Pine Acres Rehabilitation and Care Center

Inspectors wroteBased on clinical record review, staff interview, observation, and facility policy review, the facility failed to conduct comprehensive, ongoing nursing assessment and interventions for 7 of 7 residents reviewed for significant changes of condition (Resident #2, #7, #93, #71, #41, #83, #94). Resident #2 fell out of bed on [DATE] striking his face on the floor sustaining injury. The resident was sent to the emergency room (ER) where a nose fracture was ruled out and he returned to the facility. The morning of [DATE] the resident complained of pain and transferred back to the ER returning with orders for 5 days of antibiotic medication to treat a diagnosed UTI (Urinary Tract Infection) with hematuria (blood in urine). [...]

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to implement preventive measures for a resident at risk of developing pressure sores for 4 of 4 residents reviewed for pressure sore prevention and interventions (Resident #73, #83, #85, #94). The facility failed to utilize a pressure reducing wheelchair cushion until after Resident #73 developed an avoidable facility-acquired Stage 4 (full-thickness skin damage) pressure sore to the lower right posterior thigh (which presented with eschar [dead tissue] and treated with antibiotic), failed to maintain pressure relief to the area once developed, and failed to provide major reposition changes and incontinence care over a 7.5 hour period based on a continuous observation. [...]

Inspectors wroteBased on grievance forms, clinical record review, family interview, staff interview, and facility policy review, the facility failed to timely and effectively manage resident pain for 1 of 1 residents reviewed for pain management (Resident #94) and for 3 residents via grievance reports (room [ROOM NUMBER]-A, Resident #59, room [ROOM NUMBER]). The facility failed to assess and intervene upon the report of Resident #94 having acute pain and failed to initiate a new order for morphine pain medication in a timely manner on 3/23/26. The resident experienced severe, avoidable pain as evidenced by non-verbal pain indicators and family reports. The facility failed to successfully submit escripts for the acute pain medication to the pharmacy leading to a delay in obtaining and administering the medication. [...]

Inspectors wroteBased on facility grievance documents, clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to prevent physical abuse for 1 of 2 residents reviewed for abuse (Resident #81). The facility failed to perform assistance with bed mobility and transfers in a manner to prevent the occurrence of physical harm as evidenced by bruising to Resident #81's right elbow and left wrist as a result of staff holding the resident's arms too hard. The facility failed to converse with Resident #81 in a manner to prevent potential intimidation as the resident expressed a desire to shower at a different time than staff wanted. [...]

Inspectors wroteBased on clinical record review, facility document review, observations, staff interviews and policy review, the facility failed to ensure each resident received Safe Smoking Assessments quarterly and/or with change in condition, adequate supervision for smoking and fall prevention safety, and interventions to prevent accidents when smoking and reduce risks for falls for 10 of 14 residents reviewed (Resident #7, #9, #46, #51, #56, #69, #71, #78, #80, #2). Resident #80 sustained injury of a thermal burn when the end of a cigarette fell into his shoe on 5/14/26. Resident #2 sustained facial injury with abrasion to the nose when a staff member moved the bed away from the wall on 4/19/26 leading to the resident landing on his face. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, family interview, resident interview, and staff interview, the facility failed to maintain an environment free of offensive odors, which were pervasive throughout the building during the majority of the survey period. The facility reported a census of 81 residents.

Inspectors wroteBased on facility grievance forms, resident interview, staff interview, and facility policy review, the facility failed to effectively resolve grievances and failed to document written outcomes on whether grievances were confirmed or not confirmed. The Monthly Grievance Logs from January through the beginning of May 2026 revealed a total of 75 grievances filed by 36 different residents, representatives, or staff (Resident #3, #5, #6, #8, #10, #15, #16, #20, #21, #22, #25, #30, #35, #36, #39, #43, #44, #45, #46, #49, #51, #52, #58, #59, #64, #66, #72, #73, #74, #78, #81, #83, #84, #85, #88, #92). The failure has the potential to impact all residents in the building, indicating a widespread issue. The facility reported a census of 81 residents.

