Rancho Rehab and Healthcare Center

Inspectors wroteBased on record review and interview, the facility failed to ensure 10 of 10 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) were free from misappropriation of resident property when the former Business Office Manager (FBOM) withdrew resident funds to use for his/her personal use. This had the impact to affect all residents for whom the facility managed funds. The facility census was 84.1. Record review of Resident #1's medical record showed the resident is his/her own responsible party. Record review of the facility maintained Resident Trust Statement for the period 01/01/23 through 05/21/26, showed the following sampled unauthorized withdrawals from Resident #1's account: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures for resident consumption within a safe range to prevent the potential of skin burns for two residents. Staff provided a cup of hot water to a resident (Resident #2) who requested it to give to another resident (Resident #1) who wanted to make instant coffee in his/her room. Resident #2 took the cup of hot water to Resident #1's room, placed it on the over the bed table then left the room. [...]

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to label, date, and cover food and failed to ensure an expired gallon of milk was discarded as indicated. The facility also failed to ensure kitchen equipment and the floor were kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temp logs as well as chloride testing logs. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 79. 1. Observation of the kitchen on 3/5/25 at 11:37 A.M., 3/6/25 at 3:33 P.M., and 3/10/25 at 11:15 A.M., showed the following: -Dry storage room: -A bucket of peanut butter without a date; -An opened bottle of lemon juice without a date; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year. Eight CNAs (CNA U, CNA V, CNA W, CNA X, CNA Y, CNA J, CNA Z, CNA H), and two Certified Medication Technicians (CMTs), (CMT L and CMT AA) were sampled. The facility failed to document the length of time the training was provided for all sampled staff. The census was 79. 1. Review of CNA U's employee file showed: -Date of hire: 10/19/21; -One in-service was completed; -The in-service failed to show the length of time the training was provided. 2. Review of CNA V's employee file, showed: -Date of hire: 10/19/21; -Twelve in-services were completed; -The in-services failed to show the length of time the training was provided. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for five staff members. A sample of eight employees hired were reviewed. The facility hired at least 80 new employees since the last survey. The census was 79. Review of the facility's Staff Screening policy, dated 10/22/24, showed the following: -Policy: The Facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers; -Prior to employment or commencement of a contract, the Facility will verify and document or obtain a copy, if applicable, of the following information that may include, but not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 18 out of 30 days reviewed for staffing. This had the potential to cause unmet health needs for all residents. The census was 79. Review of the Nursing Department - Staffing, Scheduling & Postings policy, revised 10/24/22, showed the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days per week, unless a waiver applies. Review of the facility's daily staffing schedule, dated 2/10/25 through 3/11/24, showed no RN coverage on the following dates: 2/11/25, 2/12/25, 2/14/25, 2/15/25, 2/16/25, 2/18/25, 2/19/25, 2/20/25, 2/23/25, 2/24/25, 2/27/25, 2/28/25, 3/1/25, 3/4/25, 3/5/25, 3/6/25, 3/9/25 and 3/10/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure they followed their policy to act on any irregularities noted by the pharmacist during the monthly Medication Regimen Review (MRR), which affected five out of five residents sampled for unnecessary medications review (Residents #53, #42, #6, #38 and #51). The census was 79. Review of the facility's Drug Regimen Review policy, dated 10/24/22, showed: -Policy: The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications; -The pharmacist will report any irregularities to the attending physician and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility had two medication rooms, six medication carts and one treatment cart. Both medication rooms, three medication carts and the treatment cart were reviewed, and issues were found with all. The census was 79. Review of the facility's Medication Storage Policy, dated 2007, showed: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a process was in place for physician ordered laboratory tests to be completed and results received in a timely manner for four residents (Residents #42, #18, #46 and #11). The sample was 18. The census was 79. Review of the facility's Laboratory, Diagnostic, and Radiology services policy, dated 10/24/22, showed: -Policy: Laboratory, diagnostic and radiology services will be coordinated pursuant to an order by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with the scope of practice under state law; -The Facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for