Pleasant Meadows Senior Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately perform, and document required skin assessments and failed to provide assistance with daily sock changes for one (R2) of three residents reviewed for neglect related to pressure ulcers. This failure resulted in a delay in identifying skin deterioration, allowing R2 to develop an unstageable pressure ulcer to the right heel with suspected Osteonecrosis. R2's Electronic Health Record (EHR) documents that R2 was re-admitted to the facility on [DATE] following a brief hospitalization from 7/12/26 - 7/15/26. R2's hospital Discharge summary dated [DATE] documents that R2 was found to have a pressure injury of the right heel. An x-ray report dated 7/12/2026 documented articular surface collapse of R2's right foot, likely representing osteonecrosis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents for risk of entrapment from a bedrail and failed to calibrate an alternating air flow mattress setting for a resident's weight. These failures resulted in R12's mattress becoming overinflated which caused R12 to fall into the bedrail and to the floor. During the fall R12's arm became entrapped in the bedrail and R12 was unable to reposition R12's head and neck away from the bedrail which resulted in neck and sternum injuries. These failures affect eleven of eleven residents (R4, R6, R7, R10, R12, R13, R27, R28, R29, R30, and R31) reviewed for side rails and accidents on the sample list of 31. The Immediate Jeopardy began on 03/05/26, when the facility added bed siderails and a low air loss mattress to R12's bed, without completing a side rail assessment for safe use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain complete and accurate medical records for three residents (R2, R5, and R20) out of four reviewed for safety/medical records on the sample list of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a resident's Power of Attorney/ Family Representative of a significant torso bruise. This failure affects one of three residents (R5) reviewed for injuries of unknown origin/family notification on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from potential abuse by failing to appropriately recognize, investigate, and respond to an injury of unknown origin before concluding there were no concerns for abuse for one of three residents (R5) reviewed for bruises/injury of unknown origin, on the sample list of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' right to be free from misappropriation of money and blank checks. This failure affected one of seven residents (R4) reviewed for misappropriation on the sample list of 31.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to operationalize their abuse prevention policy by failing to inform a resident and resident's family representative of a misappropriation, investigation results. This failure affected one of seven residents (R4) reviewed for misappropriation on the sample list of 31.

Inspectors wroteBased on observations interviews and record review the facility failed to report an injury of unknown origin to the State Agency for one of three residents (R5) reviewed for bruises/injury of unknown origin/reporting on the sample list of 31.

