Pride Tlc Therapy and Living Campus

Inspectors wroteBased on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System, within 14 days after completion of resident assessment for 3 of 3 sampled residents (R4, R5, R1).-R4's MDS assessment dated [DATE] was listed as export ready on 07/21/26.-R5's MDS assessment dated [DATE] was listed as in progress on 07/21/26.-R1's MDS assessment dated [DATE] was listed as export ready on 07/21/26.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections with the potential to affect 17 of 17 residents. - Facility staff did not perform appropriate hand hygiene during cares and while serving meals. - Facility staff did not ensure a dropped cover to a milk jug from dining room refrigerator was properly cleaned before replacing it. - Facility did not ensure covers were available and utilized for transporting fluids to resident rooms.

Inspectors wroteBased on interview and record review, the facility transferred a resident (R) (R29) to acute care and did not notify R29 or the Long-Term Care (LTC) Ombudsman of R29's discharge or provide a bed hold notice per the facility policy.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents (R) received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 resident reviewed. (R6)R6 did not have a recent audiologist screening and hearing aids were not working. This is evidenced by:R6 was admitted to the facility on [DATE] with pertinent diagnosis of unspecified hearing loss. R6's most recent quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, noted a Brief Interview for Mental Status (BIMS) score of 02/15 indicating severe cognitive impairment. R6 was noted to have highly impaired hearing and has hearing aids. R6's care plan, dated 06/27/21, with a target date of 05/13/25, states: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infections and prevent new ulcers from developing for 1 of 2 residents (R), (R5). This is evidenced by:The facility policy, titled Skin and Wound Management Program, last reviewed 4/2025, states in part, Ongoing Skin and Wound Assessment (6) Progress toward healing is monitored, Part C: The complexity of a resident's condition may affect responsiveness or tolerance to treatments, and this is considered in the review of the care plan and goals of treatment. Part D: Benefit and risk documentation shall occur as needed based on resident expressed preferences, choice and participation in skin and wound management recommended treatments and interventions. [...]

Inspectors wroteBased on observations, interviews and record review, facility did not ensure a resident with an identified decline in range of motion (ROM) received services and treatment to prevent further decline for 1 of 2 residents (R) (R6) reviewed. R6 had contracture with impaired ROM in right hand and did not receive therapy services. This is evidenced by:R6 was admitted to the facility on [DATE] with pertinent diagnoses of malignant neoplasm of temporal lobe, disorientation, left foot drop, localized edema, and unspecified hearing loss. R6's most recent quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, noted a Brief Interview for Mental Status (BIMS) score of 02 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observations, record review and interview, the facility did not store and distribute foods in a sanitary manner. The facility practice has the potential to affect all 21 residents. This is evidenced by: Surveyor reviewed the facility policy titled Food Handling and Sanitation, most recently revised on 3/2024. The policy in part read: Policy: The food service department will comply with federal, state and county food codes to ensure food safety. Cover all equipment with a garbage bag when not in use and at the end of the business day: this includes but not limited to small and large equipment (utensils, can openers, mixers, blenders ect.) ~Hairnets shall cover 100% of the hairline, beards nets will be worn if not shaved. On 05/06/24 at 8:14 AM, Surveyor conducted the initial tour in the facility kitchen with Dietary Manager (DM) I. [...]

Inspectors wroteBased on observation, interview and record review, facility staff did not ensure adequate supervision and safety to prevent accidents from occurring by not using a gait belt when warranted for a resident transfer affecting 1 of 3 residents (R) reviewed for transfer and falls (R7). This is evidenced by: Facility policy titled Transfer and Body Mechanics Policy, dated as most recently revised on 12/03/23 was reviewed by Surveyor. The policy in part reads: Procedure: The intent of this policy is to ensure every resident receives specialized rehabilitive services as determined by their comprehensive plan of care to assist them to attain, maintain or restore their highest practicable level . Protocol: Guidelines and tips for using proper body Mechanics: ~Use a gait belt at all times. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff did not perform hand hygiene when warranted while providing care to 1 of 3 residents (R) observed for care (R7). This is evidenced by: Surveyor requested and reviewed the facility policy titled Hand Hygiene Policy. The policy in part reads: This policy will provide staff for hand washing and hand hygiene techniques that will aid in the prevention of the transmission of infections. Hand washing with soap and water: Staff will perform hand hygiene by washing their hands .under the following conditions: Before moving from a contaminated body site to a clean site during resident care; for example: after providing peri care, before applying moisture barrier cream . [...]