one resident (Resident #15) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications) and when staff provided care for one resident on EBP (Resident #235) then provided care on another resident wearing the same gown (Resident #11) and when staff failed to perform hand hygiene [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify the residents' dialysis treatments (Residents #53 and #62). The sample was 18. The census was 79. Review of the facility's Resident Assessment Instrument (RAI) Process policy, dated 10/24/22, showed: -Purpose: To ensure that the Resident Assessment Instrument is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician orders were accurately recorded and updated for three sampled residents (Residents #46, #18 and #6) out of 18 sampled residents. The facility failed to serve Resident #46 with physician ordered double portions. The facility also failed to ensure oxygen tubing was dated and oxygen equipment was covered per infection control standards for Resident #18. In addition, the facility failed to obtain documentation of Resident #18's cardiology progress notes from the most recent appointment when Resident #18 received a blood pressure machine that reported results directly to the cardiologist. The facility also failed to ensure Resident #6's neurological checks (medical assessments used to evaluate the function and health of the nervous system) were completed and maintained in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for three residents by failing to ensure one resident received his/her showers as scheduled (Resident #38) and failed to ensure residents were clean and odor free (Residents #38, #2 and #6). The sample was 18. The census was 79. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Required set-up or clean assistance with personal hygiene; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a motorized wheelchair was in working order after it was reported to facility staff that there were broken or missing parts (Resident #29). The sample was 18. The census was 79. Review of the facility's Maintenance Work Orders policy, dated 10/24/22, showed: -Purpose: To protect the health and safety of residents, visitors, and Facility Staff; -Policy: Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority; -Procedure: To enable the Maintenance Department to prioritize tasks PE - 02 - Form A - Work Order Form or other similar document will be filled out and forwarded to the Director of Maintenance; -Department directors/supervisors are responsible for completing such work orders and forwarding them to the Director of Maintenance; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) services had written communication with the dialysis center. The facility identified two residents who received dialysis services. Two residents were sampled (Resident #62 and #53), and issues were found with both residents. The sample was 18. The census was 79. Review of the facility's Dialysis Care policy, dated 10/24/22, showed: -Purpose: To provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments; -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an as needed (PRN) controlled pain medication, as ordered by the prescriber, to meet the needs of one sampled resident (Resident #38). The census was 79. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/25, showed: -Cognitively intact; -Required substantial/maximal assistance with shower/bath; -Occasional urinary incontinence; -Frequent bowel incontinence; -Diagnoses included heart disease, high blood pressure, traumatic brain injury, anxiety disorder and manic depression. Review of the resident's care plan, in use at time of survey, showed: -Focus: Resident is on pain medication therapy, opioid analgesics related to chronic neck pain, lower back pain, and right leg pain; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, three errors occurred during medication administration for one resident (Resident #7), resulting in a 10% error rate. The census was 79. Review of the facility's Medication Administration Policy, dated October 24, 2022, showed: -Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law; -Nursing staff will keep in mid the seven rights of medication when administrating medications: the right medication, the right amount, the right resident, the right time, the right route, the right indication and the right outcome; -Additional considerations: the resident has right to know what the medication does; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors. The facility failed to ensure one resident's (Resident #11) treatment plan was transcribed on the physician order sheet. This failure resulted in one anti-seizure medication not being adjusted for 46 days. The sample was 18. The census was 79. Review of the facility's Physician Order policy, dated 10/24/2022, showed: -Purpose: this will ensure that all physician orders are complete and accurate; -Telephone orders: a licensed nurse will record telephone orders on the telephone order sheet with the date, time and signature of the person receiving the order or in the electronic health record (EHR); -The order is transcribed onto the physician's order form at the time the order is taken; [...]

