Red Cliffs Health and Rehab

Inspectors wroteBased on interview and record review, it was determined that for 2 of 10 sampled residents, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry our the activities of daily living. Specifically, residents were not provided bathing/shower assistance. Resident identifier: 1 and 5. Findings Included: On March 24, 2025, the surveyor interviewed Resident 1. Resident 1 stated that she was not receiving her scheduled showers from the facility and had occasionally gone a week without a shower. On March 25, 2025 the surveyor reviewed Resident 1's medical record, and the following entries were observed: A care plan dated August 8, 2024, revealed that Resident 1 had an ADL (Activities of Daily Living) self-care performance deficit and required substantial/maximal assistance with bathing/showering. [...]

Inspectors wroteBased on interview and record review, it was determined that for 1 of 10 sampled residents, that the facility failed to provided the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, a resident was not provided showers or oral care as scheduled. Resident identifier: 4. Findings Included: On March 24, 2025 the surveyor reviewed resident 4 ' s medical record, and revealed the following. Resident 4 had an ADL (activities of daily living) self care performance deficit related to paralysis of the left side and aphasia following a CVA (cerebrovascular accident) and requires substantial/maximal assistance with bathing/showering, and is DEPENDENT on staff for personal hygiene. Resident 4's showers were scheduled for twice a week, shower documentation revealed the following: [...]

Inspectors wrote4. Resident 367 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, dependence on renal dialysis, type 2 diabetes, hypertensive chronic kidney disease stage 5, chronic atrial fibrillation, and cognitive communication deficit. Resident 367's medical record was reviewed on 6/2/24-6/6/24. On 9/18/23, resident 367's Brief Interview for Mental Status (BIMS) Assessment documented that resident 367 had a score of 11, which would suggest moderate cognitive impairment. Resident 367's progress notes and incident reports revealed the following: a. On 9/19/23 at 5:09 PM, the incident report documented, Adon [assistant director of nursing] received phone at 1600 [4:00 PM]. Transport stated she strapped resident in, but while driving she hit her breaks [sic] and resident fell backwards in wheelchair. [...]

Inspectors wroteBased on interview and record review, it was determined the facility did not immediately consult with the 2 of 53 sample residents' physicians after there was a need to alter treatment significantly. Specifically, one resident had symptoms of a change in condition and the facility physician instructed the facility nurses to contact the surgeon, but no evidence could be located that this occurred. This resulted in the finding of a harm for this resident. In addition, a resident experienced elevated blood glucose levels without timely notification of the physician. Resident identifiers: 53 and 365.

Inspectors wroteBased on interview and record review it was determined, for 5 out of 53 sampled residents, that the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a staff member recorded a video in the shower room while a resident was in the bathtub naked, a cognitively impaired resident kissed two different cognitively impaired residents on two different occasions and another resident who was cognitively impaired was involved in a sexual relationship. Resident Identifiers: 5, 12, 17, 36, 42, and 374. Findings Included: 1. Resident 42 was admitted to the facility on [DATE] with the following diagnoses of delirium, unspecified dementia with psychotic disturbance, anxiety disorders, cognitive communication deficit, and major depressive disorder. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 53 sample residents received treatment and care in accordance with professional standards of practice. Specifically, one resident experienced a change in condition, and the facility did not act in a timely manner to treat the condition. This resulted in a finding of harm for this resident. In addition, one resident was not monitored for a change in condition after a dental procedure, and a resident who was incontinent developed Moisture Associated Skin Damage (MASD). Resident identifiers: 5, 7, and 365.

Inspectors wroteBased on interview and record review it was determined that for 2 out 53 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to extent possible. Specifically, a resident developed a UTI after facility staff were not instructed and trained on the proper changing, frequency, and monitoring of the resident's PureWick urinary system device and a resident had a delay in starting antibiotic therapy for a UTI. Resident identifiers: 36, 54. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 53 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences. Specifically, the resident's pain medication was not administered per the physician orders and the resident had complaints of uncontrolled pain. Resident identifier: 50.

Inspectors wroteBased on interview and record review, the facility did not ensure, for 3 of 53 sampled residents, were free of significant medication errors. Specifically, a resident was given linezolid for more days than what was ordered by the hospital, narcotics were given outside of physician ordered parameters, and lorazepam was given more often than what was ordered. Resident identifiers: 41, 50, and 372. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility must assist a resident in making appointments and arranging for transpiration to and from the dental services location. Specifically, a resident had teeth extracted and there was no follow-up appointment for dentures scheduled. Resident identifier: 53.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 3 of 53 sampled residents received services in the facility with reasonable accommodation of resident needs and preferences. Specifically, residents were not provided with transportation for personal needs, and one resident was not provided with incontinence briefs despite developing a rash from the ones that the facility offered. Resident identifiers: 7, 15, and 114.

