Regency Coupeville Rehab and Nursing Center

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents right to be free from physical abuse for 2 of 3 sampled residents (Residents 4 and 5) reviewed for resident-to-resident altercations. Additionally, the facility failed to consistently supervise, accurately assess, and care plan 1 of 1 sampled resident (Resident 5) who had a known history of verbal and physical outbursts towards others, reviewed for 1:1 monitoring. Resident 5 caused an unsafe environment for Resident 6 when they blocked them from leaving a public area. This failure placed residents at risk for potential physical or mental abuse, feeling safe, experiencing fear, intimidation, and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 2 of 3 sampled residents (Residents 1 and 3) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete, accurate, and accessible clinical records for 5 of 8 sampled residents (Residents 1, 2, 3, 10 and 11) reviewed for complete and accurate medical records. The failure to maintain clinical records in accordance with professional standards of practice placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences (a collaborative care plan meeting where a resident's care was discussed and coordinated by a team of health care providers, family members and residents) for 1 of 3 sampled residents (Resident 1) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's responsible party of orders for a new medication for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and being knowledgeable about medications the resident was taking.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 2) reviewed for the Pre-admission Screening and Resident Review (PASSR) process received the required follow up from the Regional Developmental Disabilities Act (DDA) Intellectual Disability (ID) or Related Condition (RC) PASRR team before admission to the facility and failed to ensure they were referred for a PASRR Level 2. These failures placed Resident 2 at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure required notices were provided to 3 of 4 residents (Residents 11, 23 and 43) reviewed for hospitalizations. Failure to provide and follow-up to ensure communication of the required notices, placed residents and their representatives at risk of being uninformed of their legal rights related to bed hold and transfer/discharge status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were reviewed and acted upon for five of six months reviewed. This failure placed residents at risk for delays in necessary medication changes, risk for adverse side effects, and receiving medications without required pharmacist oversight.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant medication errors for five of eight residents (3, 10, 12, 13, and 21) reviewed for medications. Failure to follow physician's orders related to medication parameters placed residents at risk for adverse outcomes including low blood pressure which can result in dizziness and fainting from receiving medications which were outside of the ordered parameters for administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and discarded when expired on 2 of 2 medication carts and 1 of 1 medication storage room reviewed. This failure placed residents at risk for not receiving the full benefits of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of six of eight residents (Residents 4, 8, 10, 21, 70 and 72) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and follow up of laboratory results along with a risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system in which resident records were complete, accurate, accessible, and that documentation was in accordance with state law for 6 residents (Residents 3,8,10,30,32,and 43), and on one of two resident units. Failure to ensure records included accurate and timely entries and prohibit the use of stamped signatures on medical records, placed residents at risk for records that did not accurately reflect their care, and placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the Level II Preadmission Screening and Resident Review (PASRR, a federally required screening of all individuals who have a serious mental illness (SMI) report into the resident's assessment, and care planning for 1 of 1 resident (Resident 8) reviewed for PASRR. Facility failure to incorporate the PASRR recommendations into the residents' assessment and care plan delayed the implementation of recommendations and left the residents at risk for unmet mental health and activity needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were completed timely following a significant change in status for 2 of 5 residents (Residents 10 and 21) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASRR services for Residents 10 and 21, and placed other residents at risk for unmet mental health needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for 1 of 5 residents (Resident 13) reviewed for medication management. Failure to obtain a doctor's order and failure to monitor residents use of their own medical equipment, placed residents at risk for injuries and potential adverse outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacy services were provided to meet the needs of 2 of 3 residents (Resident 70 and 72) reviewed for Admission/Discharge planning. Failure to ensure medications were acquired and administered as ordered, and to follow facility processes for medications not available, placed residents at risk for adverse events related to missing medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) timely to respond correctly to a medical emergency for 1 of 2 residents (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when the resident was found unresponsive, required CPR that was not initiated by facility staff and an unexpected death occurred. The facility staff were aware of the CPR protocol but failed to follow directives that resulted in a delay in 911 EMS call, and the initiation of CPR was delayed by 45 minutes. These failures placed all residents at risk of unmet care needs and potential neglect. The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff recognize and report timely allegations of abuse/neglect for 2 of 2 residents (Resident 1 and 2) reviewed for allegations of abuse/neglect. These failures to timely report and investigate allegations of abuse/neglect and unexpected death placed residents at risk for potential abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure thorough investigations were completed for 3 of 3 residents (Residents 1, 2, and 3) reviewed for allegations of abuse and/or neglect. Failure to conduct thorough investigations to identify root cause(s) and all contributing factors related to allegations of abuse and/or