Inspectors wroteBased on review of the facility assessment, resident council meeting minutes, facility grievance forms, resident interview, observation, family interview, and staff interview, the facility failed to provide sufficient staffing to meet resident needs in a timely manner in regards to answering call lights, providing incontinence care, and overall assistance with activities of daily living. The evidence identifies staffing concerns reported by 2 resident council meetings that had 18 and 14 attendees respectively and 23 different residents affected (R#1, #4, #8, #9, #12, #13, #21, #22, #25, #30, #35, #43, #44, #45, #49, 52, #59, #64, #72, #73, #74, #78, #81, #85 and 3 discharged residents identified by room numbers 504, 504-A, 205-B), indicating a widespread issue. The facility reported a census of 81 residents.

Inspectors wroteBased on filed grievances, recertification survey outcomes, resident interviews, observations, family interview, and staff interviews, the facility failed to provide effective leadership and administration of resources to ensure a safe, clean environment, free from abuse and neglect, with quality of care services provided by sufficient and competent staff. This failure was a widespread systemic failure affecting all residents in the building. The facility reported a census of 81 residents.

Inspectors wroteBased on facility document review, observation, staff interview, and facility policy review, the facility failed to revise the facility assessment as needed to identify the changes to the leadership team, the high number of residents who required assistance with transfers and incontinence care, and how those changes directly impacted the assessment and determination of how many staff were needed to meet resident needs. The facility assessment affects all residents in the building and the facility reported a census of 81 residents.

Inspectors wroteBased on previously imposed Directed Plan of Correction monitoring, filed grievances, current survey outcomes with repeat deficiencies and identification of 6 Substandard Quality of Care tags with 3 rising to the level of immediate jeopardy, staff interview, and facility policy review, the facility failed to effectively monitor and improve the quality of care residents received. The failure represented a systemic, widespread failure with potential to impact all residents who resided in the facility. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, record review, resident and staff interviews and policy review, the facility failed to implement and practice infection control policies and practice Enhanced Barrier Precautions (EBP) according to resident care plans for 6 of 6 residents reviewed (Residents #19, #6, #83, #52, #85, and #73). The facility failed to practice appropriate infection control measures with soiled laundry and the delivery of clean laundry. The facility failed to implement an effective infection control program due to the lack of tracking records for the entire facility and antibiotic stewardship program from January 2026 to June 2026. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital, failed to obtain bed hold notifications, and failed to document disposition of resident belongings and discharge status, for 5 of 5 residents (Resident #1, #2, #7, #52, #93) reviewed for discharge processes. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to revise care plans to accurately reflect resident needs in a timely manner for 3 of 3 residents triggered for care plan revisions (Resident #1, #86, #52). The facility reported a census of 81 residents.

Inspectors wroteBased on grievance documents, clinical record review, resident interview, observation, and staff interview, the facility failed to provide timely and complete assistance to residents who needed help with toileting / incontinence care, grooming, oral care, and transferring for 6 residents reviewed for assistance with personal cares (Resident #81, #73, #83, #53, #85, #86) and 14 residents identified via grievance forms (Resident #81, #49, #43, #45, #78, #8, #83, #52, #22, #59, #25, #64, #66, formerly room [ROOM NUMBER]-B). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a restorative program to residents with mobility concerns for 4 of 4 residents reviewed (Resident #3, #71, #83, #85). The facility reported a census of 81.

Inspectors wroteBased on observations, record review, staff interviews, and facility policy review, the facility failed to ensure nursing staff demonstrated the competencies and skills necessary to provide nursing services that met residents' needs. This was evidenced by Certified Nursing Assistants (CNAs) failing to perform proper hand hygiene, provide appropriate incontinence care, and demonstrate knowledge and implementation of Enhanced Barrier Precautions (EBP) and other infection prevention and control practices for 4 residents whose care was observed (Resident #83, #85, #52, #73). The facility also failed to ensure licensed nursing staff possessed the knowledge and competencies necessary to assess, monitor, and provide individualized, person-centered care based on residents' clinical conditions. [...]

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to label and date open food items in the refrigerator, and freezer. During the initial observation of the kitchen numerous food items were not stored in a safe manner that would prevent foodborne illness to the residents and several food cooking surfaces were in need of cleaning. The facility reported a census of 81 residents.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain essential equipment to ensure safe operating condition. On inspection, 2 out of 2 commercial dryer lint filters were completely filled with lint that decreased airflow. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to respect a resident's dignity throughout all care provided and talk to resident with dignity and respect for 1 of 6 residents reviewed (Resident #25). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, resident interview, observation, and staff interview, the facility failed to honor a resident's choice of bathing time for 1 of 1 residents reviewed for choices (Resident #81). The facility reported a census of 81 residents.

