Perry Health & Rehab Center

Inspectors wroteBased on review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents with pressure ulcers for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart for three of four medication carts (Second Floor B, C, G Hall Medication Cart, Third Floor Front Hall Medication Cart and Third Floor Back Hall Medication Cart).

Inspectors wroteBased on review of facility provided documents and staff interviews, it was determined that the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents (Resident R3).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R1 and R4) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of three resident hospital transfers (Residents R1 and R4) .

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and resident, and staff interviews, it was determined that the facility failed to make certain call lights were answered timely for four of 12 residents as required (Resident R1, R2, R3, and R4).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of six residents (Resident R1, R2, and R3) and one of two shower rooms on the second floor (Large Shower Room). Findings Include:Interview with the Nursing Home Administrator on 12/10/25, at 12:51 p.m. indicated the facility does not have a policy regarding homelike environment. Review of the clinical record indicated Resident R1 admitted to the facility on [DATE]. Review of the clinical record indicated Resident R2 admitted to the facility on [DATE]. Review of the clinical record indicated Resident R3 admitted to the facility on [DATE]. Review of the Grievance Log dated December 2025, indicated on 12/8/25, Resident R1's family filed a grievance regarding a pipe in the room. Interview on 12/9/25, at 9:05 a.m. [...]

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse for one of three residents (Resident R4). This failure was determined to be past noncompliance as of 12/5/25.

Inspectors wroteBased on review of facility policy, resident clinical records, facility provided documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R4).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R4).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to properly monitor residents in room personal refrigerator temperatures for two of three residents (Residents R33 and R46) which created the potential for food borne illness, failed to implement appropriate transmission-based precautions for nine of 18 residents (Residents R46, R55, R75, R92, R102, R153, R163, R169, and R173), and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46).

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for two of three residents (Resident R42 and R62).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R91).

Inspectors wroteBased on clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to provide in a timely manner, notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), Form CMS - 10055 for one of two residents reviewed (Resident R142).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of eight medication carts (second floor cart).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R119).

Inspectors wroteBased on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46).

Inspectors wroteBased on a review of facility documentation, resident and staff interview it was determined that the facility failed to provide an on-going program of activities to meet the interests of and support the physical, mental, and psychosocial and well-being of residents for one of seven residents (Resident R128).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of four residents (Residents R56 and R57).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R13 and R77).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R17 and R65).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of four residents reviewed (Residents R111 and R119).

Inspectors wroteBased on review of facility policy, facility documentation, clinical record review, resident and staff interview it was determined that the facility failed to provide medically related social services to help a resident reach their highest practicable psych-social needs for addressing the recommendations of a psychologist report for one of two residents (Resident R128).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure medications on one of eight medication carts (Dover Medication Cart), failed to properly label medications upon opening on one of eight medication carts (Royal Pavilion Back Hall Medication Cart), and failed to properly secure a medication cart while not in use for one of eight medication carts ([NAME] Gardens Medication Cart).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post contact information for Adult Protective Services, and State Long-Term Care Ombudsman program as required for three out of three nursing floors (First Floor, Second floor, and Third Floor)

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Resident R2, R3, and R4).

Inspectors wroteBased on observation, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received the correct medications upon admission to the facility.

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of seven residents (Residents R1), which resulted in actual harm when Resident R1 fell out of bed and sustained a right hip fracture and head contusion. Review of the facility policy Fall Prevention and Management dated 3/4/25, reviewed 3/14/25, stated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage resident's care if a fall occurs. A fall assessment should be completed upon admission, quarterly, and with any significant changes. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for one of one coffee area (first-floor lobby). Findings Include: Review of the facility policy Resident Rights last reviewed 3/14/25, indicated it is the policy of this facility to provide resident care that meets the psychosocial, physician and emotional needs and concerns of the resident. Safety of residents, visitors and employees is a top priority of care During an observation completed on 7/1/25, at 9:08 a.m. the first-floor lobby coffee area revealed the following: · The ice machine with white substance on catch tray, the counter area under the ice machine had white substance and debris. · The microwave revealed brown splatter debris on inside. [...]

