one resident's lower extremity (Resident #2), who has a medical history of chronic (long term) edema (swelling) and cellulitis (infection of the skin and tissue below the skin) and apply a dressing to one resident's (Resident #269) gastrostomy tube (g-tube, a tube that is surgically inserted into the abdomen and used for liquid nutrition and medications) site. The sample was 17. The census is 67. Review of the facility's physician order policy revised, 6/21/20, showed: -Policy: To transcribe and follow-physician orders accurately; -Procedure: Orders received by the physician are to be followed as prescribed. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident, identified by the facility as dependent with mobility and high risk for development of pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) was routinely turned and repositioned by staff. The resident developed a new pressure ulcer to his/her coccyx (tailbone area) and upon identification of the pressure ulcer, staff failed to report it to the nurse, in accordance with the facility's policy (Resident #32). The sample was 17. The census was 67. Review of the facility's Policy and Procedure for Skin Protocol, dated 1/5/24, showed: -In order to prevent skin breakdown and promote the health of our residents, it is the policy of the facility to perform skin assessments on a weekly basis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received tube feeding in accordance with physician orders to support adequate nutritional intake (Resident #32). The facility identified eight residents receiving tube feedings, three of which were sampled and problems were found with one. The sample was 17. The census was 67. Review of the facility's Specific Medication Administration procedures policy, dated 6/1/18, showed: -Guidance for staff to administer medications via feeding tube; -No any other guidance for staff related to the technical aspects of feeding tubes, including verification of functionality and feeding tube care. Review of Resident #32's medical record, showed diagnoses included dysphagia (swallowing disorder), heart failure and dementia. Review of the resident's electronic Physician Order Sheet (ePOS), showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure side rails were accurately assessed as a necessary device prior to installation and use. The facility failed to obtain physician orders for the use of side rails and to document side rail use on care plans for four residents (Residents #32, #55, #47 and #50). The facility identified 47 residents with side rails in use. The census was 67. Review of the facility's Restraints/Side Rails policy, dated 4/28/17, showed: -Restraint Evaluation and Utilization Guideline: -The facility does not typically utilize restraints, however if a restraint is utilized to treat a resident's medical symptoms, to prevent injury and promote the highest practicable level of independence, careful evaluation will precede this decision; -The least restrictive device will be used; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received nectar-thick liquids (Resident #269) and one resident received a mechanical-soft diet (Resident #32) in accordance with physician orders. The sample was 17. The census was 67. 1. Review of Resident #269's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/24, showed: -Diagnoses of acute respiratory failure and dysphagia (difficulty swallowing); -Moderately impaired cognition. Review of the resident's Physician's Order Sheet (POS), showed an order, dated 7/9/24, for nectar thickened liquids. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident receives a mechanical soft diet with nectar thickened liquids; -Goal: utilize interventions to help maintain weight and skin integrity; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have the most recent annual survey's plan of correction and statements of deficiencies with the corresponding plans of correction completed for any abbreviated survey completed since the most recent annual survey, available to residents and visitors at all times without them having to be requested. The sample was 17. The census was 67. Review of the facility's Resident's Rights, provided to residents upon admission, showed the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and receive information from agencies acting as client advocates, and to be afforded the opportunity to contact these agencies. Review of a sign posted near the main entrance, reviewed on 8/27/24 at 7:41 A.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 42 opportunities, 5 errors occurred, resulting in an 11.9% error rate (Residents #3 and #4). The census was 67. Review of the facility's Medication policy dated, June 1, 2018, showed: -ADMINISTRATION PROCEDURES FOR ALL MEDICATIONS; -Policy: To administer medications in a safe and effective manner; -Procedures: Review 5 Rights (3) times: -Prior to removing the medication package/container from the cart/drawer; -Check MAR for order. -Check the label against the order on the medication administration record (MAR); -After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or treatment administration record (TAR), and controlled substance sign out record, if indicated; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to do neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) per the facility's policy for one of three residents sampled for falls (Resident #3). The sample was six. The census was 70. Review of the facility's Fall Management Guidelines Policy, dated 10/20/21, showed: -Following a resident's fall: the licensed nurse assesses the resident