neglect placed all residents at risk for unidentified abuse or neglect, unidentified corrective actions, potential harm and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that thorough investigations were completed for 2 of 4 residents (Resident 1 and 2) reviewed for allegations of abuse/neglect. Failure to conduct thorough investigations to identify root cause and all contributing factors related to allegations of abuse/neglect placed all residents at risk for unidentified abuse, unidentified corrective actions, and potential harm and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility administration failed to ensure the facility maintained substantial compliance with federal and state regulatory requirements and to meet the significant needs of the residents. The administration failed to provide sorely needed administrative oversight and monitoring of facility personnel, systems, policies and practices related to residents' care plan timing and revision, professional standards of care, ensuring competency of nursing staff and completion of required nursing assistants performance reviews, psychotropic medication management, infection control and coordination of dental services. This failed practice placed all residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistant competencies were assessed and completed yearly, for 5 of 5 staff (L, N, O, P and Q) employee files reviewed. This failed practice had the potential to negatively affect the competency of the nursing assistants and impact the quality of care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 5 of 5 employees (Staff L, N, O, P, and Q ) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and stored under sanitary conditions in 2 of 2 nourishment rooms (East and [NAME] units) and 1 of 1 facility kitchens. The failure to ensure overhead light fixtures, toasters, microwave ovens and refrigerator/freezer units were sanitary placed residents at risk for foodborne illnesses and diminished quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents environment was clean and sanitary, and failed to identify and provide the necessary housekeeping services to ensure privacy curtains were laundered or replaced in resident (Residents 4 and 7) rooms on 1 of 2 units. These failures placed residents at risk for infectious disease and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly resolve and document resident grievances for 2 of 3 sampled residents (Residents 67 and 4) reviewed for grievance resolution. The failure of staff to document, investigate, and resolve resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing clothing, and placed residents at risk for frustration and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a Significant Change in Status (SCSA) Minimum Data Set (MDS- an assessment tool) was completed for 1 of 3 sampled residents (Resident 12) reviewed for decline in Activity of daily living (ADL). This failed practice placed residents at risk for inadequate care planning and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 2 of 3 sample residents (Residents 67 and 65) reviewed for devices and 1 of 2 residents (Resident 4) reviewed for pressure injuries. This failure placed the residents at risk for not receiving the care and service required to meet the residents' needs and for inaccuracies in care planning of the residents' care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) screening for residents for a serious mental illness (SMI), intellectual disability (ID) or a related condition was completed if the scheduled discharge did not occur for 1 of 5 sampled residents (Resident 18) reviewed. Additionally, the facility failed to ensure a resident with a Level 1 PASRR screening form was accurate prior to admission to the nursing facility for 1 of 5 sample residents (Resident 38) reviewed. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or intellectual disability care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that care plans were revised to reflect changes or current status of 3 of 7 sample resident (Residents 4, 7, and 17) reviewed for care plans. These failures placed residents at risk of less-than-optimal care, staff not knowing how to properly care for a resident, a decreased quality of life with potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed professional standards of practice for 2 of 2 sampled residents (Residents 7, 17) reviewed for physician's orders on medication parameters and 1 of 1 sample residents (Resident 38) reviewed for admission orders. The failure to implement and follow physician prescribed orders placed residents at risk for adverse effects, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to advocate and assist 1 of 1 sampled residents (Resident 38) with their rights within the facility. The failure to assist the resident in having care planning meetings to ensure their voice was heard regarding their care and preferences placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on record review and interview the facility failed to ensure 2 of 5 sampled residents (Resident 38 and Resident 58) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behaviors). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, behavior monitoring and to attempt gradual dose reductions (GDR). These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of life.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to assist with access to preventative (and emergency) dental services for 2 of 3 sampled residents (Residents 44 and 15) reviewed for dental services. Failure to follow up on dental referrals and ensure the coordination of dental services for residents who had missing, and broken teeth placed the residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigations for 3 of 7 sample residents (Residents 1, 6, and 7) reviewed for accidents/incidents. Failure to conduct a thorough investigation to identify root cause(s) and consistently consider all potential contributing factors, such as last time checked on, last time toileted/changed, and other factors placed the residents at risk for unidentified abuse and/or neglect, inappropriate corrective actions, and ineffective care planning that potentially impacted the overall well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for 3 of 7 residents (Residents 1, 6, and 7) reviewed for incidents and care and services. The failure to ensure thorough documentation of incidents, care and services, and food preferences placed residents at risk for unmet needs, repeat occurrences of incidents, and diminished quality of life. The failure to obtain witness statements for incidents resulted in lost evidence regarding incidents that occurred in the facility making it impossible to ascertain what occurred.