Inspectors wroteBased on observation, interviews and record review, the facility failed to recognize and thoroughly investigate an injury of unknown origin one of three residents (R5) reviewed for bruises/injury of unknown origin, on the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to restrict an employee from working while investigating an allegation of abuse for one of 13 residents (R6) reviewed for staff behavior in the sample list of 21. The employee had access to R13-R21 during this time period. The facility's Abuse Prevention Program dated October 2022 documents visitors are encouraged to report suspected concerns of abuse immediately to the administrator or to an immediate supervisor who immediately reports to the administrator. This policy documents employees accused of abuse will be removed from resident contact immediately and not permitted to return to work until the results of the investigation have been reviewed by the administrator and determined abuse is unsubstantiated. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and report changes in condition and follow physician's orders for four of six residents (R1, R2, R6, R11) reviewed for changes in condition in the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to accurately transcribe and follow physician's orders which resulted in multiple significant medication errors for two of six residents (R11, R4) reviewed for change in condition in the sample list of 21.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of verbal abuse to the state survey agency for one of 13 residents (R6) reviewed for staff behavior in the sample list of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately label an insulin vial, insulin pens, and eye and ear drops with the date opened and failed to discard an insulin pen and ear drops for four (R11, R36, R69, R85) of seven residents reviewed for medication administration on a sample list of 41. Findings Include:On 1/13/2026 at 10:00 AM, the facility's Main Skilled Medication Cart located on the 200 Hall was inspected in the presence of V6 Licensed Practical Nurse (LPN). During the inspection, R11's Basaglar pen and Adelong pen were found without any documented date of opening. Additionally, R36's Novolog Flex Pen was labeled with an open date of November 26, 2025. Further review revealed that R69's Ofloxacin and R85's Latanoprost also lacked documented dates of opening. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement proper hand hygiene during medication administration for three residents (R40, R43, R63) of seven reviewed for medication administration on a sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms and equipment were clean and in good repair for two of three residents (R8 and R25) reviewed for homelike environment in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R4) was free of a restraint which limited her ability to move about freely of one resident reviewed for restraints in a sample list of 41. Findings Include:R4's Care Plan dated 9/8/25 lists then following diagnoses: Osteomyelitis, Pressure Ulcer of the Sacrum, Neoplasm of the Spinal Cord, Type II Diabetes, Polyneuropathy, Unsteady on Feet, and Neurofibromatosis. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. On 1/11/26 R4 was seated in a (Geriatric) Chair in her room. This chair does not allow R4 to self-propel herself. R4's personal wheelchair was sitting on the other side of her room. R4 stated I want to sit in my chair R4 gestured to the wheelchair across the room with her name on it. I can't even move around in my room in this chair. I HATE it. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident receive proper treatment and assistive devices to maintain vision for one resident of one resident (R53) reviewed for vision and hearing out of a sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to be free from verbal abuse of one (R1) resident from another resident (R2) out of four residents reviewed for abuse in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound care of one (R2) residents Right Ankle Arterial wounds out of three residents reviewed for wound care in a sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident elopement by failing to ensure an exit door was alarmed/monitored to prevent residents from exiting unnoticed and failed to develop and implement a care plan for a resident at risk for elopement for one of three residents (R1) reviewed for elopement on a sample list of five. These failures resulted in R1, a cognitively impaired resident at risk for falls, leaving the facility unsupervised in a wheelchair in the dark. R1 was found three tenths of a mile from the facility in the middle of a country road near railroad tracks by a local citizen who alerted facility staff of R1's location.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record included an elopement event for one of three residents (R1) reviewed for elopement in the sample list of five. R1's admission Record dated 9/23/25 documents R1 admitted to facility 8/28/2019. The admission Record documents R1's medical diagnoses include Congestive Heart Failure with presence of Cardiac Pacemaker, Age-Related Cognitive Decline, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Lack of Coordination, Parkinson's Disease Without Dyskinesia, Need for Assistance with Personal Care, Unsteadiness on Feet, and Insomnia. R1's Minimum Data Sheet (MDS) Section C dated 8/15/25 documents R1 has moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R3, R4) of six reviewed for abuse in the sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate assistance and supervision during dining and failed to serve a hot beverage at a safe temperature. This failure resulted in R1 suffering a preventable, second degree burn to her bilateral upper legs. R1 is one of three residents reviewed for incident/accidents on the sample list of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to notify a family representative of a change in resident condition for one of three residents (R6) reviewed for accidents/incidents on the sample list of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to resolve resident grievances of missing money. This failure affects two of five residents (R2 and R4) reviewed for missing personal belongings on the sample list of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to recognize and report a facial bruise of unknown origin to the Abuse Prevention Coordinator for one of three residents (R6) reviewed for incident/accidents on the sample list of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders and prevent cross contamination during wound care treatment administration. These failures affected one of three residents (R1) reviewed for accidents/skin impairment on the sample list of 17.

Inspectors wroteBased on observation, interview and record review the facility repeatedly failed to maintain complete and accurate medical record for one of eight residents (R6) reviewed for medical records on the sample list of 17.

