Putnam Center

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure a clean, safe, comfortable, home-like environment by not preventing odors throughout the building. This was a random opportunity for discovery and this failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census:116.

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly investigate allegations of neglect This was true for two (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47 and #102. Facility census: 116. Findings Include: b) NeglectOn 10/27/25 at approximately 3:00 PM, a review of a FRI dated 07/19/25. The review of the FRI found the allegation of neglect was made by Resident #102 and #47. The allegation was that neither resident had received incontinence care since 5:00 AM on 07/19/25. The residents reported this to NA #116 upon delivery of the lunch trays. NA #116 got another NA #130 to assist with the incontinence care for both residents at 1:00 PM. The assigned NA #135 was noted to be on her personal phone at the nurses' station and was rounding on the other residents on her hall. [...]

Inspectors wroteBased on resident interview, staff interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided to dependent residents. This was true for three (3) of three (3) residents reviewed during the survey process. Resident Identifiers: #93, #8, and #102. Facility Census: 116. Findings Include: a) Resident #93 An interview was held with Resident #93 on 10/30/25 at 10:35 AM. Resident #93 stated, I have been trying to get a shower since Monday (10/27/25) so maybe I will get one tomorrow. I have had problems before with getting my showers but I think they are getting it worked out. A review of showers from 09/01/25 through 10/30/25 was completed on 10/30/25 at 09/12/25-09/19/25 at 10:50 AM. The review found the following: No showers from 10/03/25 to 10/14/25 which was 11 days. No showers from 10/23/25 to 10/30/25 which was seven (7) days. [...]

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure continuity of care by not seeking order clarification from the physician regarding oral medication orders for a resident who was NPO (nothing by mouth) and failed to ensure respiratory equipment was obtained for a newly admitted resident. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #66, #93, #8 and #121. Facility Census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the pharmacist reported any irregularities to the attending physician, the facility's medical director and the director of nursing and the reports were acted upon. This failed practice was identified for three (3) out of three (3) residents with an NPO (nothing by mouth) order. Resident Identifier: #66, #93, and #8. Facility Census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's medical record was accurate for physician orders for fall interventions and the medication route does not follow the physician's order for NPO (nothing by mouth). This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #66, #93, and #8. Facility Census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were free from neglect, and verbal abuse. This was true for seven (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47, and #102. Facility Census: 116.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for a residents fall interventions. This failed practice had the potential to affect a limited number of residents . Resident Identifier: #66. Facility Census: 116.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide an environment free of accident hazards due to medication being at bedside for Resident #60. This was a random opportunity for discovery. Resident Identifier: #60. Facility Census: 116. Findings Include:a) Resident #60On 10/27/25 at 5:40 PM, an observation was made of the medication Clotrimazole & Betamethasone % cream in a tube at bedside. At this time, Licensed Practical Nurse (LPN) #69 was notified and removed the medication from the nightstand. On 10/27/25 at 5:48 PM, the Corporate Registered Nurse # 132 was notified and stated, let me have them check that there is no other medications at bedside.

Inspectors wroteBased on observation, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to serve meals in a sanitary manner by serving a cup that had been dropped on the floor to a resident during meal time. This was true during a random opportunity of discovery for Resident #102. Facility Census 116. Findings Included: a) On 10/29/25 at 11:52 AM Registered Nurse RN #130 was observed walking out of the kitchen holding a cup can a lid. She dropped the lip the the floor of the dining room, bent down to pick it up. She then placed it on the counter as she filled the cup with ice and drink and handed it to Nurse Aide #81 who had just walked over to her. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for the residents. This was a random opportunity for discovery. Resident Identifiers: Facility. Facility Census: 119Findings Included:a) Facility cleanlinessOn 09/18/25 at 12:25 PM observation found the floors in the facility to be cluttered with particles of paper, dust and spilled dried liquid in need of being swept and mopped. Trash cans were full and personal items were in the foor to the point of housekeeping not being able to sweep in some rooms. During a walk through with the Administrator he agreed, that in particular, the following rooms on that unit were the worst. room [ROOM NUMBER], 152, 153 and 154. On 09/18/25 at 12:45 PM he confirmed the faciity auto scrubber was down and the floors needed swept and mopped. [...]