Inspectors wroteBased on grievance document, clinical record review, resident interview, staff interview, facility investigation review, and facility policy review, the facility failed to report allegations of abuse involving injuries of unknown origin (Resident #71) and bruising that occurred as a result of staff grabbing a resident too hard (Resident #81) to the Department of Inspections, Appeals, and Licensing (DIAL) in a timely manner for 2 of 2 residents reviewed for abuse reporting. The facility reported a census of 81 residents.

Inspectors wroteBased on grievance document, clinical record review, resident interview, observation, staff interview, facility investigation review, and facility policy review, the facility failed to conduct thorough investigations of allegations of abuse including bruising that occurred as a result of staff grabbing a resident too hard and allegation of intimidation/verbal abuse for 1 resident (Resident #81) and allegations of abuse involving injuries of unknown origin rib fractures for 1 resident (Resident #71), for 2 of 2 residents reviewed for comprehensive abuse investigations (Resident #81, #71). As a result, the facility could not ensure that allegations of abuse and injuries of unknown origin were fully investigated in accordance with facility policy and regulatory requirements. The facility reported a census of 81 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure complete discharge planning and documentation for an individual who chose to leave the facility against medical advice (AMA) for 1 of 1 residents reviewed (Resident #92). The facility reported a census of 81.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to document under Section A of the MDS assessment, the presence of a PASRR (Preadmission Screening and Resident Review) Level II condition of a serious mental illness and/or intellectual disability or related condition for 2 of 4 residents reviewed for accurate MDS (Minimum Data Set) assessments (Resident #1, #16). The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to include high risk medications and smoking status for 2 of 2 residents reviewed (Residents #1 and Resident #71) for Care Plans. The facility reported a census of 81.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to ensure staff followed a gastrostomy tube (G-tube) feeding order for 1 of 4 residents reviewed (Resident #85) reviewed for nutrition. The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to administer oxygen in accordance with physician orders for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to administer insulin medication as ordered for Resident #79 and failed to discontinue an anticoagulant (blood thinning) medication for Resident #52, for 2 of 2 residents reviewed for significant medication errors. The facility reported a census of 81 residents. 1. Resident #79's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented active diagnoses of hypertension (high blood pressure), diabetes mellitus (chronic high blood sugar), anxiety (excessive persistent worry), and depression (persistent sad mood). [...]

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure the medication cart was locked when the Certified Medication Aide (CMA) responsible for the cart was not in sight. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to maintain accurate medical records for 2 of 2 residents triggered directly for review of accurate records (Resident #86, #72). The facility failed to record accurate weight records and maintain a clinical record without discrepancies for Resident #86 as 7 weight values struck out months after the initial recording of the values and the different areas of the clinical record did not reflect the same information pertaining to either a weight loss or weight gain. The facility also failed to record accurate clinical record for Resident #72 as the nurse practitioner documented an in the facility visit and a complete assessment for Resident #72 who was in the hospital, not in the facility. The facility reported a census of 81 residents.

Inspectors wroteBased on observation and staff interviews, the facility failed to post the daily staffing report as required in a public location for residents and visitors to see on a daily basis. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly secure medications from unauthorized access by failing to lock 2 of 2 medication carts observed. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, resident and staff interview, and facility policy review the facility failed to prepare and serve food that was palatable for one of four hallways observed. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 11 residents' information accessible when staff walked away from the Electronic Health Record (EHR) laptop. The facility reported a census of 81 residents.

Inspectors wroteBased on record review, observations, resident interviews, staff interviews and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for one of twelve residents observed and required assistance for eating (Residents #30). The facility staff also failed to respond in a timely manner to call light and assist a resident off the toilet, and failed to administer pain medication for one of twenty-five residents sampled (Resident #7), and failed to knock and wait for a response before entered a resident's room (Resident #72 & #74) . The facility reported a census of 81 residents.