Inspectors wroteBased on interview and record review, the facility did not consider the views of a resident group, nor did they act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. In addition, the facility was not able to demonstrate their response and rationale for such response. Specifically, residents voiced similar concerns over time in the resident council, and the facility did not follow up in a manner that significantly resolved the concerns.

Inspectors wroteBased on record review and interview, it was determined, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, for 4 out of 53 sampled residents, exhibit 358 entity reports of neglect and abuse allegations were not submitted to the SSA in a timely manner. In addition, exhibit 359 follow-up investigation report of one resident was submitted to the SSA seven working days after the neglect incident was reported. Resident identifiers: 364, 367, 370 and 374.

Inspectors wrote7. Resident 368 was admitted to the facility on [DATE] with diagnoses which included, palliative care, cirrhosis of the liver, hepatic failure, type 2 diabetes with chronic kidney disease, altered mental status, depression, insomnia, and hypothyroidism. Resident 368's medical record was reviewed 6/2/24-6/6/24. No documentation could be located in the medical record indicating that resident 368 had been evaluated to safely self administer medications. An admission Brief Interview for Mental Status (BIMS) dated 9/25/23 documented that resident 368 had a score of 9. A BIMS score of 9 indicated moderately impaired cognition. Resident 368's progress notes and incident reports revealed the following: a. On 10/2/23 at 9:35 AM, the Incident Note documented, resident was found on the floor by her husband. He came out saying she needed assistance. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not develop and implement a baseline care plan for the resident within 48 hours of the resident's admission and must include at a minimum the initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and any pre-admission screening and resident review PASARR recommendations if applicable. Specifically, the resident did not have a baseline care plan initiated within 48 hours of admission. Resident identifier 36.

Inspectors wroteBased on interview, observation and record review it was determined, for 10 out of 53 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, residents voiced concerns with call light wait times and not receiving assistance with bathing and pain management. In addition, concerns with regard to staffing issues were raised during resident council on repeated occasions. Resident identifiers: 7, 10, 15, 36, 41, 50, 54, 55, 116 and 376.

Inspectors wroteBased on interview, record review, and observation, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. In addition, the facility did not develop and implement appropriate plans of action to correct identified quality deficiencies. Resident identifiers: 5, 7, 12, 17, 18, 31, 36, 41, 42, 43, 50, 53, 54, 365, 367, 372, and 374.

Inspectors wroteBased on interview and record review, it was determined for 1 of 53 sampled resident, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a residents, a resident was not assessed prior to having liquid medication all over her body after the resident sustained an unwitnessed fall. Resident identifier:

Inspectors wroteBased on observation, interview and record review it was determined, for 2 out of 53 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident choice. Specifically, residents were not offered showers according to their preferences. Resident identifiers: 15 and 27.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not ensure that the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Specifically, a resident's bathroom toilet was not secured to the ground and wobbled and the toilet seat was not secured to the base and moved from side to side. Resident identifier: 36.

Inspectors wroteBased on observation, interview, and record review, the facility did not prevent misappropriation of resident's medications for 3 of 53 sample residents. Specifically, cognitively impaired residents had missing fentanyl patches on numerous occasions. Resident identifiers: 5, 42, and 43. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. On 6/5/24 at 11:44 AM, an observation was made of resident 5 in their room. Resident 5 was brought back to their room by the licensed practical nurse (LPN) 4 and regional nurse consultant (RNC). [...]

Inspectors wroteBased on interview and record review it was determined, for 2 of 53 residents sampled, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Specifically, residents with a serious mental illness (SMI) were not referred for a Level II PASARR assessment with a newly evident SMI or upon a significant change in status. Resident identifier: 36 and 44.

Inspectors wroteBased on interviews and record review, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 out of 53 sampled residents, the residents care plan did not identify tasks related to the proper changing and monitoring of the resident's PureWick urinary system device and the resident received a urinary tract infection while using this device. Resident Identifier: 54. Findings Included: [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, the resident desired to transfer to another long term care facility closer to family and the facility did not follow-up with the resident or family for the transfer. Resident identifier: 7.

Inspectors wroteBased on interview and record review it was determined, for 1 of 53 residents sampled, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, a resident was not provided bathing/shower assistance in a timely manner. Resident identifier: 36.

Inspectors wroteBased on interview and record review, it was determined that, for 1 of 53 sampled residents, that the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, a resident was not provided showers for weeks at a time. Resident identifier: 41. Findings Included: 1. [...]