Inspectors wroteBased on observation and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was a random opportunity for discovery. Resident Identifiers: room [ROOM NUMBER]A, 150A, 155, 156A, 161, 162A. Facility Census: 119. Findings Include:a) Bedside water cupsOn 09/18/25 at 12:30 PM during a walk through at the facility it was observed that several residents on the 100 hallway did not have fresh, if any, water at bedside. Residents in rooms #148A, 150A, 155, 156A, 161 and 162 had no, or room temperature water at bedside. Observation on 09/18/25 at 12:38 PM found the resident in 150A had been at bedside eating his noon meal. He had just finished. He had no drink with his meal. There were two staff members at the door and told the Resident they were taking him for an appointment. [...]

Inspectors wroteBased on observation and staff interview the facility failed to follow Physicians orders by not placing heel boots on a resident to help prevent pressure ulcers to her heels. This was a random oportunity for discovery. Resident Identifier: #1 Facility Census: 119 Findings Include:a) Resident #1On 09/18/25 at 3:15 PM observation found that Resident #1 did not have her heel boots on as ordered from the Physician. On 09/18/25 at 3:25 PM Nurse Aide (NA) # 2 was asked if she could tell the surveyor why the resident did not have them on. NA #2 stated she did not know because she had just picked up that hall at noon. The surveyor ask NA #2 if she would please try and place the boots on the resident. When NA #2 obtained the boots from under the sink and ask Resident #1 if she wanted the boots on, the resident stated Yes, go ahead. [...]

Inspectors wroteBased on observation, resident interview, family interview, and staff interview the facility failed to maintain a clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers #52, #24, #128. Facility census 114. Findings Include: a) Resident #52 An observation on 04/29/25 at 11:32 AM, found Resident #52's bathroom that adjoins next door to have 3 briefs that appeared to be soiled in the floor, along with 4 articles of clothing. On the floor and commode seat there was a brown, dried substance. During an interview on 04/29/25 at 11:32 AM, Resident #52 stated, I don't use that bathroom and my roommate doesn't either. It must be the people next door. There is always shit in there. [...]

Inspectors wroteBased on resident interview, observation and staff interview, the facility failed to serve food that was palatable and at a safe appetizing temperature. This was found true for one(1) resident investigated for the care area of nutrition during the Long-Term Care Survey process. This failed practice had the potential to affect more than a minimal number of residents residing in the facility, Resident identifier: #54 Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to maintain an affective infection control program to prevent the spread of disease and infections. This was true for three (3) of thirty-one (31) residents observed during the long-term survey process and one (1) random opportunity for discovery. Resident identifiers: #69, #158, #264 and #25. Facility Census:

Inspectors wroteBased on observation and staff interview, the facility failed to ensure Resident #264 was treated in a dignified manner due to being exposed, and in view of passersby and, by failing to knock before entering his room. This was a random opportunity for discovery. Resident identifier: #264. Facility census: 114.

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to provide residents a choice regarding bathing preferences. This was true for two (2) of eight (8) residents reviewed for Activities of Daily Living (ADL). Resident identifiers: #101 and #81. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #87 was free from chemical restraints by failing to ensure a PRN (as needed) order for Ativan did not last longer than 14 days, and by failing to attempt non-pharmacological interventions before the administration of PRN Ativan. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #87. Facility census: 114.

Inspectors wroteBased on record review and staff interview, the facility failed to implement the care plans for Resident #87 related to non-pharmacological interventions before administration of PRN Ativan, and the care plan related to activities for Resident #33. This was true for two (2) of 31 care plans reviewed during the survey process. Resident identifiers: #87, and #33. Facility census: 114.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide a program of activities to meet the needs and interest of the residents. This failed practice was found true for (1) one of (4) four residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier #33. Facility Census 114. Findings Include: a) Resident #33 Resident #33 During the initial observation on 04/29/25 at 12:41 PM, revealed Resident #33 lying in bed, still in her nightgown with the lights off. No television (TV) or radio was playing. Resident #33 was talking out loud to herself. Further observation of Resident #33 on 04/29/25 at 3:10 PM, revealed Resident #33 lying in bed, continues to be in her nightgown. No TV or radio was playing. Resident #33 was holding and rubbing the sides of a cup. [...]