Inspectors wroteBased on record review, resident interview, staff interviews, and policy review, the facility failed to include interventions for a resident who sustained a fall with an injury (#71) and antianxiety medication and target behaviors for 1 of 5 residents (#41) in the residents' Care Plans. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to follow the physician's orders for 1 of 3 residents reviewed for change in condition (Resident #83). The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to protect a resident's (#54) heels during a mechanical lift transfer and failed to provide supervision for an at-risk resident who went to the courtyard and smoked. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, resident and staff interviews, facility document review and clinical record review, the facility staff did not consistently answer call lights within a reasonable amount of time. Family members and residents reported having to wait thirty to forty-five minutes for the call light to be answered numerous times during the evening and night time. Residents reported during evening cares and shift change the wait is longer. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, hospital record review, resident and staff interviews, and policy review, the facility failed to administer accurate medications to 1 of 13 residents (#38) resulting in a fall and hospitalization due to low pulse and blood pressure. The facility reported a census of 81 residents.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to implement infection control practices to prevent urinary tract infections (UTI) by lifting an indwelling catheter drainage bag above the resident's bladder during perineal care for 1 of 1 resident (#16). The facility reported a census of 81.

Inspectors wroteBased on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to provide the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #12). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interviews, facility policy review and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to administer the COVID-19 vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #20). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, hospital record review, facility policy review, family and staff interviews, the facility failed to provide timely assessment and intervention for 2 of 3 (Resident #1 and Resident #8) residents in the sample. The facility failed to respond to reports of a change in condition for Resident #1, which resulted in a hospitalization for sepsis; and failed to notify the provider of the need to evaluate and review a 30-day order for psychotropic medications for a new admission (Resident #8) prior to their expiration. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to follow physician orders to remove a fentanyl patch prior to applying a new patch for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of residents.

Inspectors wroteBased on observations, resident and staff interviews and facility policy review, the facility failed to maintain a safe, clean and comfortable environment, free of possible hazards. The facility reported a census of 79 residents.

Inspectors wroteBased on record review, resident interviews, observations, staff interviews, and policy review the facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner to 5 of 5 residents reviewed (Resident #8, #12, #17 , and #5). The facility reported a census of 79 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews and policy review the facility failed to maintain infection control practices for 8 of 8 residents reviewed. The facility failed to ensure use of EBP when required, failed to maintain hand hygiene with dining and failed to maintain infection control practices during catheter care. The facility reported a census of 79 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (#11) of three residents reviewed. The facility reported a census of 79 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification survey. The facility reported a census of 75 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to document a resident's transfer to the hospital, physician and family notification, and a bed hold for 1 of 3 residents reviewed. (Resident #7) The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to accurately complete a Minimum Data Set (MDS) Assessment by not identifying a resident had a serious mental illness as considered by the state level II Preadmission Screening and Resident Review (PASRR) for 1 of 16 residents (Resident #34) reviewed. The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 4 residents reviewed with mental health diagnosis and medications (Resident #31). The facility reported a census of 75 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 20 residents reviewed (Resident #25). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to accurately reflect status of 1 of 20 (Resident #48) residents reviewed. The facility reported a census of 75.

Inspectors wroteBased on observation, record review, resident interviews, staff interviews and policy review, the facility failed to ensure the resident's environment was free from hazards and each resident received adequate supervision to prevent accidents and ensure safety for 2 of 4 residents reviewed (Resident #75 and #5). The facility reported a census of 75 residents.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure knowledge and techniques necessary to care for residents' medication management in a timely manner for 1 of 5 residents reviewed for unnecessary medications, chemical restraints/psychotropic medications and medication regimen review (Resident #31). The facility reported a census of 75.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to safely store and label resident's medications. The facility reported a census of 75 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility policy review, the facility failed to provide assessments, obtain orders, or follow up with physician on a resident with an identified central line for 1 of 3 residents (Resident #2) reviewed for assessment and intervention. The facility reported a census of 65 residents.