for injuries (including neuro checks if indicated) and provides necessary treatment; the physician and resident's representative are notified; appropriate interventions are implemented; continue ongoing assessment and documentation by licensed nurses per practice; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for one resident (Resident #80) per the resident's wishes. Resident #80 was found to be unresponsive and without signs of life. Staff began CPR, then stopped. When Emergency Medical Services (EMS, 911, first responders, paramedics, police officers and/or fire fighters) arrived, staff were not performing CPR. The sample was 19. The census was 92. The Administrator was notified on [DATE] at 1:44 P.M. of an Immediate Jeopardy (IJ) of past non-compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the deficient practice to not administer CPR to a resident who wished to receive it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the medical director failed to attend the facility's QAPI meetings. The census was 92. Review of the facility's Roles and Responsibilities of QAPI policy, undated, showed: -QAPI meets monthly the third week of the month to establish QAPI projects and all personnel involved in QAPI projects. Purpose of meeting is to establish roles and responsibilities of educators and trainers on how quality assurance project will be established and performed for all members of the QAPI team; -QAPI team consists of nursing, housekeeping, maintenance, activities, social services, dietary, management, and administrative staff; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity when the Director of Nursing (DON) confronted a resident in the hall in front of Certified Nurse Aide (CNA) F, raised her voice, and talked disrespectfully to them. CNA F was later observed to talk disrespectfully to the same resident during a different interaction (Resident #1). In addition, staff entered Resident #37's room to make personal phone calls and FaceTimed (video called) when in the hall during a fire alarm, where residents could potentially be seen by the other person on the phone. The census was 92. Review of the Resident Rights, provided to residents upon admission, showed residents had the following resident rights: -The right to be treated with respect and dignity; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, by not ensuring privacy curtains, air conditioning (AC) units, walls, floors, handrails, shared showers, shared bathrooms and equipment were clean. The sample was 19. The census was 92. Review of the Housekeeping Disinfecting Cleaning Schedule, revised 2/24/23, showed: -Housekeeping staff is responsible for the cleaning and disinfection of residents' room. Staff have responsibilities that are scheduled on a daily, weekly and monthly basis; -Housekeepers are responsible for every resident room on their halls, which includes Suites, Gardens and Terrace; -Cleaning consists of: -Pull all trash in the rooms and bathrooms; -Disinfects bathrooms, toilets, rails; -Wipe sink and clean mirrors with Spic and Span; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit resident Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for 3 of 3 months reviewed. The census was 92. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; -The manual includes a submission timeframe table for MDS record types. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for three of three narcotic books reviewed. The census was 92. Review of the facility's Narcotic Count Change of Shift policy, dated 1/4/23, showed: -Narcotics must be counted with the nurse/certified medication technician (CMT) at the change of shift; -The nurse/CMT must count the total number of cards/packages and note the total on the count sheet; -Each card/package must be counted to ensure that the total number of narcotics is accurate and matches the total number of narcotics in the card/package; -The nurse arriving for their shift and leaving their shift must initial the change of shift count sheet; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control protocols and universal standards when a staff member used a plunger to clear a clogged sink, did not disinfect the sink and used it to wet a towel which they then used to provide perineal care for two residents. Staff did not adequately wash their hands (Resident #50 and Resident #13). Another staff member cross-contaminated when he/she wore soiled gloves and took soiled items in a resident's room for one resident (Resident #62) and dragged soiled trash bags on the floor. Staff also failed to perform proper hand hygiene when providing care. Staff failed to sanitize shared equipment, such as blood pressure cuffs, between residents. Additionally, staff improperly cleaned a blood sugar finger stick (BSFS) machine with an alcohol wipe. The sample was 19. The census was 92. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable nursing standards of practice related to enteral tube (a tube that is inserted directly into the stomach to provide food, fluid, and medication) medication administration for one resident (Resident #81). The facility failed to remove an order for a wanderguard (an electronic monitoring device used to keep residents at risk for elopement safe) and nursing staff continued to document the device as checked twice a day when the resident did not wear the device (Resident #6). The sample was 19. The census was 92. 