Inspectors wroteBased on record review, resident interview and staff interview the facility to follow the Physicians orders relating to administering medications in a timely manner, obtaining blood lab orders and following the hypoglycemia protocol as written. Resident Identifiers: #12, #24 and #101. Facility Census: 114 Findings Include: a) Resident #12 On 05/01/25 at 12:20 PM record review of laboratory results for Resident #12 shows an Ammonia level drawn on 03/07/25 at 5:53 AM had abnormal results indicating an elevated Ammonia level. This was addressed by the Unit Manager with a Physicians order to increase Lactulose to 15 ml twice a day and repeat the ammonia level in one week. Review of the following laboratory results for the rest of March, 2025 found no repeat ammonia level was completed. [...]

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure residents received the correct prescription of reading glasses as ordered by the Ophthalmologist. This failed practice was found true for (1) of (1) residents reviewed for vision services during the Long-Term Care Survey Process. Resident identifier #52. Facility Census 114. Findings Include: a) Resident #52 During the initial interview on 04/29/25 at 11:28 AM, Resident #52 stated, The eye doctor checked my eyes six months ago and ordered me glasses and I still have not gotten them. They gave me these, but I can't see good out of them. A record review revealed Resident #52's last Ophthalmologist appointment was dated 01/16/24. Final Spectacles Prescription read as follows: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. A mattress was left lying on the floor in the hallway. This was a random opportunity for discovery. Facility census: 117.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was true for two (2) of thirty one (31) residents reviewed for hydration during the Long Term Care Survey Process. Resident Identifiers: #23 and #36. Facility Census: 114 Findings Include: a) Resident #23 On 04/29/25 at 8:30 AM Resident #23 states it is hard to get water at around here. Observation at that time finds a disposable cup on the over the bed table dated 04/28/25 to be empty. Further observations on 04/29/25 at 1:20 PM and 04/29/25 at 4:20 PM found a disposable cup on the over the bed table dated 04/28/25 to be empty. It was confirmed with the Administrator on 04/29/25 at 4:30 PM that this resident has not had proper hydration on 04/29/25. She agreed. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to provide routine dental services to Medicaid funded residents. This failed practice was found true for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Facility Census 114. Resident identifier: #52.

Inspectors wroteA review of the electronic health record was conducted on 04/29/25. During the review it was noted Resident #72 was admitted [DATE] and had suffered seven (7) falls during this time. The falls were on the following dates: 04/14/25, 04/19/25 04/20/25 04/23/25 04/27/25- three (3) times During a review of, on 04/30/25, of the post fall neurological assessments completed by the facility, it was determined that one that was scanned into the resident's health record did not have correct dates and was not signed, in eight (8) instances, by the nurse completing the assessments. A neurological assessment was performed for a fall suffered by Resident #72 on 4/23/2025 at 6:00 PM. [...]