Inspectors wrote2.) R44's weight flow sheet documents on 05/12/2024, (R44) weighed 125.8 lbs. On 10/04/2024, R44 weighed 101.2 pounds which is a 19.55 % Loss. R44's Wound Care Telemedicine initial evaluation dated 10/18/24 by V7, Wound Physician documents R44 developed a facility acquired Stage III Pressure Ulcer of greater than 10 days duration on the coccyx. 10/29/24 12:39 PM V19 Registered Dietitian stated The facility does not reach out to me when a resident has a wound or a significant weight loss. Yes I should be notified of a significant weight loss and/or a wound and I should evaluate these residents. V19 verified V19 has not evaluated R44. 3.) R52's weight flow sheet documents on 09/03/2024, R52 weighed 131.2 lbs. on 10/15/2024, R52 weighed 123.6 pounds which is a 5.79 % loss. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free of misappropriation of money and personal property for four of five residents (R13, R130, R25 and R46) reviewed for misappropriation in a sample list of 40 residents. Failing to prevent the misappropriation of R13's commemorative coin set, which is not replaceable, resulted in R13 being tearful and experiencing feelings of sadness and loss due to the sentimental value of the coins. Findings Include: The facility Abuse Prevention Program dated October 2022 documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, implement treatment orders timely, administer treatments as ordered, maintain wound dressings, accurately complete skin and wound assessments, and implement interventions to prevent the development and worsening of pressure ulcers for four (R8, R32, R52, R44) of four residents reviewed for pressure ulcers in the sample list of 46. These failures resulted in R8 developing stage three pressure ulcer and R32 developing an unstageable pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report allegations of misappropriation to the facility's administrator and failed to report allegations of misappropriation to the State Agency (SA) and law enforcement for four residents (R13,R130,R25,R46) of five residents reviewed for misappropriation in a sample list of 46 residents. These failures have the potential to affect all 73 residents residing in the facility. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate allegations of misappropriation of money and personal property and implement corrective action to prevent further incidents of misappropriation for four residents (R13,R130,R25,R46) of five residents reviewed for misappropriation in a sample list of 46 residents. These failures have the potential to affect all 73 residents residing in the facility. Findings Include: The facility Abuse Prevention Program policy dated October 2022 documents all incidents or allegations of abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, that was alleged or suspected will be documented and result in an investigation. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent, investigate, and implement systemic interventions to address allegations of misappropriation. This failure affects four (R13, R25, R46, R130) residents and has the potential to affect all 73 residents who reside at the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement Program that demonstrates systematic identification of problematic areas within the facility along with reporting, investigation, and analysis of those areas to prevent adverse outcomes to the residents. This failure affects seven (R13, R25, R46, R130, R8, R44, and R52 ) residents and has the potential to affect all 73 residents who reside at the facility. Findings Include: The facility's ongoing Grievance Log dated September - October 2024 documents misappropriation of money for R13, R25, R46, and R130. [...]

Inspectors wroteBased on interview and record review the facility failed to take actions aimed at performance improvement, implement those actions, measure its success and track performance. This failure has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to hold quarterly Quality Assurance Performance Improvement meetings with all required attendees. This failure has the potential to affect all 73 residents who reside at the facility. Findings Include: The facility's Quality Assurance Performance Improvement (QAPI) sign in sheets dated 10/9/24 does not contain V39 (Former DON (Director of Nursing)/Infection Preventionist) signature as attending the meeting. The QAPI sign in dated 7/26/24 does not include V39 or V40's Medical Director signature as attending the meeting. The QAPI sign in dated 4/10/24 does not contain V40's signature as attending the meeting. On 10/30/24 at 11:21 AM, V1 Administrator stated V1 has only been employed at the facility for three weeks therefore has not attended a Quality Assurance Performance Improvement (QAPI) meeting. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 73 residents in the facility. B. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBPs) and provide hygienic wound care for three (R8, R32, R69) of five residents reviewed for EBP in the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to follow their influenza (flu) vaccination policy for five (R1, R8, R32, R63, R66) of five residents reviewed for immunizations in the sample list of 46. This failure has the potential to affect all 73 residents residing in the facility. The facility also failed to track and offer pneumococcal vaccinations to ensure residents are up to date for three (R32, R63, R66) of five residents reviewed for immunizations in the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to follow its Compliance and Ethics program by failing to have a committee that meets on a quarterly basis. This failure has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent the potential for a fire hazard by failing to maintain facility laundry dryers in a safe operating condition. This failure has the potential to affect all 73 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide fingernail care, bathing, and timely toileting/incontinence cares for five (R11, R30, R37, R131, R230) of 19 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 46 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the environment was free from hazards for seven of seven residents (R21, R53, R29, R39, R16, R61, R66) reviewed for safety and supervision in the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to date and secure oxygen tubing, humidification bottle, and nebulizer tubing for one of three residents (R25) reviewed for oxygen on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to regularly assess for the use of psychotropic medications for four (R1, R44, R8, R46) of five residents reviewed for psychotropic medication use in a sample list of 46 residents.

