Perry Creek Health and Rehabilitation Center

Inspectors wroteBased on record review and interviews with staff and Physician, the facility failed to consult with the physician when a resident was unable to swallow his medications. This was for 1 of 3 sampled residents reviewed for medical care during acute illness (Resident # 1).

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner (NP), and contracted lab company, the facility failed to ensure labs to check the resident's medical condition following a hospitalization stay within the last month were completed as ordered by the provider. This was for 1 of 3 sampled residents reviewed for medical care following acute illness (Resident #4).

Inspectors wroteBased on observations, record review, and interviews with resident, responsible party, and staff, the facility failed to treat residents with dignity and respect when Nurse Aide #1 was watching a video on her cell phone while assisting Resident #72 with eating and Resident #106's clothes were not provided to her for a 3 day period after they were sent to the laundry resulting in the resident having to wear a hospital gown, feeling annoyed, and causing her not to leave her room. A reasonable person would expect Resident #72's caregiver to be focused on them during the provision of care. This deficient practice affected 2 of 4 residents reviewed for dignity (Resident #72 and Resident #106).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a resident's Minimum Data Set (MDS) assessment for 2 of 30 MDS assessments reviewed (Resident #3, Resident #59).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure a medication cart when the cart was left unattended for 1 of 4 medication carts observed for medication storage (500 Hall medication cart).

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations for 4 of 5 residents (Resident #37, #67, #98, and #118) and offer annual influenza vaccine for 1 of 5 (Resident #118) residents reviewed for immunizations.

Inspectors wroteBased on record reviews and interviews with staff, the facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for 1 of 3 residents reviewed for MDS assessments (Resident #89).

Inspectors wroteBased on record review and facility staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for Antipsychotic Medication Review for 1 of 5 residents reviewed for unnecessary medications (Resident #117).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove a box which contained 40 bisacodyl (a laxative) suppositories that were expired in 1 of 3 medication storage rooms (Unit 2 Medication Storage Room) reviewed for medication storage and labeling.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse #1 failed to apply all the required Personal Protective Equipment (PPE) before entering a room with a resident on contact precautions. This occurred for 1 of 7 staff observed for infection control practices.

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccinations for 1 of 5 residents (Resident #67) reviewed for immunizations.

Inspectors wroteBased on record review, observation, and staff and Medical Director interviews, the facility failed to ensure nursing staff were competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer when Nurse #1 was observed not disinfecting a shared glucometer (Resident #35). Also, Medication Aide #1 (an agency staff member) failed to clean and disinfect an individually assigned glucometer using the approved disinfectant wipes according to manufacturer's recommendations for Resident #32 who was observed having a blood glucose level checked. This occurred for 2 of 7 nursing staff members (Nurse #1 and Medication Aide #1) reviewed for competency. Immediate jeopardy began on 2/17/25 when Nurse #1 failed to demonstrate competency through her failure to disinfect a shared glucometer per manufacturer's instructions. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to implement infection control policies and procedures when staff failed to: (1) disinfect an unlabeled glucometer (a blood glucose meter) that was shared between residents for 1 of 2 residents (Resident #35) observed to have a blood glucose level checked. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer's instructions for the glucometer potentially exposes residents to the spread of bloodborne infections. This occurred with six residents in the facility identified as having a diagnosis that included one or more bloodborne pathogens; [...]

Inspectors wroteBased on record review, and staff, family member, and home health agency staff interviews, the facility failed to implement an effective discharge planning process and to ensure a resident had home health services arranged prior to discharge for 1 of 3 resident reviewed for discharge (Resident #181).

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to designate a full-time qualified director of food and nutrition services or Dietary Manager (DM).

Inspectors wroteBased on facility policy review, record review and staff interviews the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 127 of 127 residents in the facility.

Inspectors wroteBased on observations, interviews with Resident Council members and staff, and review of the Resident Council minutes, the facility failed to communicate the facility's efforts to address concerns voiced by the Resident Council members and to resolve repeat concerns in 3 of 3 months reviewed (November 2024, December 2024, and January 2025) and to maintain evidence that demonstrated the facility's response to grievances/recommendations made by the Resident Council from December 2023 through October of 2024.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to maintain shower floor tiles in good condition on 1 of 3 shower rooms (100-hallway shower room).