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to provide reasonable accommodations of needs by not ensuring residents could turn the over-bed light on and off by their own free will. This failed practice was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifier #1. Facility census: 114. Findings Include a) Resident #1 During the initial interview and observation on 04/29/25 at 10:55 AM, Resident #1 stated, Last night I had to sleep with this light on above my bed, because the light switch is not long enough for me to reach. During the interview an observation of the light string above the bed showed that the string was about an inch long and that the resident could not reach it to turn it off and on. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan regarding fall preventions for Resident #13, #32, #120 and regarding food restrictions for Resident #27. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #13. #32, #120 and #27. Facility Census: 114. Findings Include: a) Resident #13 On 01/22/25 at 1:00 PM, a record review was completed for Resident #13. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include call light within reach. On 01/22/25 at 2:00 PM, the Administrator confirmed the fall intervention should have been listed in the care plan. The Administrator stated, we have started a house-wide audit regarding fall interventions. b) Resident #32 On 01/22/25 at 1:15 PM, a record review was completed for Resident #32. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Resident # 106 was free from physical abuse from Resident #118. Resident #106 was physically abused by Resident #118. Resident #106 was a nonverbal resident who was hit on the left side of the face by Resident #118. This is true for one (1) of three (3) residents reviewed for resident to resident abuse. Resident identifiers: #106 and #118. Facility Census: 114.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards for linen storage and ice storage. These were random opportunities for discovery. Facility Census: 114. Findings Included: a) Linen carts On 09/11/23 at 9:09 PM, an observation on the South unit was made noting one (1) linen cart sitting between rooms [ROOM NUMBERS] with the cover flipped over the top, and an additional linen cart sitting by room [ROOM NUMBER] with the cover flipped over the top and a bath basin with water, soap and wash cloths sitting on top of the linen cart. On 09/11/23 at 9:11 PM, Nurse Aide (NA) #56 and NA #32 acknowledged the linen carts were uncovered and the bath basin should not be sitting on top of the linen cart. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain safe operating equipment kept in a resident area. This was a random opportunity for discovery. Facility Census: 114. Findings Included: a) Scoot chair On 09/12/23 at 12:13 PM, a leaning scoot chair missing a wheel was observed in the walk way at the foot of the beds in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #64 and Maintenance Director #46 were alerted to the broken chair. LPN #64 and Maintenance Director #46 entered the room and pulled the scoot chair into the hall. The missing wheel was found under bed A. The Maintenance Director #46 stated, the wheel is missing .all the bolts are loose while turning the bolts of the chair. The scoot chair was removed from the hallway and taken out of service. No work order had been placed prior to discovery. [...]

Inspectors wroteBased on observation, record review, resident interview, and staff interview the facility failed to ensure a resident who has an indwelling urinary catheter receives the care and services needed to ensure the resident did not develop complications related to the indwelling urinary catheter. The facility staff failed to ensure an anchor device was on Resident #105's catheter to prevent it from becoming dislodged. In addition, the nursing staff failed to identify and/or address serious problems with Resident #105's catheter prior to surveyor intervention on two (2) separate occasions on 05/09/23 and again on 05/10/23. In addition Resident #105 suffered a change in mental status which was also not identified by nursing staff until it was pointed out by the surveyor. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to reconcile the narcotic reconciliation sheets on two (2) of three (3) medication cart narcotic books reviewed. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Facility Census:

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure supplies in the medication storage room were within the expiration date in accordance with currently accepted professional principles. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to maintain complete and accurate medical records for seven (7) of 27 sampled residents reviewed during the long term care survey process. Resident identifiers: #77, #106, #58, #86, #85, #53, and #11 Facility Census: #117.

Inspectors wroteBased on staff interview and resident interviews, the facility failed to accurately explain the arbitration agreement to residents and/or their representatives. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Census 117. a) Staff Interview On 05/10/23 at 11:05 AM, the Admissions Director (AD) #88 was asked to state to the survey team how she explained the arbitration agreement to new residents and/or their representatives. AD #88 stated, she most importantly explained to the residents the arbitration agreement was voluntary, meaning they do not have to sign it. AD #88 also stated she explained to the resident if they sign the agreement, they would have a third party arbitrator to help them settle the dispute, but if they could not settle this way, then they could have a judge and jury; [...]

Inspectors wroteBased on record review and staff interview the facility failed to maintain an ongoing Quality assurance and performance improvement (QAPI) program. This failed practice had the potential to affect all residents residing at the facility. Facility census: 117.

Inspectors wroteBased on observation, record review and staff interview the facility failed to maintain a quality assessment and assurance committee (QAPI) consisting of the minimum required members. The infection preventionist failed to attend the monthly QAPI meeting. This failed practice had the potential to affect all residents currently residing at the facility. Facility census: 117.