Inspectors wroteBased on interview and record review the facility failed to obtain consents for psychotropic medication use for two (R8, R37) of five residents reviewed for unnecessary medications in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a physician's order and care plan for restraint use for one (R8) of two residents reviewed for restraints in the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for weight loss for one of 19 residents (R66) reviewed for care plans in the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound dressing changes were completed as ordered by the Physician for one of one resident (R59) reviewed for skin conditions in the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications according to Physician's Orders for one of four residents (R75) reviewed for medication administration in the sample list of 46. This failure resulted in two medication errors out of 33 opportunities resulting in a 6.06% error rate.

Inspectors wroteBased on observation and interview, the facility failed to serve palatable resident meals. This failure affects one resident (R37) of 10 reviewed for food palatability in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct pressure ulcer risk assessments (R1, R5, R6), failed to obtain treatment orders for identified pressure ulcers (R5, R6), failed to complete pressure ulcer monitoring (R5, R6), and failed to complete pressure ulcer treatments according to physician orders (R5, R6). These failures affect three residents (R1, R5, and R6) out of three reviewed for pressure ulcer services on the sample of six. These failures resulted in R5 developing a worsening stage 3 pressure ulcer.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident (R1) received appropriate treatment for an infection of the heart muscle. The facility also failed to ensure the physician and Nurse Practitioner were aware of R1's infection treatment plan. Theses failures affect one (R1) of three residents reviewed for IV Medication/Infection in a sample list of three residents. These failures resulted in (R1) being hospitalized with sepsis and subsequently expiring due to R1's worsening infection. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 6:42PM when R1's antibiotic intravenous treatment was changed for Enterococcus with Endocarditis without physician coordination of R1's Infectious Disease plan when discharged from the hospital ([DATE]). V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 11:09 AM. [...]

Inspectors wroteBased on Record Review and Interview the facility failed to provide an effective Infection prevention and control program. This failure has the potential to affect all 76 residents who reside at the facility. Findings Include: The facility's census dated [DATE] documents 76 residents reside at the facility. The facility's policy Infection Prevention and Control and Stewardship Program last reviewed [DATE] states Policy: To comply with system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement. To comply with the core elements of antibiotic stewardship to reduce the unnecessary use of antibiotics. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents intravenous therapy consistent with professional standards of practice. The facility failed to complete residents intravenous (IV) dressing changes, monitor document required measurements, specify type of intravenous (IV) access device (R1, R2 peripheral central venous catheter, and R3 implantable venous access device) including anatomical location of the residents device with an IV care plan for specific interventions. The facility also failed to obtain orders for residents IV dressing changes, device flushes, need to monitor for signs and symptoms of infection and infiltration. These failures affected three of three residents (R1, R2 and R3) reviewed for intravenous medication administration on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident. This failure affected two of four residents (R5, R6) reviewed for abuse in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. The Abuse Investigation Summary dated 7/19/24 documents R5 and R6 were in a verbal altercation in their shared room. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from abuse by failing to prevent misappropriation of a resident's physician prescribed medication. This failure affected one of three residents (R3) reviewed for abuse in the sample of nine. Findings Include: The Abuse Prevention Program dated October 2022 documents the term Abuse can include misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Incident Report for the incident of 7/22/24 documents R3's Semaglutide Injectable medication could not be found. R3's Physician Order Sheet dated July 2024 documents R3 is diagnosed with Diabetes. [...]

Inspectors wroteBased on interview and record review the facility failed to safeguard four (R1-R4) of four residents' funds from potential funds mismanagement from a total sample list of four residents reviewed for protection of resident funds.

Inspectors wroteBased on interview and record review the facility failed to provide quarterly resident trust account statements for four (R1-R4) of four residents reviewed for resident funds from a total sample list of four.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to implement fall interventions and provide a safe transfer for a severely cognitively impaired resident at risk for falls. The facility failed to follow therapy recommendations for R1's transfer and delayed treatment of R1's injuries. Failing to follow therapy recommendations for R1's transfer resulted in R1 falling backwards and R1 hitting R1's head on the floor and R1 sustaining an Occipital Fracture, Left Hip Fracture, Subarachnoid Hemorrhage (traumatic), Traumatic Intraparenchymal Hemorrhage, and Traumatic Subdural Hematoma. R1 subsequently died on [DATE] while on Hospice care. These failures affect one (R1) of four residents reviewed for falls on the sample list of four residents. [...]