Inspectors wroteSee Event ID Y0PE12. Based on interview and record review, the facility failed to follow physician's orders and facility policies for one resident with a history of pain. The resident was admitted to the facility from the hospital on [DATE], with an order for acetaminophen (non-narcotic pain medication for mild pain) PRN (as needed/as necessary) and Oxycodone (narcotic pain medication for moderate to severe pain) PRN and diagnoses that included advanced metastatic (the cancer has spread from where it started to another part of the body) cervical cancer (cancer of the cervix (the lowest region of the uterus)) and pressure ulcers (localized skin and soft tissue injuries). The facility failed to process the resident's orders for the Oxycodone and acetaminophen upon admission. [...]

Inspectors wroteSee Event ID Y0PE12. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 10/1/24. Based on interview and record review, the facility failed to follow their policy when staff failed to thoroughly document pain assessments and interventions (pain location, what pharmacological/non-pharmacological interventions were attempted in response to pain, and follow-up to determine if an intervention was effective) for one resident when staff identified the resident had pain based on pain scale rating of 1-10 (Resident #11). Twelve resident's were sampled and problems were identified with one. The census was 88. Review of the facility's Pain Management policy, last revised on 10/24/22, showed: -Purpose: To ensure accurate assessment and management of the resident's pain; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse. On the evening of 9/19/24, the resident became upset with Licensed Practical Nurse A (LPN A) when he/she removed the resident's oxygen concentrator from the room. The resident, who had diagnoses of anxiety and chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe by restricting airflow in the lung), was observed following LPN A out of his/her room telling LPN A he/she needed the oxygen. The resident became angry, yelling and cursing, and hit LPN A in the face at least twice. LPN A forced the resident to the ground and placed a knee on top of the resident. After pulling the resident up to a standing position, LPN A forced the resident back to his/her room. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the Department of Health and Senior Services (DHSS) as required by state and federal regulations, when an allegation of staff to resident abuse was made. On the evening shift of 9/19/24, Licensed Practical Nurse (LPN) A forced a resident (Resident #2) onto the floor, held the resident's hands down and placed his/her knee on the resident to keep the resident on the floor. After pulling the resident up off the floor and to a standing position, the LPN forced the resident to go to his/her room. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders and facility policies for one resident with a history of pain. The resident was admitted to the facility from the hospital on [DATE], with an order for acetaminophen (non-narcotic pain medication for mild pain) PRN (as needed/as necessary) and Oxycodone (narcotic pain medication for moderate to severe pain) PRN and diagnoses that included advanced metastatic (the cancer has spread from where it started to another part of the body) cervical cancer (cancer of the cervix (the lowest region of the uterus)) and pressure ulcers (localized skin and soft tissue injuries). The facility failed to process the resident's orders for the Oxycodone and acetaminophen upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacological interventions were only used when non-pharmacological interventions are ineffective or when clinically indicated for one (Resident #2) of five sampled residents. On the evening of 9/19/24, Licensed Practical Nurse (LPN) A removed the resident's oxygen concentrator from his/her room. The resident had diagnosis of chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems). Removing the concentrator caused the resident to yell, curse, and hit LPN A. LPN A forced the resident onto the floor, and then forced the resident to his/her room. LPN A contacted the Director of Nurses (DON) who contacted the resident's psychiatrist and received an order for a Haldol (an antipsychotic) injection. [...]

Inspectors wroteBased on interview and record review, the facility failed accurately document an event that occurred with one resident (Resident #2) on 9/19/24. Documentation did include Licensed Practical Nurse (LPN) A's actions of forcing the resident onto the floor, holding the resident's hands down, placing his/her knee on top of the resident, and making the resident return to his/her room. In addition, LPN A failed to document in the resident's progress notes, physician's order sheet (POS) and the medication administration record (MAR) the orders for and administration of Haldol (an antipsychotic) 5 milligrams (mg) intramuscular (IM) and Benadryl 25 mg by mouth (PO) as ordered by the psychiatrist. Five residents were sampled. The census was 89. Review of the facility Physician Orders policy, revised on 10/24/22, showed: -Purpose: This ensure that all physician orders are complete and accurate; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) arrived for his/her heart valve surgery with blood thinners placed on hold per order. The resident missed two surgery appointments due to facility error. The facility also failed to ensure one resident (Resident #2) was properly dressed and safe when he/she was sent to dialysis with no pants on, only a brief and no lift pad under him/her despite physician orders for transfers via mechanical lift. The sample was 12. The census was 92. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide protective oversight for one resident (Resident #3) who eloped, leaving the facility and facility grounds. The resident was missing for at least 30 minutes without staff's knowledge. The facility noted the resident was missing when the police department brought the resident back to the facility, asking if he/she belonged there. Staff failed to document the resident's activity preferences in the care plan, which would distract the resident from wandering. This had the potential to affect all residents who wander and/or exit seek. The sample was 12. The census was 92. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for one resident. Staff failed to provide personal hygiene for one resident who readmitted to the facility from the hospital and had not received personal hygiene care for over 8 hours (Resident #1). In addition, staff failed to provide eating assistance for the residents. The sample size was 3. The census was 93. Review of the facility's Perineal Care (cleansing of the area to include the buttocks and genitals) policy, revised 10/24/22, showed: -Purpose: To maintain the cleanliness of the perineal area, to reduce odor and prevent skin infection and breakdown; -Policy: perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need. Review of the Facility's Nutrition/Hydration Management policy, revised 10/24/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support in a timely manner, including cardiopulmonary resuscitation (CPR, an emergency lifesaving technique used when someone's breathing or heartbeat has stopped) for one of four sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). The census was 91. The Administrator was informed on [DATE] at 3:18 P.M. of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's policy titled, Medical Emergencies-Code Blue, revised [DATE], showed the purpose of the policy was to ensure the prompt and effective response by facility personnel during medical emergencies through the use of the code blue procedure. [...]