Inspectors wroteBased on interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include providing oral care of 1 of 3 sample residents (Resident 1) reviewed for ADL's. The failure to provide oral care placed residents at risk for poor hygiene, unmet needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, update and consistently implement the care plan to prevent accidents/falls for 1 of 3 residents (Resident 1) reviewed for accidents. The facility failure to provide adequate supervision and implement appropriate interventions placed residents at risk for future falls, injury, and diminished quality of life.

Inspectors wroteBased on observation and interview, facility staff failed to use appropriate standards of infection control practice for 2 of 2 residents (Residents 2 and 3) observed during resident care. Failure to utilize appropriate hand hygiene and to provide incontinent care without staff contaminating the resident's environment placed residents at risk for cross-contamination and for living in a contaminated environment.

Inspectors wrote[NAME] Based on interview and record review, the facility failed to provide resident focused care through consistent monitoring, assessment and evaluation of the resident's condition to identify a change in condition for a suspected urinary tract infection (UTI) and to implement physician orders for 1 of 5 residents (Resident 1) reviewed for quality of care. This failed practice placed residents at risk for unmet needs, hospitalization, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure timely physician visits (once every 30 days for the first 90 days after admission) were completed for 1 of 4 residents (Resident 1) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an allegation of abuse was reported immediately, not longer than 2 hours after the allegation of abuse was made for 1 of 3 (Resident 1) residents reviewed for abuse allegations or injury of unknown source. This failure placed Resident 1 and other residents at risk for potential continued abuse, unrecognized abuse, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were protected during the facility's investigation phase to prevent further potential abuse or mistreatment for 1 of 3 residents (Resident 1) investigations reviewed for abuse when they allowed the staff member to continue to work with Resident 1 and other residents after an allegation of abuse. This failure placed all residents at risk for continued potential abuse from Staff E, Nursing Assistant Certified (NAC), and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 4 sampled residents (Residents 169, 13, and 37) reviewed for accidents, were free of accident hazards, individualized care plan approaches were followed, effectiveness of current care plan interventions were evaluated, addition preventative measures to prevent falls were implemented, and assistance with meals was provided. Resident 169 was harmed when the identified care plan interventions to assist the resident with one-person maximal assistance with walking were not followed and the resident experienced a fall with fracture injury to their left greater trochanter (upper part of the thigh bone). These failures placed residents at risk for further accidents, falls, and a decreased quality of life.

Inspectors wroteBased on observation, and interview, the facility failed to provide a dignified and homelike dining experience in 1 of 3 dining rooms (East) during 1 of 3 dining observations for dignity witnessed when a resident was in respiratory distress (an abrupt change in a resident's breathing abilities) in the East dining room observed by other residents. These failures placed residents at risk for feelings of anxiety, fear, and concern.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed and provided written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a wide range of healthcare decisions and includes resident's wishes if they became incapacitated) for 4 of 6 residents (Resident 54, 172, 6, and 13) reviewed for ADs. The failure to offer assistance or choose to refuse to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure written notification of facility initiated transfer and/or discharge was completed for 5 of 5 sampled residents (Residents 37, 59, 68, 219 and 44) reviewed for hospitalizations. The facility failed to ensure the transfer/discharge notice with all the required information was provided in a timely, practical manner upon an emergent transfer to the hospital. This failure placed residents and their representatives at risk of not receiving accurate information related to resident's discharge, and potential for diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide a bed hold notification for transfer to the hospital for 5 of 5 sampled residents (Residents 37, 59, 68, 219 and 44) reviewed for hospitalizations. This failed practice placed the resident or the resident's representative at risk for a lack of knowledge regarding the facility's bed hold policy a resident was admitted to the hospital and did not allow an opportunity to the resident or their representative from making an informed bed hold decision.