Inspectors wroteBased on interview and record review the facility failed to transfer residents to the hospital timely for evaluation, notify the physician of a resident's change in condition, and provide medical care timely after falls for two of four residents (R1 and R4) reviewed for falls on the sample list of four residents. Failing to transfer R1 to the hospital timely and notify the physician of neurological changes after R1 fell resulted in a delay in treatment and R1 experiencing pain and vomiting.

Inspectors wroteBased on interview and record review the facility failed to provide inservicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 81 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to document an initial wound assessment and weekly wound measurements, failed to document a months worth of wound treatments, and failed to obtain physician orders for wound treatments. These failures affected one of three residents (R1) reviewed for wound care. Findings Include: The facility's Pressure/Skin Breakdown Clinical Protocol dated January 2017 documents the facility is to document an individual's significant risk factors for pressures sores, document a complete admission assessment of skin conditions including location, stage, measurements, and current treatments, consult the physician to assist in defining the type of ulcer and to authorize pertinent orders for wound treatments and other related interventions. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain ordered kidney function laboratory work and failed to complete neurological exams following a fall with a head injury for one of three residents (R3) reviewed for falls. These failures resulted in R3 being admitted to the hospital for Acute Kidney Injury, Dehydration and Altered Mental Status.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions to prevent falls for three of three residents (R2, R3, R4) reviewed for falls in the sample list of five. These failures resulted in R2 and R3 falling and suffering head lacerations that required staples at the emergency room.

Inspectors wroteBased on interview and record review the facility failed to ensure four Certified Nurse Aides (CNA) completed competency skills checks. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to employ a qualified Director of Food and Nutrition Services. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent potential cross-contamination and food borne illness by failing to maintain the facility dishwashing machine at a safe chemical level, failing to maintain the facility ice machine in a clean sanitary manner, and failing to maintain a commercial food mixer free of paint chips, food-like build-up and rust. These failures have the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure four Certified Nurse Aides (CNA) had a minimum of twelve hours of education annually. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond in an amount sufficient to protect all resident personal trust funds. This failure affects 49 residents (R1, R3, R6, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R22, R23, R25, R26, R27, R29, R32, R33, R34, R35, R39, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R53, R54, R55, R56, R57, R58, R61, R63, R64, R70, R71, R72, and R77) out of 49 reviewed for resident trust funds on the sample list of 64.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans to include care categories including smoking, oxygen use, dialysis, and wounds. This failure affects four residents (R17, R30, R60, and R65) out of 19 reviewed for care plans on the sample of 64.

Inspectors wroteBased on observations, interviews and record review the facility failed to obtain physician orders for respiratory equipment use, failed to care plan respiratory care and interventions, repeatedly failed to maintain/clean and store respiratory equipment in a clean sanitary manner and off the floor, and failed to date and initial respiratory equipment when changed, as directed by the facility oxygen policy. These failures affect three (R30, R41, R54) residents of three residents reviewed for respiratory/oxygen on the sample list of 64.

Inspectors wroteBased on record review and interview the facility repeatedly failed to follow their policy for receiving and disposing of controlled medications for one of five residents (R13) reviewed for unnecessary medications on the sample list of 64.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R60) resident and failed to perform hand hygiene and maintain a hygienic environment when assisting residents (R22, R23, R47, R49) with meals. These failures affected five residents out of six residents reviewed for Infection Control in a sample list of 64 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a homelike environment for one (R284) resident out of one resident reviewed for homelike environment in a sample list of 64 residents.

Inspectors wroteBased on interview and record review, the facility failed to timely transmit a resident's quarterly modified minimum data set. This failure affects one resident (R47) out of 20 reviewed for minimum data sets on the sample list of 64.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Pre-admission Screening and Record Review to determine the presence of mental illness. This failure affects one resident (R63) out of two reviewed for preadmission screening on the sample list of 64.