Inspectors wroteSee Event ID 8D9Z12 Based on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from accident hazards when staff failed to ensure a resident who was a fall risk, had left sided weakness and required total assistance from staff for personal care (Resident #300) had an appropriate bed to provide stability while staff provided care. The census was 94. Review of Resident #300's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/6/23, showed: -Moderate cognitive impairment; -Impairment to one side of upper extremities; -Required substantial assistance from staff to roll from left to right in bed; -Always incontinent of bowel and bladder; -Diagnoses included diabetes, hemiparesis (paralysis on one side), malnutrition and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food and drink to the residents that was palatable, attractive, and at an appetizing temperature during the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one (1) of one (1) kitchen reviewed for food service, in that: 1. Dented cans were found in the for-use section of the dry storage. 2. One pound box of potato pearl was no dated nor sealed. 3. The ice machine was not clean. 4. The indoor central air conditioning unit's return vent was not clean. 5. The backsplash had a black and greenish- substance speckled around the dish machine and pre-wash area. 6. Carts used to distribute resident meal trays were not clean. 7. Hair restraints were not used to cover facial hair and head hair by six (6) of eight (8) dietary staff. 8. There were no sanitizing wipes to clean off the food thermometer when staff took the food temperatures during the lunch meal observed. 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for one (1) of one (1) dumpster reviewed for garbage disposal. The facility also failed to ensure the dumpster lids for two (2) of two (2) dumpsters and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (1) of one (1) dish machine. The dish machine in the kitchen was not operated within the manufacturer's specification. This failure could place residents who received meals and snacks from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective pest control program as evidenced by flies in the facility for residents for three (3) of four (4) facility units (Halls 100, 200 and 300) and one (1) of one (1) dining room observed for environment. The facility had an ineffective pest control program with observations of flies in the 100, 300 and 300 halls of the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure that efforts were made to ensure the reasonable accommodation of resident needs and preferences in relation to call light access for residents on two (2) of four (4) halls the facility. (100 and 200 halls).

Inspectors wroteBased on interview and record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 97. Review of the facility's Resident Funds-Handling and Recording Policy, dated 5/1/23, showed the following: -Purpose: To provide a means to protect resident funds managed by the facility and account for funds received and disbursed on the resident's behalf; -Policy: In the event that the facility manages the resident's funds, resident funds will not be commingled with the facility's operating funds. The facility maintains accounting records of resident funds and has a surety bond to protect such funds on deposit with the facility. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure two (2) of four (4) units were cleaned and well-maintained to provide for a homelike environment.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to assist one (1) of 32 sampled residents to maintain his/her dignity by ensuring the resident was dressed appropriately. Resident #79, who was identified as having a self-care deficit with self-performance of activities of daily living (ADLs), was observed wearing his/her T-shirt on inside-out and backwards with the resident's last name and first initial printed across the top in large letters with a black marker. Staff interview revealed the resident did not independently dress himself/herself and did not disrobe after being assisted with dressing.

Inspectors wroteBased on interview, record review, policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment when indicated for one (1) of 32 sampled residents. On 7/23/23, Resident #18 was determined to have a life expectancy of less than six (6) months and the resident was admitted into hospice services. A comprehensive assessment was not completed within 14 days of the determination of terminal prognosis and election of the hospice benefit.

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to ensure that a resident's Care Plan was reviewed and revised after an emergency transfer to the hospital due to a change of condition (Resident #57).

Inspectors wroteBased on staff interview and record review, the facility failed to administer medications as order to one (1) of 32 sampled residents (Resident #196).