1. Review of the facility's Specific Medication Administration Procedures, dated 6/1/18, showed the following procedures for enteral tube. Types of enteral tubes include the gastric tube, (g-tube) medication administration: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities to meet the interests and well-being of Resident #37 by failing to assist the resident from bed to wheelchair and to the activity location (Resident #37). The resident sample was 18. The census was 92. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/23, showed: -admission date of 9/6/22; -Cognitively intact; -Diagnoses of hypertension and major depressive disorder. Review of the Resident's Care Plan, dated 3/31/23, showed: -Care Area: Resident requires extensive to total assist with ADL's. She is total assist with Hoyer lift (mechanical lift) with two staff for transfers and maximum assist with grooming, toileting, positioning, and bathing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound care as ordered by the physician for one resident (Resident #67). The resident had orders for daily wound care for three wounds, which was not completed for three days. Staff charted wound care was completed, although the dressings showed they were not by the date on indicated on the dressings and confirmed by the wound nurse. The sample was 19. The census was 92. Review of Resident #67's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/19/23, showed: -Cognitively intact; -Resident is at risk of developing pressure ulcers: Yes -Resident has unstageable pressure ulcers: Yes, 1; -Resident has diabetic foot ulcers: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received the proper care necessary to maintain good personal hygiene and to prevent infection and odor for one of three residents observed (Resident #62). The census was 92. Review of the facility's Peri-Care (perineal care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, dated January 25, 2017, showed: -Purpose: To cleanse the perineum. To prevent infection and odor; -Cleansing resident from front to back thoroughly cleaning right and left genitals rotating disposable wipe between each wipe; -Wipe the peri rectal area from front to back using a disposable wipe; -Wipe the buttocks from the center of the body to the outside of the body with a disposable wipe; -Repeat process until disposable wipe is free of soiling and discard. [...]

Inspectors wroteBased on observation, interview and record review, the facility employed non-certified Nurse Aides (NAs) for more than 4 months without them becoming certified. Observation of personal care provided to a resident by one of the NAs, showed the NA was not competent to provide care consistent with acceptable nursing practices or following proper infection control practices (Resident #62). Two NAs were identified to work more than 4 months without becoming certified. The census was 92. Review of the Facility Assessment, dated 11/22/22, showed: -Average daily census 71-81; -Resident support/care needs included: Activities of daily living, mobility and fall preventions, bowel and bladder, and skin integrity; -Facility resources needed to provide competent support and care for our resident population every day and during emergencies, included: [...]

Inspectors wroteBased on observation and interview, the facility staff failed to post required nurse staffing information, which included the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The census was 92. Observation on 9/19/23 at 11:50 A.M., showed no postings of nurse staffing information available throughout the facility. During an interview on 9/19/23 at 11:56 A.M., the staffing coordinator said that she is responsible for posting nurse staffing information. She said she does not regularly post it and does not remember the last time she did. During an interview on 4/20/23 at 9:22 A.M. the administrator said he would expect the staffing coordinator to post staffing information.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure the resident's environment remains as free of accident hazards as is possible when a closet door fell and hit a resident (Resident #76). In addition, the facility left potentially harmful treatment supplies accessible to residents in a resident room (Resident #28) and in a small storage area on one unit. This had the potential to affect all residents who were able to move freely around the facility. The census was 90. Review of the facility's Accidents Policy, dated 10/15/19, showed: -The health and safety of each resident is of the upmost importance at the facility. In order to obtain and maintain the highest level of health and safety for its residents, the facility will ensure: -The resident environment remains as free of accident hazards as is possible; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to complete a gradual dose reduction (GDR) as indicated for one resident of eight residents investigated for unnecessary psychotropic medications(Resident #43). The sample size was 18. The census was 90. Review of Resident #43's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/19, showed: -Cognitively intact; -Required no assistance by staff for activities of daily living (ADLs); -Wheelchair/walker for mobility; -Medications included: -Antipsychotics, 7 days a week; -Antidepressants, 7 days a week; -Diagnoses included dementia, seizure disorder, depression, and diabetes. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff protected food from contamination by not ensuring drinks were covered while serving residents in the dining room. This had the potential to affect all residents in who dined in the facility. The census was 90. Observation of the resident dining room, showed: -On 1/21/20 at 5:27 P.M., staff pushed a two tiered serving cart through the dining room beside seated residents. Approximately 20 drinks, sat on the bottom tier of the cart and were uncovered; -On 1/22/20 8:39 A.M., dietary staff pushed a two tiered serving cart through the dining room, beside seated residents. A tray on top of the cart filled with orange juice and milk, sat uncovered; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for one resident's missing a coat. Staff failed to investigate the missing coat, failed to ensure management was made aware of the missing coat and sent the resident out in the community wrapped in a blanket in place of a coat, for one of 18 sampled residents (Residents #76). The census was 90. Review of the facility's Resident Protection Investigation Paths, dated 12/14/18, showed: -Determine whether a missing item is theft: All missing items need to be investigated in accordance with the facility's missing item protocol. However, the loss of an item in and of itself does not constitute theft. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were able to self-administer medication only if the interdisciplinary team has determined that this practice is clinically appropriate, for two residents found to have medications left at the bedside for self-administration (Residents #139 and #49). The census was 90. Review of the facility's undated Self-Administration of Medication policy, showed: -Policy statement: For administration of medications by a resident the individuals must be deemed competent for self-administration prior to the physician or authorized prescriber ordering the medication via a self-administration assessment. This assessment will be completed initially upon request to self-administer, quarterly and upon change of condition from baseline to ensure continued safe-administration; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately reconcile bank statements for 5 of 12 months reviewed. The census was 90. 1. Record review of the facility's resident trust statements, showed the following: -July 2019: Bank statement ending balance, showed an amount of $53,821.63; -The facility monthly reconciliation form, showed an ending balance amount of $39,925.76; -Neither amounts matched the resident ledger; -August 2019: Bank statement ending balance, showed an amount of $67,375.75; -The facility monthly reconciliation form, showed an ending balance amount of $58,971.54; -Neither amounts matched the resident ledger; -September 2019: Bank statement ending balance, showed an amount $51,480.65; -The facility monthly reconciliation form, showed an ending balance amount of $47,102.91; -Neither amounts matched the resident ledger; -October 2019: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospital, for three residents who were recently transferred to the hospital for various medical reasons (Residents #64, #139, and #32). The sample was 18. The census was 90. Review of the facility's undated transfer and discharge policy, showed when a resident is transferred or discharged from the facility, a discharge letter is sent with the resident. The letter will indicate the name of the resident with the date, the reason for the discharge and the location to where the resident is sent. The social service department will keep a copy of the letter in the binder and at the first of the following month the list of all the residents will be faxed to the ombudsman. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of practice by failing to ensure all physician orders were followed when staff failed to obtain a daily blood pressure prior to administration of a blood pressure medication and/or administered blood pressure medication when the results were outside normal parameters, for one resident (Resident #42). The sample size was 18. The census was 90. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/19, showed: -Cognitively intact; -Diagnoses includes atrial fibrillation (irregular heart beat), coronary artery disease (heart disease), heart failure, hypertension (HTN, high blood pressure) and stroke. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to provide showers and nail care for one resident who was dependent on staff for care needs (Resident #12). The sample was 18. The census was 90. Review of the facility's shower policy, revised 1/2017, showed: -Purpose: To provide showers on a bi-weekly basis; -A shower schedule will be maintained at each nurse's station for each division reflecting days and shift for each room/bed shower to be completed. Accommodations for requested days of the week or times will be made; -Residents right to refuse showers will be respected and addressed via the plan of care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when staff failed to address an observed skin irritation and bleeding for one resident. The staff also failed to notify the resident's physician and family and failed to document the observation and report the findings to oncoming nursing shifts (Resident #28). The sample was 18. The census was 90. Review of the facility's skin assessment policy, dated 8/17/17, showed: -In order to prevent skin breakdown and promote the health of the residents, it is the policy to perform skin assessments on a weekly basis. Skin assessments are to be performed by a registered nurse (RN) or licensed practical nurse (LPN); -Procedure: The LPN or RN are to visually inspect all areas of the body and note/document any abnormalities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident receives appropriate treatment and services for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine) for one resident. The facility identified three