Inspectors wroteBased on record reviews, observations, and staff, Pharmacist and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled medications. In [DATE], this affected six residents reviewed for misappropriation of property (Resident #232, Resident #109, Resident #87, Resident #81, Resident #16 and Resident #14) and on [DATE], Resident #14's discontinued controlled medications were removed from 300-hall medication cart and not returned to the pharmacy.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Pre-admission Screening and Resident Review (PASARR) (Resident #17, Resident 67, and Resident #4), use of opioid pain medication (Resident #14), schizophrenia (Resident #41) and anticoagulants (Resident #10) for 6 of 54 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, and staff and Pharmacist #1 interviews, the facility failed to complete a return pharmacy form and return discontinued non-controlled medications and controlled medications for 11 of 11 residents whose controlled medications were observed located in the Director of Nursing office (Resident #70, Resident #113, Resident #96, Resident #400, Resident #71, Resident #85, Resident #14, Resident #401, Resident #402, Resident #124, Resident #95).

Inspectors wroteBased on record review, and staff , Pharmacist Consultant, and Physician interviews, the facility failed to administer antibiotic medications as ordered by the physician which resulted in a delay in starting antibiotic therapy for 2 of 4 residents reviewed for administration of significant medications (Resident #90 and Resident # 59).

Inspectors wroteBased on observation, and staff and Pharmacist interviews, the facility failed to maintain controlled medications on the medication carts that provided a separately locked and permanently affixed compartment for storage until the controlled medications were returned to the pharmacy for 1 of 1 filing cabinet observed storing control medications (Director of Nursing's filing cabinet).

Inspectors wroteBased on record review, observations, and staff, resident council, and resident interviews, and test tray, the facility failed to provide food that was palatable and served at an appetizing temperature for 10 of 13 residents (Residents #60, #85, #74, #70, #61, #5, #87, #62, #109, and #106) reviewed for food concerns.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement an effective training program to ensure staff received required training and to maintain documented evidence of trainings for 4 of 4 Nursing Assistants (NA #2, NA #8, NA #9, and NA #11). This practice had the potential to affect all residents.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to: ensure an independent and unsupervised smoker was able to exit the smoking area to return inside the building without assistance when the designated smoking area was moved to a new location that had a concrete slope from the interior of the facility to the exterior area (Resident #37); and to place a resident's call light within reach to allow the resident to request staff assistance as needed (Resident #12) for 2 of 8 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, staff interviews, Physician interview, and record review, the facility failed to notify the Physician of Resident #25's complaints of pain after an unwitnessed fall for 1 of 4 residents (Resident #25) reviewed for notification of change.

Inspectors wroteBased on observation and staff interviews, the facility failed to protect a resident's health care information by leaving confidential medical information unattended, visible and accessible to others on the computer screen for 1 of 5 medication carts observed for privacy and confidentiality (100-hall medication cart).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a written notice of transfer and/or discharge to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization (Resident #90).

Inspectors wroteBased on record review and resident representative and staff interviews, the facility failed to provide incontinent care to a resident that was dependent on nursing staff assistance for activities of daily living (ADL) for 1 of 3 residents reviewed for ADL (Resident #33).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to equip 2 of 2 designated resident smoking areas with fire preventative equipment (Smoking Area #1 and Smoking Area #2) and to complete a quarterly smoking assessments for 1 of 1 resident reviewed for smoking (Resident #37).

Inspectors wroteBased on observation, record review, and staff and Physician interviews, the facility failed to ensure effective pain management for a resident with an unwitnessed documented fall on 1/27/25 and failed to provide pain management when assessed by the floor nurse during neurological assessments (an assessment done by the nurse to evaluate for potential brain injuries by checking mental status, level of consciousness, motor function, sensation, coordination, and reflexes) and used a numerical pain scale (a scale that uses numbers from 0 to 10 to measure pain with 0 meaning no pain and 10 meaning the worst pain) and having pain verbalized a 3 out of 10 for three (3) assessments and 6 out of 10 for four (4) assessments for 1 of 1 resident reviewed for pain management (Resident #25).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 3 of 92 days reviewed for staffing (12/30/24, 1/2/25 and 1/3/25).