Inspectors wroteBased on observation and staff interview the facility failed to provide dignity during care for Resident #50. This failed practice was a random opportunity for discovery and was true for only Resident #50. Resident identifier: #50. Facility census: 117.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure one (1)resident was provided a clean, sanitary homelike environment. The resident had dirty sheets his bed. This was a random opportunity for discovery during the long term care survey. Resident identifier #11. Census 117.

Inspectors wroteBased on record review and staff interview the facility failed to have an accurate MDS (Minimum Data Set) discharge for Resident #116. This was true for one (1) out of four (4) reviewed for the care area of discharges during the Long Term Care Survey Process. Facility census 117.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening (PAS) for one (1) of three (3) residents reviewed for the category of PASARR (pre admission screening and resident review), during the long term care survey process. Resident identifier #85. Census 117. Findings Included: a) Resident #85 On 05/08/23 at 2:14 PM, a record review of Resident #85's electronic medical record (EMR), found the resident's most recent PAS, dated 03/29/21, indicated no level II was needed. It was also noted on this PAS the resident did not have any behaviors. This PAS was completed by a home health agency for his admission to the facility. The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement the care plan for monitoring behaviors for Resident # 117 and failed to develop a care plan for Resident #41's bipolar disorder. This was true for two (2) out of 27 residents reviewed for care plans. Facility census 117.

Inspectors wroteBased on record review and resident interviews, the facility failed to revise care plans to reflect the resident's preferences and meet the resident's needs for three (3) of three (3) residents reviewed for the category of activities, during the long term care survey. Resident identifiers #11, #100, and #84. Census 117. Findings Included: a) Resident #11 On 05/08/23 during a resident interview the resident stated he doesn't go to activities because he doesn't like BINGO. A record review was conducted on 05/09/23 of the resident's Recreation Quarterly assessment dated [DATE]. It included, .List independent leisure pursuits: watching TV/movies independently and/or with other residents, resting, reading newspaper/daily chronicle, talking/visiting with office staff and other residents, going outside, smoking, collecting recipes .List the most frequently attended group programs: [...]

Inspectors wroteBased on record review, resident observation and staff interview the facility failed to ensure residents who are dependent on staff for carrying out thier Activities of Daily Living (ADL) recieve the necessary services to maintain good nutrtion, grooming, and personal hygiene. The was true for three (3) of three (3) residents reviewed for the care area of ADL care during the long term care survey process. Resident Identifiers: #424, #217, and #70. Facility Census: 117.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. An accurate skin assessment was not completed for Resident #4. Appropriate action was not taken in a timely manner for an incident involving injury for Resident #50. These failed practices were a random opportunity for discovery and was true for Resident #4 and Resident #50. Resident identifiers: #4, and #50. Facility census: 117.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the resident weights were confirmed by a reweight when there was a 5 pound difference from the previously obtained weight. Failure to confirm the weights made it difficult for the dietician and other healthcare professionals to monitor Resident #82's nutritional status. This was true for one (1) of two (2) residents reviewed for the care area of nutritional status during the Long Term Care survey process . Resident Identifier: #82. Facility Census: 117.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the physician responded timely to monthly drug regimen reviews. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #84. Facility census: 117.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a residents drug regimen was free from unnecessary drugs. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identified: #117 Facility census 117.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident did not receive unnecessary psychotropic medications (a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior.) This was true for One (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #117. Facility census 117.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #93 was hoisted in a lift in the hall way outside of his room and then transported in the lift from the hallway to his room where he was placed in his bed by the window. Mechanical lifts are transfer devices only and are not to be used as transport devices due to the risk of serious harm and/or death to residents. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #93 at risk for serious harm and/or death. The facility was notified of the IJ at 3:41 pm on 02/08/22. The facility submitted a Plan of Correction (POC) at 5:24 pm on 02/08/22 at which time it was accepted by the SA. The plan of Correction read as follows: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to employ a qualified dietitian and/or a certified dietary manager on a full-time basis. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 118.

Inspectors wroteBased on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for three (3) of six (6) residents in the long-term care survey sample. Resident identifier #51, #68 and #63.

Inspectors wroteBased on record review and staff interview the facility failed to implement there abuse prohibition policy in regards to reporting and the investigation of serious bodily injury. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident Identifier: #55. Facility Census: 118. Findings Included: a) Policy Review A review of the facility's Abuse Prohibition policy with an effective date of 06/01/96 and a review and revision date of 04/09/21 on 02/09/22 found the following: --7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (Center Executive Director) or designee will perform the following. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure that nurse aides we competent to carry out the duties of their job. The facility had a total of 42 nursing assistants working at the facility. Of those 42 only four (4) had competency evaluations completed in the last year. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Staff Identifiers (All Nurse Aides): #44, # 23, #19, #84, #65, #98, #122 , #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95. Facility Census: 118. Findings Included: a) NA Competencies On 02/08/22 at 11:22 am, the Center Nurse Executive (CNE) was asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic medications. Resident #43 received an as needed (PRN) anti-anxiety medications even though they had demonstrated no target behaviors to warrant the use of the PRN medication and the facility failed to attempt non-pharmacological interventions prior to administering the PRN anti-anxiety medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Long-Term Survey Process Survey (LTCSP). Resident identifier: #43. Facility census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure professional standards and practices to maintain accurate and complete medical records. This was true for four (4) of 30 residents reviewed during the Long-Term Care Survey Process. Resident Identifier: #60, #111, #37 and #112. Facility Census: 118. Findings Included: a) Resident #60 A review of the medical record for Resident #60 was completed on 02/09/22. This review found a diagnosis list which contained a diagnosis of an unstageable pressure ulcer of left heel. This unstageable pressure ulcer diagnosis was not added until 01/04/22. At which time the onset date was listed as 01/04/22 and resolved date was added for 12/29/21. A progress note dated 12/29/21 by Registered Nurse (RN) #6 stated Wound rounds completed with NP (Nurse Practitioner), pressure area to left heel resolved. [...]

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections including COVID - 19. Nurses failed to maintain infection control procedure during medication pass and the staff failed to dispose of COVID-19 contaminated gowns properly. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers #23 and #90 Facility Census 118 Findings Included: a) Medication Pass 1)Resident #23 On 02/08/22 at 8:20 AM, this surveyor observed Licensed Practical Nurse (LPN) # 110 shake a Sennosides-Docusate Sodium Tablet 8.6-50 MG from the bottle into her hand then place the pill into Resident #23's medication pill cup. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure Resident #93 was provided care in a manner which preserved his dignity. Resident #93 was placed in a full body lift while in the hallway outside of his room. This was random opportunity for discovery. Resident Identifier: #93. Facility Census: 118. Findings Included: An observation on 02/08/22 at 11:06 am found Nurse Aide (NA) #36 and NA #111 was in the process of transferring Resident #93 from the shower bed back to his bed. The nurse aides lifted Resident #93 up in the total lift from the shower bed while still in the hallway outside of his room. With Resident #93 still in the sling on the lift the nurse aides pushed the lift into resident #93's room to transfer him back to bed. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain a safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #68. This was a random opportunity for discovery. Resident identifier: #68 Facility census: 118.

Inspectors wroteBased on record review and staff interview the facility failed to ensure all falls which resulted in serious bodily injury was reported to the appropriate state agencies within the required time frames. Resident #55 fell from bed and fractured her left hip. This was not reported within two (2) hours of the facility having knowledge of the fracture (serious bodily injury). This was true for one (1) of nine (9) residents reviewed for the care area of falls during the long term care survey process. Resident Identifier: #55. Facility Census: 118. Findings Included: a) Resident #55 A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information: Root Cause/Conclusion: [...]

Inspectors wroteBased on record review and staff interview the facility failed to investigate a fall with a serious bodily injury to determine the cause and to initiate corrective action to prevent similar instances from happening again as required. This was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier: #55. Facility Census: 118.