residents as having an indwelling urinary catheter, two were included in the sample of 18 and issues were identified with one resident (Resident #8). The census was 90. Review of the facility's undated Catheter Care policy, showed: -Purpose: To monitor the necessity of urinary catheters and to maintain the patency of these catheters; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who require dialysis (process of filtering toxins from the blood for individuals with kidney failure) receive such services, consistent with professional standards of practice by failing to follow the facility policy and provide ongoing communication with the dialysis center for two residents. The facility identified five residents as receiving dialysis. Of those five, three were included in the sampled of 18 and issues were identified with two (Residents #76 and #64). The census was 90. Review of the facility's Dialysis Policy, dated 9/1/19, showed: -It is the standard at the facility to meet the health care needs of its residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors, for one resident when the facility staff administered the wrong dose of insulin (Resident #84). The census was 90. Review of the facilities Specific Medication Administration Procedure, Administration procedure for all Medications policy, dated 6/1/18, showed: -Policy: to administer medications in a safe and effective manner; Procedure: Review five rights three times: Prior to removing the medication package/container from the cart/drawer; check the medication/treatment administration record for order; check for vital signs, other tests to be done during/prior to medication administration; Prepare resident for medication; Prior to removing the medication from the container, check the label against the order on the medication administration record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance to current acceptable professional standards for two of five observed nurse medication carts, one of two observed nurse treatment carts and one of three observed medication rooms. The census was 90. Review of the facility's Medication Ordering and Receiving from Pharmacy policy, dated 6/1/18, showed: -Policy: Medications are labeled in accordance with the facility requirements and state and federal laws. Only the dispensing pharmacy/registered pharmacist can modify, change, or attach prescription labels; -Procedures: Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly onto the product, e.g. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ordered STAT (immediate) laboratory testing had been obtained and results received in a timely manner for one resident and failed to obtain a laboratory test for one additional resident (Resident's #38 and #52). The sample was 18. The census was 90. 1. Review of Resident #38's care plan, updated 11/15/19, showed: -Problem: Occasionally incontinent; -Goal: Measures will be taken to prevent skin breakdown; -Interventions: Staff to assist to change incontinence pad as soon as possible after voiding, provide daily skin inspections, keep the skin clean, dry and free of irritants. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/19, showed: -Moderate cognitive impairment; -Felt depressed two to six days; -No behaviors; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for three residents with missing behavior documentation, sleep disturbance documentation and/or non-phrenological interventions implemented, and had improperly documented diagnoses (Residents #42, #32 and #38). The sample was 18. The census was 90. 1. Review of the Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/19, showed: -Cognitively intact; -Diagnoses includes coronary artery disease, heart failure, high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), pneumonia, diabetes, hyperlipidemia (high level of lipids), stroke, dementia, anxiety, depression, asthma, and respiratory failure; -No behaviors; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and effective infection prevention and control program by failing to follow the facility's transmission based precaution policy for one resident on isolation (Resident #288). The sample was 18. The census was 90. Review of the facility's Transmission Based Precautions Isolation Precautions policy, dated 11/7/17, showed: -This policy outlines the precautions required to prevent transmission of infectious agents. Standard precautions are to be followed at all times. Additionally, transmission-based precautions may be required on a case by case basis and will be determined by the Director of Nursing (DON); -Transmission-Based Precautions include standard precautions, and are divided into three categories: Contact Precautions, Droplet Precautions and Airborne Precautions; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the opportunity to receive the pneumococcal vaccine, unless documentation showed the vaccine was medically contraindicated, refused or the resident was already immunized by failing to offer the pneumococcal vaccine to three residents (Residents #18, #28, and #8) out of five residents sampled for the pneumococcal vaccine. The resident sample was 18. The facility census was 90. 1. Review of Resident #18's medical record, showed the following information: -admission date of 10/12/17; -Diagnoses included high blood pressure, diabetes, stroke, seizure disorder, and depression; -No documentation in the medical record or electronic medical record that the pneumococcal vaccine was offered or received. 2. Review of Resident #28's medical record, showed the following information: -admission date of 7/23/13; [...]