Inspectors wroteBased on review of facility policy, clinical records, resident interviews and staff interview it was determined that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for two out of seven residents (Closed Record (CR) Resident R1 and Resident R3).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of eleven residents (Resident R1). This failure created an immediate jeopardy situation for 1 of 124 residents. Review of the facility policy Elopement Prevention and Management Overview dated 10/24/24, defined elopement as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. Unsafe wandering is defined as when a resident/patient enters an area that is physically hazardous or contains potential safety hazards. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to fully investigate an incident to eliminate possible neglect for one of two residents (Resident R1). Review of the facility policy Abuse, Neglect and Misappropriation, dated 4/18/24, with a previous review date of 8/21/23, indicated that the facility will provide resident centered care and the intent of the facility is to prevent the abuse, mistreatment or neglect of residents. The accurate and timely identification of any event which would place our residents at risk for potential abuse is the primary concern. Each occurrence of resident incident, bruise, etc., will be identified and reported to the supervisor and investigated immediately. In the event a situation is identified as abuse, neglect, etc., an investigation by the executive leadership will follow. [...]

Inspectors wroteBased on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aide personnel records Nurse Aide (NA) Employee E26, E27, E30, E31, and E33).

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products in the Main Kitchen (Main Kitchen) and failed to properly label and date food in one of two nursing unit pantries (Third Floor Unit Pantry) which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage: Cold Foods last reviewed 10/24/24, and previously reviewed 9/9/23, indicated that all foods will be wrapped or stored in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. During an observation and interview in the Main Kitchen walk-in freezer, on 10/27/24, at 9:30 a.m., an open bag of chicken breast was found to be unsealed, unlabeled and undated, and an open package of ravioli was found to be opened, unlabeled, and undated. [...]

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to maintain and implement an effective Quality Assurance and performance improvement program that focuses on outcome by failing to implement a QAPI for 11 previously cited citations.

Inspectors wroteBased on review of facility documentation, observations, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2024 election and the facility failed to provide a dignified dining experience for one of three Residents (Resident R43).

Inspectors wroteBased on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of 10 residents (Residents R17, R50, and R71).

Inspectors wroteBased on review of facility policy, resident council minutes, group and staff interview it was determined that the facility failed to respond to resident concerns and grievances identified during resident council meeting for six of six months reviewed (May 2024 to October 2024).

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for three out of six resident rooms (Resident R12, R75, and R83), and one out of four medication carts (100 RP Wing Med cart).

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for six of six residents with facility-initiated transfers (Residents R20, R36, R41, R42, R48, and R101).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for six of six resident hospital transfers (Residents R20, R36, R41, R42, R48, and R101).

Inspectors wroteBased on review of clinical records and observations, as well as staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for four out of nine sampled residents (Resident R27, R46, R48, and R87).

Inspectors wroteBased on a review of the clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for six of six residents (Residents R1 and R112 and Residents R200, R201, R202, and R203).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for residents with an indwelling urinary catheter (a tube inserted in the bladder to drain urine) for three of four residents reviewed (Residents R42, R48, and R107).

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that refrigerated medications are stored at proper temperatures for one of four medication rooms (Third Floor Medication Room), failed to store medications properly and securely in medication carts, failed to secure treatment carts on two out of five treatment carts (Second Floor C1-Nursing unit, and D Unit Treatment carts), failed to ensure a medication room was properly locked (Second Floor D Wing Medication Room), failed to properly store medical supplies and biologicals in one of two medication rooms (Second Floor D Wing Medication Room), failed to store treatments for residents properly to prevent cross contamination for three of four medication carts (First floor RP Medication cart and Second Floor D Wing Medication cart, Third floor East medication [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for four of four residents (Resident R7, R47, R77, and R101) failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for two of three residents reviewed (Residents R48 and R113) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (Third Floor Medication Room).

Inspectors wroteBased on review of facility documentation, resident and staff interview it was determined that the facility failed to maintain an effective pest control program for two of three floors ( first and second floors).

Inspectors wroteBased on facility policy, resident representative and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Closed Resident Record R177).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview it was determined the facility failed to notify the physician of a change of condition for one of eight residents (Resident R173).

Inspectors wroteBased on review of facility policy, resident council interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to ensure anonymous grievance forms are readily accessible for resident use on one of three floors (Second floor).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, resident representative interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent physical neglect for two of four residents (Resident R87 and R107).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and resident and staff interviews, it was determined that the facility failed to report allegations of neglect in the required timeframe one of three residents (Resident R48).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order for two of three sampled residents (Residents R5 and R88) and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of three sampled residents (Resident R5).

Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician orders for negative pressure wound therapy devices (NPWT or wound vac - used to draw out fluid and infection from a wound to help it heal) for one of three residents (Resident R107), and failed to obtain physician treatment orders for an as needed dressing for one of three residents (Resident R64).

Inspectors wroteBased on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care for one of three sampled residents (Resident R27).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform timely and accurate post-fall documentation and failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R50).

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R85). Findings Include: A review of the facility policy Medication Administered by Enteral Tube (surgically placed device through an artificial opening in the abdominal wall) dated 10/24/24, indicates this policy addresses guidance for the clinical administration of medications through a G-tube (surgically placed device used to give direct access to the stomach). Equipment needed but no inclusive to 60cc piston syringe, the syringe is dated upon opening and changed daily. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of two residents (Resident R71 and Resident R113).

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Second floor D Wing Medication room).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by the facility after the consultant pharmacist recommendations were made for three out of 12 months (November 2023, March 2024, and April 2024).

Inspectors wroteBased on facility policy, clinical record review, and staff interview it was determined the facility failed to identify a diagnosed specific condition for treatment for one of three residents receiving psychotropic medication reviewed (Resident R93) Findings Include: Review of facility policy Resident Rights dated 9/19/23, last reviewed 10/24/24, indicated to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident. Review of the admission record indicated that Resident R93 was admitted to the facility on [DATE]. Review of Resident R93's care plan revised on 8/27/24, indicated resident R93 uses anti-psychotic medication due to behaviors: verbal outburst, violently shoving items or throwing items, tearful. Observe for side effects of anti-psychotic medications. [...]

Inspectors wroteBased on review of facility policy, clinical record review and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of eight residents (Resident R73 and R173).

Inspectors wroteBased on review of facility policy, resident clinical records, and resident and staff interviews, it was determined that the facility failed to provide routine and emergency dental services for one of two residents (Resident R27).

Inspectors wroteBased on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of two residents ordered an NPO (nothing by mouth) diet.

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain essential equipment heating units for three rooms on the second floor (238, 239, and 251).

Inspectors wroteBased on an observation and staff interviews, it was determined that the facility failed to prominently display Nurse Staffing Information for two of five days (10/30/24 and 10/31/24).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a safe, clean and homelike environment in resident public areas. (Front entrance outside walkways). Findings Include: Review of the facility policy Resident Rights dated 4/18/24, indicated - Dignity: a state worthy of honor or respect; includes but not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing, sanitary food and hydration; respecting resident choice and attending to needs in a timely fashion. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, resident clinical records, facility documents, resident and staff interviews, it was determined that the facility failed to report an allegation of physical abuse for one of three sampled residents (Resident R3).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of five residents (Resident R2 and Resident R4).

Inspectors wroteBased on review of facility policy, observations, resident council minutes, resident and staff interview it was determined that the facility failed to maintain a clean and safe, homelike environment in one of two community bathrooms (across from room [ROOM NUMBER]), one of six resident rooms (Resident R1), and failed to have an ample linen supply available for two of six residents (Resident R1 and Resident R2). Findings Include: Review of the facility policy Resident Rights dated 4/18/24, indicated dignity is a state worthy of honor or respect; includes but not limited to speaking respectfully to residents, providing privacy for care and treatment, providing safe and secure housing, sanitary food, and hydration; respecting resident choice and attending to needs in a timely fashion. Observation on 7/23/24, at 9:15 a.m. [...]

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in operating condition for one resident common area (Second floor D-lobby ) and two out of 11 resident rooms (Resident R1 and Resident R2).

Inspectors wroteBased on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to identify and report an allegation of neglect in the required timeframe for three of three abuse allegations (Resident R1, R2, and R3).

Inspectors wroteBased on review of facility policy, observations, review of grievances, resident and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of 13 residents (Resident R1, R2, R3, R4, R5, R6 and R7). Findings Include: Review of facility's Nurse Aide job description last revised dated June 2019, previously reviewed 4/18/24, indicated the nurse aides provide routine nursing and personal care for residents to assure that the highest degree of quality resident care is maintained at all times. This position must work effectively with team members ensuring that work is accomplished and quality care delivered. [...]

Inspectors wroteBased on a review of facility policy, clinical records, grievance logs, and Concern Forms it was determined that the facility failed to perform a thorough and complete investigation for grievances that were submitted in the facility related to resident care and call bell times for three of three residents (Resident R1, R2, and R3).

Inspectors wroteBased on review of facility policies, clinical records, facility's grievances, resident and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect for two of four residents (Resident R1 and Resident R3).

Inspectors wroteBased on an abbreviated survey in response to a complaint completed on June 4, 2024, it was determined that Quality Life Services- [NAME] was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations. Based on a review of the facility's policies, plans of corrections and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on review of facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for four out of five residents (Residents R1, R3, and R12)

Inspectors wroteBased on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for four of five residents (Residents R1, R3, R12, and R19).

Inspectors wroteBased on facility policy, job descriptions, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five units (E Wing.) Findings Include: Review of facility's Nurse Aide job description last revised dated June 2019, previously reviewed 4/18/24, indicated the nurse aides provide routine nursing and personal care for residents to assure that the highest degree of quality resident care is maintained at all times. This position must work effectively with team members ensuring that work is accomplished and quality care delivered. Review of the facility's Nurse Shift Change and Walking Rounds policy dated 4/18/24, indicated the nurse will provide reports and changes to on-coming nurse assistants. During an interview on 5/22/24, at 10:36 a.m. [...]

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R12).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify family of a change in condition of a resident for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for two of three residents. (Resident R1 and Resident R44)

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician admission orders for one of three residents (Resident R2).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to obtain physician admission orders for one of three residents (Resident R). Review of the facility policy Resident Rights dated 10/17/23, indicate to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Review of the facility policy Enteral General Nutrition (tube feeding) guidelines indicate to verify physician orders for type of enteral formula, amount, frequency, flush volume, and method of delivery. [...]

Inspectors wroteBased on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication and medication was provided as per order for one of three closed records (Closed Resident Record CR1)

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, properly restrain hair and perform hand washing and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Cold Foods last reviewed 10/17/23, indicated that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy Staff Attire, last reviewed 10/17/23, indicated that all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. [...]

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R81).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for four of twelve residents (Residents R1, R3, R62, and R71).

Inspectors wroteBased on facility policy, clinical record review, resident interviews, resident representive interview, and staff interviews, it was determined that the facility failed to make certain that showers and assistance for activities of daily living were consistently provided for two of ten Residents (R7 and R67). Review of the facility policy Routine Resident Care, last reviewed 10/17/23, indicated that routine care by a nursing assistant includes assisting or providing for personal care including bathing. Review of Resident R7's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 8/26//23, included diagnoses of paraplegia (paralysis of the legs and lower body), stage four pressure ulcer (pressure injury with full thickness skin loss with extensive destruction; tissue necrosis: [...]

Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to provide sufficient wound care equipment for negative pressure wound therapy devices (NPWT or wound vac - used to draw out fluid and infection from a wound to help it heal) for two of two residents (Resident R121 and R118 ) and failed to follow physician treatment order for one of two residents (Resident R118).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Resident R1, R3, R29, R55, and R62).

Inspectors wroteBased on review of facility policy, resident interviews, resident representative interviews. observations, group resident interviews, grievance review, and Resident Council documentation, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of six residents (Resident R8, R16, R67, R230). Findings Include: Review of the policy Resident Rights last reviewed 10/17/23, indicated the dignity includes but is not limited to respecting resident choice and attending to needs in a timely fashion. During an interview on 10/23/23, at 9:23 a.m., Resident R230 stated that she had her call bell on one time for two to three hours and no one came. I peed my pants. [...]