Inspectors wroteBased on record review and staff interview the facility failed to ensure transfer documents and appropriate information were communicated with the receiving health care facility. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process. Resident Identifier # 111 Facility Census 118 Findings Included: a) Resident # 111 Record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. A copy of the interact transfer form was provided to the local hospital on [DATE]. The reason for the transfer was behavioral reasons. On 02/08/22 at 1:32 PM, the Corporate Nurse (CN) stated the facility has a check list of items they send to the hospital but the facility doesn't keep a copy of each document sent with the resident to the hospital. The CN provided a copy of the check list with the Resident's name at the top of the check list. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process. Resident Identifier # 111 Facility Census 118 Findings Included: a) Resident # 111 A record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. The reason for the transfer was behavioral reasons. A copy of the bed hold notice policy and authorization form shows the Resident's name printed on top of form and a registered nurse signature at the bottom of the page dated 10/17/21. The review found the rest of the form was not complete. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Sets (MDS)accurately reflected the resident's status. This was true for two (2) of thirty (30) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #43's MDS was inaccurate in the area medication (gradual dose reduction (GDR)). Residents #112s MDS was inaccurate in area of nutritional/weight. Resident's identifiers: #43, and #112. Facility census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed. This was true for two (2) of 30 residents reviewed during the long term care survey process. Resident Identifier: #317 and #55. Facility Census: 118. Findings Included: a) Resident #317 1) Smoking Status On 02/07/22 at 3:43 PM, Registered Nurse (RN) # 63 stated there are no current smokers except the one resident who is grandfathered in. Please note that Reisdent #317 is not resident allowed to smoke. On 02/08/22, a review of Resident #317's Care Plan dated 02/01/22 states resident may smoke independently. The Smoking assessment dated [DATE] states the resident may smoke independently as well. An admission Minimum Data Set (MDS) dated [DATE] Section J1300 was coded as (0) which indicates no tobacco use. [...]

Inspectors wroteBased on record review, observation, and staff interview the facility failed to ensure Resident #55's care plan pertaining to falls was revised when the residents condition changed. This was true for one (1) of 30 resident reviewed during the long term care survey process. Resident Identifier: #55. Facility Census: 118. Findings Included: Observation of Resident #55 on 02/07/22 01:48 pm found she was a bilateral below the knee amputee. A record review of Resident #55's medical record on 02/08/22 found the following care plan. Focus Statement: Risk for further falls and injury related to recent fall with left hip fracture, new right BKA (Below the knee amputation). [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #25, the facility failed to follow physician ordered parameters for Midodrine, a medication to treat hypotension and Resident #107, had neurological checks, after a fall, which were incomplete. Resident identifiers: #25 and #107. Facility census: 118.

Inspectors wroteBased on observation, staff interview and record review the facility failed to maintain an environment appropriate to prevent urinary tract infections and trauma by not having Resident #46's catheter tubing secureed to his leg. This was true for one (1) of one (1) residents investigated for the care area of catheter care. Resident Identifier # 46 Facility Census 118. Findings Included: a) Resident # 46 On 02/08/22 at 3:00 PM, this surveyor observed Nursing Aide (NA) #38 complete catheter care on Resident # 46. During catheter care it was observed Resident # 46's catheter tubing was not secured to his leg . When NA #38 was asked what was used to secure Resident #46's catheter tubing, NA #38 stated the RN (Registered Nurse) was in charge of that. On 02/08/22 at 3:05 PM, RN #113, was asked if Resident # 46 should have a securing device on his catheter. RN # 113 stated she would have to ask. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of two (2) residents reviewed during the survey process. Resident identifiers: #33, and #82. Facility census:

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to provide necessary care and services for Resident #39, who required hemodialysis due to end stage renal disease. The facility failed to assess the arteriovenous fistula in the left arm prior to and after receiving dialysis treatments and they obtained blood pressures (b/p) in the left arm eventhough it was a restricted limb. Resident identifier: #39. Facility census: 118.