Inspectors wroteBased on observation, interviews and record review it was determined, the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 2 out of 53 sampled residents, residents with limited range of motion were not given restorative nursing services to prevent a further decrease in range of motion in upper and lower extremities. Resident Identifiers: 7, 54. Findings Included: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined, for 2 of 53 sampled residents, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident was not provided the necessary equipment to prevent water buildup in their nasal cannula, and a resident's oxygen tubing was not changed weekly. Resident identifiers 36 and 41. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 53 sampled residents, that the facility did not ensure each resident's drug regimen remained free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued. Specifically, a resident's medication was not being monitored and this resulted in the resident being hospitalized . Resident identifier: 41. Findings Included: 1. [...]

Inspectors wrote2. Resident 47 was admitted to the facility initially on 4/2/23, and was readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia without behavioral, psychotic, mood and anxiety disturbance, type 2 diabetes, bipolar disorder, panic disorder, major depressive disorder, and history of falling. Resident 47's medical records were reviewed between 6/2/24 and 6/6/24. A annual Minimum Data Set (MDS) dated [DATE] revealed that resident 47 had a Brief Interview for Mental Status (BIMS) of 13, indicating resident 47 was cognitively intact. The MDS also revealed that resident 47 did not exhibit any negative behaviors. Additionally, the MDS revealed there had been no Gradual Dose Reductions (GDR) attempted and the physician had not documented that a GDR was clinically contraindicated. On 4/2/23, a physician order documented, Risperidone Oral Tablet 0.25 MG [milligram]; [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, fentanyl patches were not disposed of properly and discontinued eye drops were available for use in a resident room. Resident identifiers: 5, 41, 42, and 43. Finding Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that laboratory services were provided to meet the needs of 2 of 53 sample residents. Specifically, labs were not obtained per the physician order. Resident identifiers: 36 and 42.

Inspectors wroteBased on interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not promptly notify the ordering physician or provider of the laboratory results that fall outside of clinical ranges. Specifically, a resident's lithium levels and urinalysis results were not reported to the physician. Resident identifier: 36.

Inspectors wroteBased on interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier: 36.

Inspectors wroteBased on observation, interviews and record review it was determined, the facility did not provide for 1 out of 53 sampled residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided specialized rehabilitation services that were documented as being needed by the facility medical doctor upon admission. Resident Identifier: 54. Findings Included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. [...]

Inspectors wroteBased on interview and record review it was determined, for 3 of 53 sampled residents, that the facility did not keep confidential all information contained in the resident's records, regardless of the form or storage method of the records. Additionally, the facility did not maintain the medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, a resident's name was included in a different residents medical record, and a resident's medical records from the hospital were not included in the residents electronic medical records at the facility. Resident identifiers: 18, 42, and 43. Findings Included: 1. Resident 43 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, hypothyroidism, muscle wasting, adult failure to thrive, nicotine dependence, and osteoarthritis. [...]

Inspectors wroteBased on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not demonstrate having an assessment to identify Legionella and other opportunistic waterborne pathogens, control measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor them. Additionally, a resident was observed helping another resident during dining and was touching the other resident's food with bare hands. Resident identifier: 24 and 46.

Inspectors wroteBased on interview and record review it was determined that for 1 of 31 sample residents that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan. Specifically, a resident experienced a change of condition (wound worsened) without the appropriate interventions and failed to notify the appropriate physician, as well as the facility did not monitor and reassess resident's vitals signs when they had changed. Resident Identifier: 57.

Inspectors wroteBased on observation and interview, it was determined that the facility did not distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a walk-in freezer were open to air, the walk-in freezer was not functioning properly, food items in the walk-in refrigerator were open to air, and the kitchen was not clean.

Inspectors wroteBased on interview and record review, it was determined that the facility did not inform residents, resident's families and representatives of a confirmed COVID-19 infection in a timely manner. Specifically, the facility did not send a notification to resident families and representatives by 5 p.m. the next calendar day following the occurrence of a confirmed COVID-19 infection.

Inspectors wroteBased on interview and record review it was determined, for 4 of 31 sample residents, that the facility did not ensure that resident's had the right to request, refuse, and /or discontinue treatment and to formulate an advance directive. Specifically, resident's were not given the right to request, refuse, and/or formulate an advance directive. Resident identifiers: 40, 58, 62, and 332.

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure that each drug regimen was free from unnecessary drugs for 3 of 31 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, the facility was not assessing residents' blood pressure levels as necessitated for safe administration of blood pressure medication, causing residents to receive blood pressure medications outside of the medical provider's established parameters. Resident identifiers: 58, 62, and 74.