Inspectors wroteBased on staff and resident interviews, clinical record review, staff training schedule review, and facility policy review, the facility failed to ensure the behavioral health program was effective for a resident with history of Substance Use Disorder (SUD), when direct care staff reported a lack of training for SUD, resident plan of care lacked plans to prevent substance use in the facility, or interventions for suspected or identified substance use by resident, and lacked plans for the potential of an overdose emergency, when Resident #1 displayed erratic behaviors resulting in hospitalization with positive Methamphetamines drug test for 1 of 3 residents (Resident #1) reviewed for behavioral health. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, record review, family and staff interviews, hospital notes, Emergency Medical Service (EMS) report and policy review, the facility failed to ensure residents were adequately supervised for 1 of 3 resident's reviewed for elopement (Resident #1). The facility staff failed to know Resident #1 left the facility unattended, was severely cognitively impaired and wore a wander guard bracelet to alert staff if attempting to leave the facility. Resident #1 was last seen by staff on 10/21/24 at approximately 1:45 PM. The resident ambulated approximately 0.2 miles from the facility and suffered a fall. The EMS was called and they alerted the facility on 10/21/24 at approximately 2:15 PM that the resident had fallen and would be transported to the Emergency Department (ED) for evaluation. [...]

Inspectors wroteBased on observations, clinical record review, hospital documentation, staff interviews and facility policy review the facility failed to ensure 1 of 3 residents reviewed (Resident #2) was free from accidents. Resident #2 experienced a fall on 6/26/24 and staff were to ensure he had gripper socks on per his care plan. On 6/27/24 Resident #2 experienced another fall and was found to have regular socks on, not gripper socks. Resident #2 complained of right hip pain and the nurse noted the resident's right foot to be rotated externally. The resident was sent to the hospital for evaluation and found to have a right hip fracture. The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interviews and laboratory interview, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 3 residents reviewed (Residents #2, #3). The facility failed to obtain labs per Physician orders. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record reviews, observations, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #3) for falls. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review the facility failed to provide appropriate incontinence care for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 55 residents.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to provide oxygen according to physician orders for 3 of 4 residents reviewed (Residents #2, #6, and #7) for respiratory services. The facility reported a census of 55 residents. Findings Include: 1. The Annual Minimum Data Set (MDS) assessment for Resident #2 dated 12/4/23 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. [...]

Inspectors wroteBased on clinical record review, hospital record review, staff interview and policy review, the facility failed to arrange and/or provide transportation services to Physician appointments for 2 out of 3 resident reviewed (Residents #2, #3). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, and staff interviews, the facility failed to give medications as directed per the physicians orders for 2 or 4 residents reviewed. (Resident #1 and Resident #6). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review and staff and resident interview, the facility failed to provide two baths a week as directed for 3 out of 4 residents reviewed (#1, #2, and #3). The facility reported a census of 56 residents.

Inspectors wroteBased on facility record review, policy review, and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility identified a census of 57 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure treatment and medication carts kept locked when not attended by staff for 3 of 4 treatment carts observed. The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to ensure staff performed hand hygiene prior to or after completion of treatment and dressing change, failed to cleanse a wound after a soiled dressing removed and before application of new treatment products per physician's orders, and failed to change gloves when went from a dirty to a clean area for one of two resident treatments observed (Resident #11). The facility also failed to change gloves and sanitize hands after performed incontinence care and before touched other objects such a bed control or catheter for two of three residents observed for incontinence care (Resident #11 and #12) The facility staff also failed to wear gloves when a blood sugar performed for one of two blood sugar checks observed. The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility staff failed to follow physician's orders to cleanse a wound after a soiled dressing removed and before application of new treatment products, failed to ensure staff performed hand hygiene prior to or after completion of treatment and dressing change, and failed to change gloves when going from a dirty to a clean area for one of two resident treatments observed (Resident #11). The facility reported a census of 57 residents.

Inspectors wroteBased on record review, observation, resident and staff interviews, pharmacy interview, and policy review, the facility failed to ensure an Albuterol inhaler was reordered from pharmacy in a timely manner for one of five residents reviewed for medication administration (Resident #9). The facility also failed to follow physician's orders for obtaining daily weights, failed to notify the physician of significant weight gains, and failed to implement standards of care for resident who had diagnoses of congestive heart failure of one of five residents reviewed for assessment/intervention (Resident #9). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to provide incontinence care to prevent cross contamination and infection for two of three residents observed for incontinence care (Resident #11 and #12). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review, the facility staff failed to ensure resident's call light within reach for two of nine residents reviewed for call light response and accessibility (Resident #11 and Resident #12). The facility reported a census of 57 residents.