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to ensure quality of care for two (2) of 32 sampled residents, including failure to ensure a resident who went to the hospital due to a change of condition (Resident #57) had an updated Care Plan to reflect the change of condition. The facility also failed to ensure a resident who was dependent on staff for bed mobility, was positioned for comfort and safety. (Resident #18)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from accident hazards when staff failed to ensure a resident who was a fall risk, had left sided weakness and required total assistance from staff for personal care (Resident #300) had an appropriate bed to provide stability while staff provided care. The census was 94. Review of Resident #300's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/6/23, showed: -Moderate cognitive impairment; -Impairment to one side of upper extremities; -Required substantial assistance from staff to roll from left to right in bed; -Always incontinent of bowel and bladder; -Diagnoses included diabetes, hemiparesis (paralysis on one side), malnutrition and depression. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to ensure that a resident who was continent of bladder and bowel received the necessary services and assistance to maintain continence for one (1) of one (1) resident reviewed (Resident #73) for catheter care services out of 31 sampled residents. Specifically, the facility failed to receive a Physician's Order for catheter use to ensure appropriate care was provided to the resident.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications were stored appropriately and not kept past their expiration dates. Unsecured medications were stored at the bedside without a physician's order for one (1) for 32 sampled residents (Resident #40), and expired stock medications, prescription medications, and glucose monitoring sensors were found in one (1) of two (2) medication rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for one (1) of five (5) residents (Resident #34). Resident #34 was not served double portions of protein for the lunch meal as ordered by physician. This could affect all residents with supplements and could result in a decrease in calories and potential for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutritional supplements as ordered by the physician or recommended by the dietician, to residents identified with impaired nutritional status (Residents #24, #56, #54 and #12). The census was 72. 1. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed: -Supervision required while eating; -Weight: 154 pound (lbs); -No weight loss noted. Review of the resident's medical record, showed: -Diagnoses included dementia without behavioral disturbance, nutritional anemia, and protein-calorie malnutrition; -A physician's order, dated 1/13/20, for mechanical soft diet with double portions at breakfast and health shakes three times a day; -Weighed 156.8 lbs in December 2019; -Weighed 144.4 lbs in January 2020. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation that one physician, the facility Medical Director, saw residents according to time frames as mandated by the Centers for Medicare and Medicaid Services (CMS). The facility identified 48 residents as patients of the physician. Of those 48 residents, 12 were sampled and four of those twelve were identified by the facility as being able to provide an accurate interview. Three of those four residents said they had not seen their physician, only the physician's nurse practitioner (NP). The fourth resident was in the hospital and unavailable at the time of the interviews (Residents #42, #274 and #3). The census was 72. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/19, showed: -admission date of 5/20/19; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure super cereal (calorie dense oatmeal) was prepared and served to residents with nutritional needs and orders to receive it during one meal observation. The facility identified six residents as receiving super cereal. The census was 72. Observation on 1/16/20 at 6:24 A.M., showed [NAME] A gathered brown sugar, cinnamon, butter and whole milk to prepare super cereal. As he/she went to obtain the oatmeal, he/she said they did not have enough oatmeal to make super cereal. The residents who were to receive super cereal would not receive it on today (1/16/20). During an interview on 1/16/20 at 7:50 A.M., the Dietary Manager said they ran out of oatmeal and the food delivery was scheduled for 1/16/20, around 8:00 A.M. Food is delivered to the facility on Monday and Thursday. [...]

Inspectors wroteBased on observation and interview, the facility failed to label and properly store opened food items in the main walk-in freezer during three of four days of observation. The census was 72. Observation of the kitchen's main walk-in freezer on 1/14/20 at 8:48 A.M., showed: -Two bags of what appeared to be various frozen chicken pieces. The items were in a plastic bag, unlabeled and undated; -One bag of what appeared to be frozen chicken breast patties. The items were in an unsealed plastic bag, unlabeled and undated; -A bag of what appeared to be frozen meatballs in a plastic bag. The plastic bag was tied in a knot, unlabeled and undated; -A bag of frozen pancakes in a plastic bag. The plastic bag was tied in a knot, unlabeled and undated; -A bag of an unknown food item, in a plastic bag, tied in a knot. The item was light brown, with brown crumbs at the bottom of the bag. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure signs were posted at the front and side visitor entrances, requesting visitors not to visit if they were experiencing a cold or flu or had symptoms of either, and the facility had no personal protection supplies such as gloves or masks for visitors to use if they chose to visit while experiencing a cold or flu symptoms or if the facility was experiencing an outbreak among the residents. The census was 72. [...]

Inspectors wroteBased on interview, the facility failed to ensure residents had access to mail delivered on Saturdays. This had the potential to affect all residents at the facility. The census was 72. During a group interview on 1/16/20 at 10:00 A.M., nine residents, who the facility identified as alert and oriented, attended the group meeting. The residents said they did not receive mail on Saturdays. Four residents said they cannot receive mail on the weekends because the front office is closed and locked. During an interview on 1/21/20 at 12:13 P.M., the activities director said her department was responsible for delivering resident mail. Mail is distributed to residents Monday through Friday, but not on Saturday. Activity staff does work on the weekend, but mail is delivered to the front offices, which are locked on weekends. [...]