Inspectors wroteBased on interview and record review, the facility failed to obtain a new Pre-admission Screening and Record Review following the expiration of a temporary Pre-admission Screening and Record Review. This failure affects one resident (R17) out of two reviewed for pre--admission screenings on the sample list of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status of the resident. This failure affects one resident (R17) out of 19 reviewed for care plans on the sample list of 64.

Inspectors wroteBased on interview and record review the facility failed to obtain Physician orders, complete weekly assessments and monitor a wound caused by trauma for one (R60) resident out of three residents reviewed for non-pressure skin conditions in a sample list of 64 residents.

Inspectors wrote2.) R33 fall risk assessment dated [DATE] documents R33 is a high risk for falls and has had 1-2 falls in the past 3 months. R33's Care Plan dated 09/14/23 documents the following interventions and dates the interventions were to be implemented post falls: Bed and chair alarm due to decreased safety awareness and impulsivity, date initiated: 04/20/2023. The same care plan documents (brand name, non-slip material) to the recliner date initiated: 09/22/2022. On 12/12/23 at 10:40 am V14, Restorative/Certified Nursing Assistant (CNA) stated R33 fell in the dining room a while back, and fractured R33's wrist. V14 stated She (R33) wore a splint on her wrist for awhile. Her wrist is healed now. R33 was seated in her bedside recliner, asleep. V20, CNA stated I believe (R33) is a high fall risk. She (R33) has an alarm on her bed and she sits on an alarm pad in her wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services related to dialysis including obtaining a physician ordered diet, related monitoring of a dialysis fistula site, and obtaining daily weights. This failure affects one resident (R17) out of one reviewed for dialysis on the sample list of 64.

Inspectors wroteBased on interview and record review the facility failed to obtain psychotropic medication consents for use, failed to complete quarterly psychotropic medication assessments, and failed to include psychotropic medication use in the resident's plan of care for three of five residents (R3, R54, R232) reviewed for unnecessary medications on the sample list of 64. Findings Include: The facility's Psychotropic Medication Policy dated February 2014 documents the policy is in place to establish a process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. The policy documents psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders to obtain a blood Albumin (protein) level for one of four resident (R32) reviewed for wounds/pressure ulcers on the sample list of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify a resident, and the State Ombudsman, in writing of an involuntary facility-initiated discharge. This failure affects one resident (R1) out of 23 reviewed for transfers and discharges on the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow a hospitalized resident to return to the facility. This failure affects one resident (R1) out of 23 reviewed for transfers and discharges on the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision and ensure fall interventions were in place, failed to supervise/transfer a resident for safety, and failed to provide a safe transfer to prevent falls for three of three residents (R1, R2, R3) reviewed for falls on the sample list of five. Facility staff left R1 sitting on the side of the bed unsupervised and without fall interventions in place resulting in R1 falling and fracturing R1's hip. Facility staff failed to supervise and transfer R2 out of the wheelchair when R2 was falling asleep resulting in R2 falling out of the wheelchair and sustaining lacerations to R2's forehead which required nine sutures.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected two of four residents (R3, R4) reviewed for abuse in the sample of four.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility staff failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R17) out of five reviewed for wound care on a sample of 18. This failure resulted in R17's foot wounds becoming infested and infected with parasitic fly larvae (maggots) requiring the use of intravenous antibiotics. B. Based on record review and interview, the facility staff failed to obtain and document resident weights as ordered by the physician for relevant medical diagnoses. This failure affects three residents (R1, R16, R17) out of 12 reviewed for physician orders on a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise one dependent resident (R9) for safety to prevent a fall, and failed to complete fall risk assessments for three residents (R14, R15, R17) with known fall risks, out of five reviewed for falls and fall risks on the sample of 18. This Failure left (R9) alone sitting on edge of therapy table with no supervision and history of repeated falls, contributing to (R9) falling to floor causing injury and being sent to hospital.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to complete pressure ulcer risk assessments for residents with a known risk of pressure ulcers. This failure affects five residents (R10, R13, R15, R16, R17) out of 7 reviewed for pressure ulcers and risk assessments on the sample of 18.