Inspectors wroteBased on record review and interview it was determined, for 4 of 31 sample residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, residents Physician Orders for Life-Sustaining Treatment (POLST) forms and weekly skin notes were not included in the medical record. Resident identifiers: 40, 48, 58, and 62.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 31 sample residents that the facility did not immediately consult with the resident's appropriate physician when there was a significant change in the resident's physical status and a need to alter treatment significantly, resulting in hospital intervention. Specifically, the appropriate physician was not immediately notified when a resident's wound worsened and the resident developed decreased blood pressure with tachycardia. Resident Identifier:

Inspectors wroteBased on observation, interview and record review it was determined that for 3 of 31 sample residents, the facility did not ensure that all residents were free from abuse. Specifically, one resident repeatedly and intentionally hit, shoved, swore at (e.g. bitch, asshole, son of a bitch), and threatened other residents. In addition, abused residents occasionally hit the abusive resident after being assaulted. Resident identifiers: 29, 46 and 49.

Inspectors wroteBased on record review and interview, it was determined, for 3 of 31 sample residents, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to thoroughly investigate the abuse and identify abuse that occurred. Additionally, incidence of verbal abuse and injuries of unknown origin were not investigated. Resident identifiers: 29, 46, and 49.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed, for 1 of 31 sample residents, to develop and implement a comprehensive person-centered care plan for each resident that described services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff did not update a resident's care plan when the resident experienced a fall. Resident identifier: 62.

Inspectors wroteBased on interview and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure that residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a psychotropic medication that had a black box warning for the resident's condition was administered to the resident. Resident identifier: 22.

Inspectors wroteBased on observations and interviews it was determined that the facility did not ensure, for 2 of 31 sample residents, safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of medication were found past their dispense dates and were available for use. Resident Identifiers: 3 and 14.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not seen by a physician for approximately 9 days after falling and experiencing a change in condition, a resident with a cough had not been assessed by the physician, and a wound had not been treated timely. The findings for resident 118 were cited at a harm level. Resident identifiers: 24, 52 and 118.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents that the facility did not ensure the residents were free of significant medication errors. Specifically, a resident's anticoagulant medication was not started on admission resulting in an outcome of an extensive iliofemoral deep vein thrombosis to the right lower extremity. This occurred at a harm level. Resident identifier 21.

Inspectors wroteBased on interview and record review it was determined that for 3 of 25 sample residents the facility did not notify and consult with the physician when there was a need to alter treatment significantly. Specifically the physician was notified consulted with in a timely manner when a residents wound condition deteriorated, when a resident's catheter become clogged, or when a resident experienced a change of condition after a fall. Resident identifiers: 8, 52, 118.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure that the residents' medical records were secure and confidential. Specifically, observations were made of computer screens unattended which displayed resident personal information. Resident identifier: 9.

Inspectors wroteBased on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

Inspectors wroteBased on observation, interview, and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 25 sampled residents. Specifically, one resident who was colonized with MRSA (methicillin resistant staphylococcus aureus) did not have precautions in place to keep from infecting other residents and staff, and cross contamination was observed during medication pass and wound care. Resident identifiers: 1, 41, and 52.

Inspectors wroteBased on interview and record review, it was determined for 2 of 25 sampled residents, that the facility did not ensure that the residents were free from abuse. Specifically, one resident was grabbed on the arm by another resident, leaving a red mark. Resident identifiers: 1 and 54.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 25 sample residents, that the facility did not report the results of an abuse investigation to the State Survey Agency within 5 working days of the incident. Specifically, an allegation of abuse was not reported to the State Agency. Resident identifiers: 1, 52 and 54.

Inspectors wroteBased on interview and record review it was determined, for 2 of 25 sample resident, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to thoroughly investigated. Specifically, the facility failed to thoroughly investigate an allegation of physical abuse of a resident by another resident. Resident identifiers: 1 and 54.

Inspectors wroteBased on interview and record review it was determined for 1 of 25 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specially, a skin tear occurred for one resident that required sutures. Resident identifier: 52.

Inspectors wroteBased on interview and record review it was determined for 1 of 25 sampled residents, the facility did not ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a catheter developed an E. coli urinary tract infection. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined that for 1 of 25 sample residents the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complication of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, one resident had multiple emergency room visits for a clogged tube and went 24 hours without any food or fluids. Resident identifier: 118.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of results that fell outside of clinical reference ranges. Specifically the facility did not notify a medical provider for 39 hours after the results were complete and faxed to the facility, and did not accurately report the results. Resident identifier: 21.

Inspectors wroteBased on interview and record review it was determined that for 1 of 25 sample resident the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Specifically ones resident did not have weekly wound assessment documented in the medical record, and a weekly wound assessment was documented on a different day than it was completed. Resident identifier: 52.