Inspectors wroteBased on record review, and staff and Consultant Pharmacist interviews the facility failed to act on recommendations made by the consultant pharmacist and maintain documentation of the physician's review and response to the pharmacist's findings for 3 of 5 residents reviewed for drug regimen review (Resident #17, Resident #67 and Resident #11).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 2 of 6 residents (Residents #59 and #28) observed during the medication administration observation.

Inspectors wroteBased on record reviews, and staff, Pharmacist, Corporate Nurse Consultant, and Physician interviews, the facility failed to maintain complete and accurate medical records for medication administration (Resident #50) and for documentation of nursing assessments and accurate physician notification time (Resident #34) for 2 of 46 residents whose medical records were reviewed.

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to explain the arbitration agreement to the resident prior to having them sign the agreement and to ensure they explicitly informed the resident that signing the agreement was not required as a condition of admission. This occurred for 2 of 3 residents (Resident#72, and Resident #109) reviewed for arbitration.

Inspectors wroteBased on record review and interviews with the facility Administrator, the facility failed to include the selection of a venue that was convenient to both parties in the Arbitration Agreement. This was for 1 of 3 (Resident #70) residents who were reviewed for entering into an Arbitration Agreement with the facility.

Inspectors wroteBased on observations, record review, and interviews with resident and staff, the facility failed to ensure full visual privacy was available for 1 of 5 rooms (room [ROOM NUMBER]) reviewed for the privacy curtain.

Inspectors wroteBased on observations, staff and physician interviews and record review, the facility failed to provide care safely to (Resident (R) 5 and R8) resulting in the residents sustaining injury. On 10/7/24 during the provision of incontinence care to R5 by Certified Nurse Aide (CNA) 1, the CNA utilized the draw sheet to pull the resident toward her resulting in the resident rolling in the opposite direction and onto the floor. R5 sustained a right hip fracture requiring surgical repair. On 9/19/24, R8, a resident who was dependent on staff assistance and was at high risk for injury related to a history of osteoporosis, was identified with bruising to her left leg and her feet. An x-ray revealed a probable fracture of the fifth toe on her left foot. Additionally, the facility failed to investigate and analyze R8's unwitnessed fall that occurred on 9/24/24 to determine causative factors. [...]

Inspectors wrote2. Resident # 21 was originally admitted to the facility on [DATE]. The resident's diagnoses included in part a diagnosis of diabetes, dementia, and a history of heart attack and cancer. Review of Resident # 21's 4/12/24 quarterly Minimum Data Set assessment revealed the resident was cognitively impaired. He was able to clearly speak and make himself understood. He was also able to eat with supervision only. The resident was also coded to be a diabetic and had required insulin for seven days in the assessment period. Review of June 2024 monthly orders and the June 2024 MAR (medication administration record) revealed the following: Resident # 21 had an order, which originated on 3/25/23, for Humalog 100 units/ml give 5 units under the skin with breakfast. (Humalog is a fast-acting insulin). [...]

Inspectors wroteBased on record review, and staff, family, and physician interview, the facility to provide accurate notification to the physician of repeated episodes of Resident 22's blood glucose level registering greater than 400 milligrams per deciliter (mg/dL) (normal blood glucose level are considered to be between 70 mg/dL to 100 mg/dL) over two days and to notify the resident's physician and family when Resident #22 was found to be nonresponsive by a physical therapy staff member hours before Emergency Medical Services (EMS) was called. Resident #22 was found with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. [...]

Inspectors wroteBased on record review, staff interviews, family interview, and physician interview the facility failed to protect a resident's right to be free from neglect when they failed to comprehensively assess and effectively monitor a resident with blood glucose levels registering over 400 milligrams per deciliter (mg/dL) (normal blood sugar levels are considered to be between 70mg/dL to 100 mg/dL) over two days, accurately notify the physician of the resident's medical status to ensure necessary care and services were implemented to treat the resident, and to identify the seriousness of the resident's change in medical status and the need to immediately initiate emergency medical services (EMS) when the resident was identified as nonresponsive. EMS was not notified until hours after the resident was first observed as nonresponsive by a physical therapy staff member. [...]

Inspectors wroteBased on observation, record review, and interviews with resident, staff, and Nurse Practitioner the facility failed to ensure Resident # 1 was afforded dignity while residing in the facility. Resident # 1, who was documented to be a bedbound resident, was found with multiple maggots located in her bed, under her breast, and within her contracted hand. Prior to the maggots being found on Resident # 1, staff had observed multiple flies in the resident's room, landing on the resident, and in other parts of the facility. This was for one (Resident # 1) of five residents reviewed for respectful treatment by staff. (Resident # 1 had mental illness and was unable to express harm a reasonable person would express if they had multiple maggots located on them while relying on others for care. Therefore, the reasonable person concept was applied in determining severity to this citation).

Inspectors wroteBased on observation, record review, and interviews with residents, staff, family, and a pest control technician the facility failed to ensure they maintained routine and as needed pest control services for the entire facility. Two of twenty-seven sampled residents were affected by flies. Resident # 24 was observed trying to eat while four flies kept landing on her food. Resident # 1 was found by staff to have multiple maggots on her and in her bed during the timeframe during which the facility was without a service contract and during which time staff members, residents, and family were observing multiple flies in the facility. (Resident # 1 had mental illness and was unable to express harm a reasonable person would express if they had multiple maggots located on them while relying on others for care. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to create a person-centered baseline care plan and provide a summary to the residents and/or responsible party within 48 hours of admission for 3 (Resident #6, Resident #7, Resident #10) of 5 residents reviewed for new admission procedures.

Inspectors wroteBased on observation, record review, and resident, staff, family interview the facility failed to develop and implement a comprehensive care plan to address individual needs related to a resident refusing care secondary to mental illness (Resident # 1), a resident's need for specialized skin care secondary to a genetic disorder (Resident # 2), care for an indwelling catheter (Resident # 16), and discharge planning (Residents # 6). This was for four (Residents # 1, #2, #6, #16) residents of eleven residents whose care plans were reviewed to determine if they addressed individual needs.

Inspectors wroteBased on observation, record review, resident interview, staff and pharmacist interview the facility failed to 1) ensure an accurate accounting system for controlled substances for three (Residents # 26, #27, and #28) of three sampled residents whose controlled substance records were reviewed and during a time in which the facility was accountable for overseeing a nurse working under a restricted nursing license related to narcotic handling and 2) ensure medications were available and administered for one (Resident # 10) of seven sampled residents reviewed for pharmacy services.

Inspectors wroteBased on record review, resident interview, staff interview, pharmacist interview, and physician interview the facility failed to ensure Protimes/ International normalized ratios (INRs) were completed per orders for a resident receiving Coumadin. This was for one (Resident # 2) of one sampled resident receiving Coumadin.

Inspectors wroteBased on staff interview and record review the facility failed to accurately and consistently document vital signs, blood glucose readings, and medication administration for two (Resident #22 and Residnet #13) of three residents reviewed for accuracy of medical record documentation.

Inspectors wroteBased on record review, and interviews with residents and staff the facility failed to ensure a resident was allowed the opportunity to see the room and meet the roommate prior to being moved to a new room within the facility. This was for one (Resident # 19) of one resident reviewed for room change notification.

Inspectors wroteBased on observation, record review, and interviews with resident and staff the facility failed to ensure a room was cleaned prior to moving a resident into the room. This was for one (Resident # 19) of four residents reviewed for a homelike and clean environment.

Inspectors wroteBased on record review the facility failed to report an allegation of neglect of services to law enforcement and adult protective services for one (Resident #22) of three residents reviewed for abuse.

Inspectors wroteBased on record review, and interviews with family, staff, and physicians the facility failed to ensure a thorough investgation was conducted when they received an allegation of neglect for one (Resident # 22) of one sampled resident whose family lodged a complaint of neglect. Resident # 22's family member filed an allegation of neglect after receiving an anonymous phone call that Resident # 22 needed to be sent to the hospital. Interviews revealed the anonymous phone call was made by a medication aide when she feared the resident was about to die and was not receiving medical care while under the care of Nurse # 4. Interview with the medication aide revealed she had previously reported concerns regarding Nurse # 4 not responding to an emergeny situation and former administration did not investigate.

Inspectors wroteBased on record review, staff interviews, and family interviews the facility failed to refer a resident for home health services and order necessary equipment for 1 of 1 resident reviewed for discharge (Resident #6).

Inspectors wroteBased on family interview, record review, staff interviews, and emergency medical services (EMS) report the facility failed to obtain physician orders for one (Resident #4) of five residents reviewed for admission procedures.

Inspectors wrote3. Resident 6 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease. She was discharged to the community on 8/26/24. Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She was coded as planning to discharge to the community. Review of the resident's care plan, dated 8/1/24, revealed no mention of discharge planning. There was no documentation Resident #6, or the Responsible Party (RP) had been invited and involved in a care plan meeting. An interview with Resident # 6's RP on 8/28/24 at 2:47 PM revealed she had never been involved in any type of care plan for the resident. She stated she was initially told Resident #6 was going to be discharged on 8/17/24 and that did not happen. The RP stated she was contacted on 8/23/24 and was told the resident was going to be discharged on 8/24/24. [...]

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to implement an effective discharge planning process for one (Resident #7) of one resident who wished to discharge from the facility.

Inspectors wroteBased on record review, and interviews with resident, family, and staff the facility failed to ensure a resident received assistance with incontinent care. This was for one (Resident # 2) of four residents reviewed for activity of living needs being met.

Inspectors wroteBased on observation, record review, and interviews with staff and physicians the facility failed to obtain orders for the care of a resident's indwelling urinary catheter. This was for one (Resident # 16) of three sampled residents with indwelling urinary catheters.

Inspectors wroteBased on record review, Emergency Medical Services (EMS) record, staff and family interviews the facility failed to provide respiratory care services for one (Resident #4) of three residents reviewed for respiratory care.

Inspectors wroteBased on record review and interviews with resident, staff, and family the facility failed to ensure a system was in place to manage call outs in nursing so incontinent care and showers could be provided. This was for one of four residents reviewed for sufficient staff to meet residents' individual needs (Resident #2).

Inspectors wroteBased on observation, record review and interviews with residents and staff the facility failed to ensure a system where residents who preferred and requested larger portions received the portions per their preference without having to go to the dietary department and ask for more food. This was for two (Residents # 9 and # 11) of six sampled residents reviewed for dietary services to meet their preferences and needs.

Inspectors wroteBased on record review, family interview, and staff interview the facility failed to provide rehabilitation services per the resident's plan of care. This was for one (Resident # 16) of three sampled residents reviewed for therapy services.

Inspectors wroteBased on observation, record review, and interviews with residents, staff, pharmacists, and physician the facility failed to ensure 1) controlled drug receipt disposition records coincided with the order and administration of a resident's morphine which indicated the resident had not received the morphine as prescribed (Resident # 3) and 2) ensure non controlled medications were obtained from the pharmacy and administered per orders (Residents # 8 and # 13). This was for three of five sampled residents reviewed for medications.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and physician interview the facility failed to ensure residents received antibiotics or insulin correctly. This was for one (Resident # 1) of six sampled residents whose medications were reviewed and for one (Resident # 14) out of four residents observed during a medication pass observation.

Inspectors wroteBased on resident interviews, record reviews, staff interviews, pharmacist interviews, and physician interviews administration failed to ensure adequate training and systems were in place as the facility changed over from one medical record system to another during a week when the facility had 14 hospital admissions which required orders to be initiated for care, medications, and treatments. This was for four (Residents #1, Resident # 2, Resident # 3, and Resident # 13) sampled residents of the 13 residents who were admitted during the week of the facility's change over to their new medical record system. (One of the thirteen residents was admitted twice during the first week of transition).

Inspectors wroteBased on record review, staff, and family interviews the facility failed to notify the responsible party of a transport to the hospital for one (Resident #2) of three residents reviewed for notification of a change in condition.

Inspectors wroteBased on record review, and interviews with resident, staff, and physician the facility failed to ensure clarification was obtained when a resident arrived for facility admission without orders for a medication the hospital discharge summary indicated he needed to treat a bone infection. This was for one (Resident # 1) of three residents reviewed for provision of medical care per professional standards of practice.

Inspectors wroteBased on record review, and interviews with a resident, family, staff, and physician the facility failed to ensure orders were obtained and carried out for flushes for a peripheral inserted central catheter. (A peripheral inserted central catheter is a type of intravenous access, which requires flushes with an ordered solution to maintain the patency in order that the line not clot off). This was for one (Resident # 1) of one sampled resident with an intravenous access site.

Inspectors wroteBased on record review, and interviews with resident, family, and staff the facility failed to ensure appropriate transportation was arranged in order that a resident attend a scheduled appointment with a specialist physician. This was for one (Resident # 1) of two residents reviewed for missed appointments.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure their medication rate was below five percent. Two nurses and two Medication Aides were observed to administer medications. Three errors were detected out of 26 opportunities for error resulting in a 11.53 % medication error rate. One error was an omission, one error was because of the wrong medication administered, and one error was the wrong administration time for sliding scale insulin.

Inspectors wroteBased on observation, record review, and interviews with a resident's guardian, staff, hospice provider, and physician the facility failed to initiate a hospice referral when the resident was readmitted with clear instructions that her wishes were for comfort measures which included comfort foods and no tube feedings. After the hospice referral was made, Resident # 3's wishes were still not made known by the hospice provider and facility staff to the physician so that tube feedings could be stopped and comfort foods initiated until the guardian questioned the plan of care. This was for one (Resident # 3) of one sampled resident reviewed for hospice services provided at the facility.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to 1) perform hand hygiene while performing dressing changes and prior to obtaining supplies from the facility's treatment cart and 2) keep scissors in a clean field before using them to cut dressing items used directly in a resident's wound bed and 3) ensure caring of different wounds was a separate task with different gloves and hand hygiene to avoid potential cross contamination between wound beds. This was for one (Resident # 1) of one sampled resident who was observed during wound care.

Inspectors wroteBased on record review and interviews with staff, family, Nurse Practitioners, and physicians, for a resident with multiple wounds caused by shearing and pressure, the facility failed to have a system in place to accurately evaluate the extent nutrition was contributing to the development and non-healing of the wounds and develop a plan to address any nutritional deficit. This was for one (Resident # 4) out of three sampled residents with pressure sores.

Inspectors wroteBased on record review, and interviews with staff and the Nurse Practitioner the facility failed to ensure the medical record was complete and accurate regarding administration of treatments, administration of medications, administration of enteral feedings, and weights. This was for one (Resident # 4 of one sampled resident reviewed for accuracy of medical records.

Inspectors wroteBased on observations, record review, resident, staff, nurse practitioners, and physician interview the facility Quality Assessment Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the complaint survey completed 6/6/2024. This was for three repeat deficiencies in the areas of pressure sore care, nutritional status, and resident record documentation that were originally cited on 6/6/2024. The continued failure of the facility showed a pattern of the facility's inability to sustain an effective QAPI committee.

Inspectors wroteBased on record review and interviews with staff and physicians, for a resident whose weights showed a trending decline, the facility failed to ensure a system was in place for the registered dietician to become aware of accurate weights and develop a plan of care to address weight loss. This was for one (Resident # 4) of two sampled residents reviewed for nutritional status interventions.

Inspectors wroteBased on record review, staff, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #3 refused to assist Resident #2 with eating her meal at lunch time and then yelled at Resident #2 when her lunch tray fell on the floor. Nurse #2 observed the resident shaking and crying after the incident with NA #3. This occurred for 1 of 2 residents reviewed for dignity and respect.

Inspectors wroteBased on record review, resident, and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 4/1/21, 8/11/22 and 11/30/23 and the complaint survey of 1/18/23. This was for a deficiency in the area of Residents Rights/Exercise of Rights (F550). The continued failure during five federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, staff interviews, and Nurse Practitioner interview, the facility failed to follow a physician order for laboratory services for 1 of 1 resident reviewed for providing care according to professional standards (Resident #1).

Inspectors wroteBased on observations, record review and staff interviews the facility failed to treat a resident in a dignified manner when staff used a racial slur and vulgar hand gesture when interacting with a resident (Resident #97) for 1 of 1 resident reviewed for dignity.

Inspectors wroteBased on record review, resident and staff interviews, interview with the Pharmacy Consultant, interview with the Physician (MD), the facility failed to assess for tardive dyskinesia (involuntary movements and a side effect of long-term treatment with antipsychotic medications) for a resident prescribed an antipsychotic medication (Resident #81). Additionally, the facility failed to ensure a physician's order for as needed (PRN) psychotropic medication for a resident (Resident #56) was time limited in duration. This affected 2 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, staff, Registered Dietician, and physician interviews, the facility failed to follow a physician order for obtaining a resident's weight twice per week for 1 of 5 residents (Resident #32) reviewed for nutrition.

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to rinse soap from a resident's skin per manufacturer's directions during a bath for 1 of 4 resident reviewed for activities of daily living care (Resident #26).