Inspectors wrote2. The Quarterly MDS assessment with a reference date of 6/28/23 for Resident #1 documented a score of 10 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderate cognitive impairment. The resident had diagnoses that included dementia, osteoporosis, muscle weakness, and anxiety and required extensive assistance of one staff for bed mobility, transfer, ambulation, dressing, toilet use, and personal hygiene. The resident had no falls since reentry. A Nursing Care Plan dated as initiated on 8/1/22 identified a focus area: Activities of Daily Living (ADL) self-care deficit, with a goal of maintaining current level of function, and directed the following interventions: Transfers and ambulates with the assistance of 1 staff member and four wheeled walker (FWW), and one person assist for toileting. [...]

Inspectors wroteBased on clinical record review, hospital records, resident, staff and advanced registered nurse practicitioner interview along with the facility protocol/policy, at the time of the investigation, the facility failed to provide ongoing assessment and intervention for a resident who demonstrated an unstageable wound to the right lateral plantar foot that was covered with eschar. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure two (2) of five (5) residents actively reviewed (#1 & #4), received adequate supervision to protect against hazards in the environment. Review revealed Resident #1 required assistance of one staff with a gait belt for transfer. On 8/19/23 at approximated 6:00 a.m., Staff A, Certified Nursing Assistant (CNA) assisted Resident #1 to transfer without a gait belt. During transfer the resident became anxious, was waiving her arms, Staff A heard a loud sound and lowered the resident to the floor. Resident #1 sustained a right arm fracture and required hospitalization and surgery. Additionally, the facility failed to provide 1:1 supervision as assigned for Resident #4 identified with agitation, aggression, exit seeking and trespassing behaviors. [...]

Inspectors wroteBased on clinical record review and staff and resident interview, the facility failed to provide two baths a week as directed for 4 out of 5 residents reviewed (#6, #7, #8 and #13). The facility reported a census of 73 residents.

Inspectors wroteBased on clinical record review, resident and staff interview the facility failed to complete bathing/showers as required for 4 of 5 residents reviewed. (#6, #7, #8 and #13) The facility census was 73 residents.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure the medication cart was locked on 3 occasions when the Certified Medication Aide (CMA)/Nurse responsible for the cart was not in sight. The facility reported a census of 73 residents.

Inspectors wroteBased on clinical record review, policy and procedure review and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 5 resident reviewed. (Resident #11). The facility identified a census of 73 residents.

Inspectors wroteBased on clinical record, and staff interview, the facility failed to notify the facility physician of a urinary analysis that was not collected in a timely manner for 1 of 4 residents reviewed (Resident #5). The facility reported a census of 73 residents.

Inspectors wroteBased on clinical record review, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported immediately to management staff per facility policy and to the Iowa Department of Inspection and Appeals within two hours. (Resident #11). The facility reported a census of 73 residents.

Inspectors wroteBased on observation, clinical record review, resident, and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 3 residents reviewed (Resident #2 and #12) and failed to give medications as directed per the physicians orders during the medication pass for (Resident #15 and Resident #16). The facility failed to assure Resident #2 attended follow up cardiac appointment as ordered following a May hospitalization. Resident's appointment was canceled on 6/1/23 for lack of transportation and 6/7/23 due to lack of communication. Resident was again hospitalized and on 8/14/23 the resident was seen for a follow up cardiac appointment, however no record of her medications was sent to the clinic despite their request. [...]

Inspectors wroteBased on personnel record review and staff interview, the facility failed to do an annual performance evaluation for 1 of 6 employee records reviewed. (Staff A). The facility identified a census of 73 residents. 1. Record Review on 10/23/2023 at 11:00 a.m., revealed Staff A, Certified Nursing Assistant (CNA) had a hire date of 5/03/2017. *A Performance Evaluation dated 3/26/2021, revealed an annual evaluation, signed and dated by Staff A on 5/28/2021. The Personnel record lacked any documentation of Annual Performance Evaluations completed for 2022 and 2023. Interview on 10/24/2023 at 10:00 a.m., the facility Interim DON (corporate nurse), confirmed and verified that the personnel record lacked annual performance evaluations for 2022/2023 and that the expectations are that the performance evaluations to be completed yearly.