Inspectors wroteBased on review of facility policies and clinical records, observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent for one of three residents (Resident R89).

Inspectors wroteBased on observation, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three nursing units (first floor nursing unit). The facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of three medication rooms (E Wing Medication Room). The facility failed to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R34).

Inspectors wroteBased on review of facility documentation, resident and staff interviews it was determined that the facility failed offer residents the opportunity to vote for the May 2023 election and the facility failed to provide a dignified dining experience for one five residents reviewed (Resident R9).

Inspectors wroteBased on review of facility policy, observations, resident interview, and employee interviews it was determined that the facility failed to accommodate the call bell needs of one of six residents (Residents R10).

Inspectors wroteBased on review of facility policy, resident council minutes, group and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for five of five months (October 2023 To July 2023).

Inspectors wroteBased on review of the facility Resident Trust Bond (surety bond), it was determined that the facility failed to identify Residents that had their accounts managed by the facility as the beneficiaries bond.

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain privacy of confidential information during medication administration for two of two residents (first floor nursing unit).

Inspectors wroteBased on facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide and/or identify where the grievance forms were located, failed to inform the residents of the location, in the grievance policy failed to identify what a reasonable time frame for responding to concerns means in the grievance policy met the regulation.

Inspectors wroteBased on review of facility policy, facility documents, clinical record and staff interview it was determined that the facility failed to protect a Resident from sexual abuse, and failed to implement a long term plan to ensure safety of other residents, failed to monitor Residents for any ongoing behaviors, and failed to identify the behaviors for one of three residents reviewed (Resident R71).

Inspectors wroteBased on review of facility policies, clinical record review, observations and staff interviews, it was determined the facility failed to identify side rails as a possible restraint and failed to assess the functional status of individual residents to determine if the use of bed rails is a restraint for two of five residents (Residents R29 and R55).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of three residents (Resident R34).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for one of six residents (Resident R101).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide pressure ulcer treatment consistent with professional standards of practice and failed to prevent worsening of pressure injuries. The facility failed to promote healing and provide treatment according to the physician orders for one of three residents (Resident R34).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide appropriate assistance with transfers creating a potential accident and hazards for one of five residents (Resident R30).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner for two of five residents (Resident R10, and R118) and to identify needs for increased nutrition for one of five residents (Resident R118).

Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that an enteral feeding (nutrition through a tube in the stomach) was administered in a safe manner to one of two residents (Resident 89) who had a gastrostomy tube (surgically placed tube in the stomach).

Inspectors wroteBased on review of facility education documents and staff interview it was determined that the facility failed to ensure that nurse aides (NA) demonstrate competency and skills necessary to safely transfer a resident according to the resident's assessed needs and care plan for one of five nurse aides (NA Employee E12) and failed to ensure that an enteral feeding (nutrition through a tube in the stomach), and medications were administered in a safe manner (Registered Nurse RN Employee E8 and RN Employee E17).

Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide appropriate, ongoing assessment for two of three residents reviewed (Resident R25 and R98) who had Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions).

Inspectors wroteBased on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for one of three residents. (Resident R89).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication rooms (C Wing Medication Room).

Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide complete meals/nutrition services for three of six Residents who did not receive a meat and or protein option with their dinner meal (Resident R3, R4, and R5).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents with limited range of motion receive assessment and treatment to achieve and maintain and/or improve mobility for one of four residents (Resident R2). Finding s include: Review of facility policy dated 3/30/23, Professional Standards of Quality It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concern of the residents. The attending physician shall authenticate orders for the care and treatment of assigned residents. The attending physician or physician designee will review and approve all recommendations, orders received from an outside, non-privileged consultant medical provider. [...]

Inspectors wroteBased on review of facility policy, clinical records and staff interview it was determined that the facility failed to ensure medications were administered per physician order for one of four residents (Resident R2).