Inspectors wrote<RESIDENT 4> Resident 4 admitted on [DATE] with diagnosis to include paraplegia. According to the Quarterly MDS assessment, dated 11/01/2023, they had limited range of motion (ROM) on one side of upper extremities (UE) and both sides of lower extremities (LE). They required extensive assistance with grooming and bathing. Review of the facility shower schedule, showed Resident 4 was to receive showers on Mondays and Thursdays. Review of Resident 4's 10/01/2023 to 10/20/2023, showed the resident received four showers in October (on 10/02/2023, 10/09/2023, 10/26/2023 and 10/30/2023), and four showers in November (on 11/09/2023, 11/13/2023 and 11/16/2023, and 11/20/2023). Resident 4 did not received showers as they preferred. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly provide professional standards of care and services for 5 of 6 residents (16, 21, 36 51, and 64) reviewed for unnecessary medications and 1 of 1 resident (Resident 36) reviewed for medication management. The facility failed to hold medications per physician orders, and to reassess abnormal blood pressure (BP) values, and notify the provider of abnormal findings, medication refusals and did not include, tubing maintenance, dressing changes, flushes on a peripherally inserted central catheter (PICC). This failed practice placed residents at risk for infection, medication complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 4 residents (Resident 3, 18, and 172) with limited range of motion (ROM) received appropriate treatment and services to increase their ROM or prevent further decrease in range of motion. This failed practice placed the residents at risk for further decline in their ROM. Findings Included . <RESIDENT 172> Resident 172 was admitted to the facility on [DATE] with diagnoses to include right femur fracture, dementia, fall, and abnormal gait and mobility. Review of Resident 172's provider orders showed that they were to have a wedge/hip abduction pillow to place between legs to prevent flexion and internal rotation of right knee, ordered on 11/15/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 14 resident interviews (1, 4, 11, 16, 18, 30, 31, 32, 33, 36, 49, 55 , 64 and 171), and two-family interviews (3 and 6) and as evidenced by failed practice in other identified quality of life and quality of care areas. These failures placed residents at risk for potential harm related to anxiety, feelings of frustration and vulnerability, unmet care needs, negative outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 5 of 5 sampled staff (Staff J, AA, BB, CC & DD) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that adequate monitors were in place for psychotropic medication management for 4 of 6 residents (6, 21, 37, and 172)reviewed for psychotropic medications. These failures placed residents at risk to receive unnecessary medications, possible side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible, and systematically organized for 8 of 8 residents (4, 10, 18, 21, 37, 44 and 64) reviewed for accurate Medication Administration Records (MAR) and Treatment Administration Records (TAR). Failure to ensure clinical records were complete and accurate made it impossible to determine what care and services were provided, or should have been provided, and placed residents at risk for medical complications, unmet care needs, undocumented/unresolved grievances, and for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for one of two hallways (West Hall) and one of one residents tube feeding (Resident 44). The facility failed to ensure the staff used appropriate hand hygiene practices during meal tray pass, and during meal preparation in the kitchen. This failed place all residents and staff at risk for potential infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure responsible parties were notified timely for one of one resident (55) reviewed for incidents. This failure placed resident's representatives at risk of not being informed of resident status and potential for receiving less than optimal care.

Inspectors wroteBased on interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 6 sampled residents (Resident 221) reviewed for allegations of abuse and/or neglect. The facility failed to identify, report, and initiate timely interventions for an allegation of sexual abuse for eight hours after the allegation had been made by a resident. This failure to report to the required state agency, and law enforcement resulted in lack of timely investigations and placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect.

Inspectors wroteBased on interview, and record review, the facility failed to conduct a thorough investigation for 1 of 6 sampled residents (Resident 221) reviewed for allegations of abuse and/or neglect. The facility failed to initiate an investigation for an allegation of sexual abuse for eight hours after the allegation had been made by a resident and failed to complete a thorough investigation of sexual abuse. This failure to investigate timely and thoroughly placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 of 6 residents (Resident 172 and 44) reviewed for comprehensive care plans. The failure to develop and implement care plans for necessary supplies (a positioning wedge/pillow and pressure relieving boots) placed the residents at risk for possible adverse effects and related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that care plans were revised to reflect changes or current status of three of six (2, 18, and 23) residents reviewed for care plans. These failures placed residents at risk of less than optimal care, staff not knowing how to properly care for a resident, a decreased quality of life with potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were met for 1of 1 sampled residents (Resident 36) sampled for intravenous (IV - into the vein) medication administration. The facility failed to ensure the resident's antibiotic (medication to treat an infection) IV medication was administered by a nurse that had the appropriate certification to manage IV lines and IV medication administration. This failure placed the resident at risk for complications, a worsened infection, delay in healing, and adverse outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received necessary assistive devices to maintain vision abilities for 1 of 1sampled residents (Resident 23) reviewed for vision. Failure to ensure the resident received assistance with obtaining corrective lenses left the resident at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two residents (13 and 37), reviewed for use and care of a catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. This failure placed the resident at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they had an effective system in place for monitoring resident weights for 1 of 1 resident (Resident 64) reviewed for nutritional status and weight loss. The failure to accurately monitor, assess and document resident weights placed residents at risk for unrecognized weight loss, nutrition-related complications and for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 2) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the concentrator was set to the ordered dosage and failed to ensure oxygen tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 44) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for three of three employees (BB, CC, and DD ) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents.

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacy recommendations were timely followed up on for 2 of 3 sampled residents (Resident 37 and 64) reviewed. These failures placed residents at risk for receiving an inaccurate dosing of medication, adverse side effects, and the risk of receiving a medication longer than medically necessary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 1 (Resident 10) residents reviewed for dental care. This failure placed Resident 10 and all other residents at risk for unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on record review and interview the facility failed to develop, implement and maintain an in-service training program ensure 3 of 3 Nursing Assistant's (BB,CC and DD) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs.