River Oaks Healthcare Center

Inspectors wroteBased on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #72, #33, #81, #28, #11, #66, #15, #80, #87, #94 and #74. Facility census: 110.

Inspectors wroteBased on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #72, #33, #81, #28, #11, #66, #15, #80, #87, #94 and #74. Facility census: 110. a) Review of the food preparation policy revealed the following: All staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid potentially harmful physical, biological, and chemical contamination. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to 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 with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifiers: #128, and #128. Facility census: 110.a) Resident Wheelchairs:On 05/26/26 at approximately 2:12PM, a facility walk-through revealed Resident # 128 's wheelchair sitting in her room with cracks in the front left seat pad and right arm pad exposing the inner padding. On 05/26/26 at approximately 2:16PM, a facility walk-through revealed Resident # 2 's wheelchair sitting in his room with cracks in the front left hand rest, exposing the inner padding. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment relating to disrepair in the resident's dining room. This was a random opportunity for discovery. Facility census: 110. Findings Included: On 06/01/26 at 11:15AM the following issues were observed in the Resident Dining Room:The right-side wall had peeling paint. There were three deep unrepaired gouges in approximately 2 to 2 1/2 inches long in the sheet rock between each of the floor to ceiling windows PTAC (Packaged Terminal Air Conditioner) Units:The PTAC units were cracked and missing caulking around the 2 units. There was water damage with loose and peeling paint approximately 3 inch round hole in the lower left door facing. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident's care plan was revised in the area of enteric precautions for a Clostridium difficile Infection. This failed practice was true for 1 of 2 residents reviewed during the survey process. Resident identifier: # 78. Facility Census:110 Findings Included:During a facility walk through on 05/26/26 at 12:45PM, It was observed signage of Enteric precautions were placed on the wall by resident #78's entrance door. A record review on 05/26/26 at 1:45 PM, of Resident #78's electronic medical record found her admit date was 05/18/26 and according to the Hospital Discharge summary dated [DATE], She was admitted with a diagnosis of Clostridium difficile infection. A Further record review of Resident #78's Care plan found:Focus: resident has c-diff and is in enteric isolation. date initiated: [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents living in the facility during the survey process. Resident identifier: #4. Facility Census: 110 During a walkthrough of the facility conducted on 05/28/26 at approximately 10:15 a.m. the state surveyor observed a medication cart located on the 100 hallway near the nursing station to be unlocked and unattended. The medication cart was observed with no staff member present or actively supervising the cart at the time of the observation. The unsecured medication cart created the potential for unauthorized access to medications by residents, visitors, or other individuals within the facility. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure nutritional supplements were being offered per physician orders. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 110. Resident identifiers: #53, #67, #100, #41, #49, #75, #100 and #75.

Inspectors wroteBased on observation and record review, the facility failed to ensure Lovenox and inhalers were administered according to professional standards. This was true for one (1) resident's medication administration of 34 observed medication administrations. Resident identifier: #11. Facility census: 110.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure residents receive and provide at least 3 meals daily at regular times comparable to normal meal times in accordance with residents needs, preferences, requests, and plan of care. This failed practice was a random opportunity for discovery. Resident Identifier #67. Facility Census 110. a) Resident #67 During an interview with Resident #67 on 05/26/26 at 1:45 pm he reported he did not receive lunch that day. He stated he went to therapy in the morning and when he returned to his room, his tray was left for him on his bedside table but his roommate was eating both meals. He stated he asked for another tray and was told they would see what they could do for him. Resident #67 stated he felt the staff had forgotten about him and that it was too late to get anything because dinner was approaching. [...]

Inspectors wroteBased on observations and staff interviews. Facility failed to ensure meals are served in a sanitary way in accordance with professional standards for food service safety. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census 110. a) Review of policy for Food: Preparation. Review of procedures reads in part. 1. All staff will practice proper hand washing techniques and glove use. 2. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. b) Review of Environment Policy All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. [...]

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure it had a complete and accurate medical record related to capturing correct Diagnosis upon admission. This failed practice was found true for (1) one of (2) two residents reviewed for correct diagnosis upon admit during the Long-Term Care Survey Process. Resident identifier # 78 . Facility Census 110. Finding Included: a) Resident # 78 During a facility walk through on 05/26/26 at 2:15 PM, the surveyor observed that Resident #78's room had signage for Enteric Precautions around her door. A record review on 05/26/26 at 3:30 PM, revealed that Resident #78's list of diagnosis did not coincide with the enteric precautions orders. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the resident dining room. This was a random opportunity for discovery with the ability to effect a limited number of residents. Facility Census 110. Findings Included:a) The surveyor observed an issue on 06/01/26 at approximately 11:15 AM, in the resident dining room. The surveyor observed an approximate 3 inch round hole in the lower left doorfacing at the back exit door with sheet rock dust and chunks falling out and into the floor. This was easily accessible to all residents in the dining room. On 06/01/26 at approximately 11:25 AM, an interview with the dietician verified this finding. This finding was also acknowledged by the facilityadministrator on 06/03/26 at approximately 8:35 AM.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of two (2) resident showers rooms located in the [NAME] Fort Hall. Facility Census: 113. Findings Included:a) On 03/16/26 at approximately 1:20 PM, Surveyor observed a damaged area of the wall in the central shower room on [NAME] Fort (300-400 Hall) that was covered up with black tape.b) On 03/16/26 at approximately 1:20 PM, Surveyor observed stained/discolored tile grout located in the shower stall of the central shower room on [NAME] Fort (300-400 Hall).c) On 03/16/26 at approximately 1:25 PM., an interview with the facility's Director of Plant Maintenance verified these findings.

Inspectors wroteF689Based upon Observations and Interviews the facility FAILED to ensure an environment that remains free from accident hazards as evidenced by A) Day room (end of hall room) of [NAME] court - Sani wipes (purple top) cleaners left on top of vending machines. B) Internet cafe/storage area with multiple equipment beds, lifts, pumps, chairs, and broken picture frame with sharp edges on counter. The area is open to residents and poses multiple hazards. C) Wiring exposed in a wall box without a cover outside RM [ROOM NUMBER]. This was a random opportunity of discovery with the ability to affect more than one person.

Inspectors wroteF880Based upon Observations and Interviews the facility FAILED to have a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. This is evidenced by A) Two open soda cans on a PPE cart outside a residents room. B) Three lift pads left on top of a clean linen cart; and C) PPE/EBP signs on multiple doors with out identifying the resident to whom the precaution applies to. These were all random opportunities for discovery, with the ability to affect more than a single person. Census: 116A) The PPE cart outside RM [ROOM NUMBER] had two soda cans sitting on it. (zero sugar shasta)B) Outside RM [ROOM NUMBER] there were three lift pads on top of the linen cart exposed and not covered. An interview w/employee #105 stated that they definitely should not be on top of that cart, they should be at least inside under the cover. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Soiled briefs were being left in residential rooms following staff providing incontinence care. This was true for two (2) out of (2) residents reviewed. Resident identifiers: #92 and #78. Facility census: 115.

Inspectors wroteBased on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 107.

Inspectors wroteBased on record review and staff interview the facility failed to follow through with their plan of correction when a deficient practice was identified and investigated. This was true for ten (10) of ten (10 records reviewed. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258. Facility Census: 107 Findings Include: a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258 On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed. The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24. On 12/09/24 during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. [...]

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 107.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to protect and promote a dignified dining experience and failed to answer a resident's call light on a timely basis. These were random opportunities for discovery. Resident identifiers: #24, #71, #37, #45, #68, #27, #42, and #51. Facility census: 107.

Inspectors wrote]Based on record review, resident interviews, and staff interviews, the facility failed to ensure resident council grievances, issues, and concerns were acted upon promptly and provide a rational response. This had the potential to affect more than an isolated number of residents. Facility census: 107.

Inspectors wroteBased on observation and staff interview, the facility failed to secure and keep confidential residents' medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holder located outside of the medical records office. This was a random opportunity for discovery. Resident identifiers: #305, #155, #357, #30, #308, #28, and #100. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the dining room temperature at a comfortable temperature level. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents Residenti Identifiers: #45, #95, #37, and #8. Facility census: 107.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to make prompt efforts to resolve verbal grievances. The facility failed to act on verbal grievances related to bringing back the Soup of the Day to the menu and failed to act on a verbal grievance regarding burnt food, gnats, and food not being removed from the resident's room for three (3) days. Additionally, the facility failed to act on a verbal grievance regarding a resident's missing personal property. Resident identifiers: #24, #71, #31, #37, #70, #80, #29, and #32. Facility census: 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of showers, wound care and turning and repositioning. Resident identifiers: #20, #22, #58, #72 and #92. Facility census: 107.

Inspectors wroteBased on record review and staff interview the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences and professional standards of nursing practice for more than a limited number of residents. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, #258, #59, #89. Facility Census: 107 Findings Include: a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258 On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed. The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24. On 12/09/24 at 9: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Three (3) medication carts and a treatment cart were unlocked and unattended. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to deploy sufficient direct care staff to meet the care needs of all residents in the facility, based on the facility assessment. This has the potential to affect all residents residing in the facility. Facility census: 107.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the medication regimens for Residents #307, #38,#22, and #64 were free from unnecessary medications. This was true for four (4) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #307, #38, #22, #64. Facility census: 107.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to ensure they were able to follow menus by not having the food items needed for the preperation of the meal. This had the potentital to affcet more than a limited number of residents. Facility census: 107.

Inspectors wroteBased on observation, staff interview, and equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage in accordance with professional standards for food service safety. The facility also failed to keep the ice machine and dishwasher in safe operating condition. This has the ability to affect all residents that get their nutrition from the kitchen, and also attends food related activities. Facility Census:

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to 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. Resident #45 was allowed to play in feces until other residents intervened, wound care for a resident under enhanced barrier precautions was provided without staff wearing the appropriate personal protective equipment (PPE), linens were on the floor and a linen barrel was overflowing. These were random opportunities for discovery. Resident identifiers: #45 and #56. Facility census: 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe and homelike environment in regard to a black substance on packaged terminal air conditioner (PTAC) and ceiling vents. This had the potential to affect all residents living in the facility. Facility census: 107.

Inspectors wroteBased on record review and staff interviews, the facility failed to honor the residents right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Resident identifier: #90 and #39. Facility census: 107.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure Resident #32 received showers in accordance with her preferences. This was true for one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) during the survey process. Resident identifier: 32. Facility census: 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided with a written Notice of Transfer for an acute hospital transfer. This was true for two (2) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #71 and #89. Facility census: 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided with a written Bed Hold Notice for an acute hospital transfer. This was true for two (1) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #71. Facility census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for one (1) out of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifier #52. Facility census: 107.

Inspectors wroteb) Resident #33 A record review completed on 12/10/24 at 9:44 AM, revealed the following details regarding a resident-to-resident altercation: -The resident-to-resident incident occurred on 11/07/24 at 7:00 AM. -The incident occurred in the resident's room. -Description of incident: Resident #33 was seen grabbing a foot rest from a wheelchair and hitting her roommate (Resident #16) in the left arm. Resident #16 had a bruise to the left wrist and outer left forearm. -Review of Resident #33's care plan did not reflect a history of resident-to-resident physically aggressive behaviors. During an interview on 12/10/24 at 10:40 AM, the Director of Nursing confirmed that Resident #33's care plan had not been updated to include a history of physically aggressive behaviors toward other residents. [...]

Inspectors wroteBased on resident and staff interviews and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living (showers) to maintain good grooming, and personal hygiene. This was true for two (2) of four (4) records reviewed for showers. Resident Identifiers: #58 and #92. Facility Census: 107. Findings Include: a) Resident #58 On 12/03/24 at 10:01 AM Resident #58 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #58 should receive his showers on day shift every Monday and Friday. On 12/05/24 at 1:10 PM record review of showers given for the last thirty (30) days shows Resident #58 had eight (8) opportunities for a shower. He received five (5) of the eight (8) showers. There were no refusals documented. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to turn and reposition an immobile resident according to standard practice of nursing care to prevent new or worsening pressure ulcers. Resident Identifier: #72 Facility Census: #107 Findings Include: a) Resident #72 On 12/05/24 at 2:18 PM observation and record review identified Resident #72 has a stage III pressure ulcer to her left back. Record review and Licensed Practical Nurse #26 confirmed the wound was first identified 08/29/24. Current orders for wound care to her back are: 1) WOUND CARE: Monitor Stage 3 pressure injury to thoracic spine. Notify medical provider if presence of complications (e.g. increased redness, swelling, drainage, abnormal odor, new or worsening pain/discomfort. WOUND CARE: [...]

Inspectors wroteBased on record review and staff interview the facility failed to maintain adequate nutritional status, to the extent possible, to ensure the resident is able to maintain the highest practicable level of well-being. This was true for one (1) of three (3) records reviewed for weight loss. Resident identifier: #59 Facility Census: #107. Findings Include: a) Resident #59 On 12/03/24 at 9:15 AM record review of weights for Resident #59 found there had been a significant weight loss of 10.3% in one month. Documentation showed Resident #59 weighed 208 pounds on 10/11/24 and dropped to 186.6 pounds on 11/11/24. This reflects a weight loss of 10.3% of her weight in 30 days. A significant weight loss is defined as: 5% change in weight in 1 month (30 days) 7.5% change in weight in 3 months (90 days) 10% change in weight in 6 months (180 days) Resident #59 has the following active orders: [...]

Inspectors wroteThe facility failed to ensure that the physician or delegate responded to a new onset of symptoms, in a resident's condition, in a timely manner. This failed practice had the potential to cause more than minimal harm. Resident Identifier: #103. Facility Census:107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a physician responded to recommendations made by a licensed pharmacist for Resident #66, and to ensure the physician provided a rationale for the use of a medication Resident #38 had a documented allergy to. This was true for two (2) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #66, #38. Facility census: 107.

Inspectors wroteBased on observation and staff interview, the facility failed to offer the opportunity to receive a substitute when residents refused food items during the morning meal. This was a random opportunity for discovery. Resident identifiers: #7 and #61. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for three (3) out of four (4) records reviewed for accurate POST forms. Resident identifiers: #16, #29, and #33. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a serious bodily injury was reported timely for Resident #109. Allegations of misappropriation of Resident funds for Residents #23 and #82 was not reported to State authorities. For Resident #67 an allegation of abuse was not reported. For Resident #101 an allegation of abuse was not reported to all the required State agencies. Resident identifiers: #109, #23, #82, #67 and #101. Facility census: 106.

Inspectors wroteBased on record review, staff interview and policy review the facility failed to follow policy to re-weigh a resident when there was a five (5) pound difference in weight, to obtain a physician's order for the use of Styrofoam dinnerware, to coordinate with Hospice, to produce evidence physician orders were followed for enhanced barrier precautions and that medications were administered. Resident identifiers: #25, #106, #67, #63 Facility Census: 106 Findings Include: a) Resident #25 On 12/12/23 at 11:11 AM record review shows there were no re-weights obtained when the current weight reflected a five (5) pound difference in weight. Facility Policy #NS 1320-02 Resident Height and Weight states . 9) Re-weight Parameters: a) A plus/minus of 5 pounds of weight in one week will result in: [...]

Inspectors wroteBased on observations and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a heavily soiled floor in the storage room, several damaged floor tiles in the serving area and dish room, a trash can was parked directly in front of the hand washing sink, and dirty shelving units. This failed practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to provide hand hygiene in order to prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident Identifiers: #8, #27, #38, #40, #68, #71, #97 and #101. Facility Census: 106 Findings Included: a) On 12/10/23 at 12:11 PM it was observed that staff were passing the lunch meal trays on the [NAME] Fort Court hallway without providing hand hygiene for the residents. It was observed in Rooms 400, 401, 417 and 419 (each a semi-private room) received their meals without hand hygiene being offered or performed. The Residents affected were Resident numbers #8, #27, #38, #40, #68, #71, #97 and #101. On 12/10/23 at 12:14 PM this was confirmed with Certified Nurse Aide #34 who stated they usually give the Residents sanitizer wipes to wipe their own hands. [...]

Inspectors wroteBased on record review and staff interview the facility failed to administer seasonal influenza vaccines in accordance to the Centers for Disease Control and Prevention (CDC) guidelines for the 2023-2024 influenza season. Facility: Facility Facility Census 106 Findings Included: a) On 12/12/23 at 11:34 AM record review of facility influenza vaccines shows sixty six (66) of the 106 Residents residing in this facility have not been vaccinated for the 2023-2024 influenza season. Facility Census: 106 Influenza vaccines administered as of 12/12/23 for the 2023-2024 influenza season: 40 Consents obtained in October and on 11/01/23 for the influenza vaccine but have not been administered as of 12/12/23: 16 Residents that have been entered in Point Click Care as vaccine requested but no consent obtained as of 12/12/23: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified dining experience for Resident's #106 and #61. These were random opportunities for discovery. Resident Identifiers: #106 & #61. Facility Census: 106. Findings Included: a) Resident #106 On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed and asked why Resident #106 was served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things. On 12/11/23 at 10:20 AM, the Director of Nursing in Training (DON) was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the physician was notified of changes regarding the resident's physical status. This was true for one (1) of 28 sample residents. The physician was not notified of a significant weight loss for Resident #40. Resident identifier: #40. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed Resident #212 at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident Identifier: #212. Facility census: 106.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide a safe, clean and homelike environment for room [ROOM NUMBER] which had dirty, stained sheet rock, room [ROOM NUMBER] was noted with a heavily soiled bed curtain and holes in the blinds, and room [ROOM NUMBER] was noted with holes in the bathroom door and missing sheet rock in the bathroom . These were random opportunities of discovery. Facility Census: 106. Findings Included: a) room [ROOM NUMBER] On 12/12/23 at 8:20 AM, upon observing medication administration in room [ROOM NUMBER], an observation was made of the sheet rock of the wall by the window. The sheet rock appeared to be dirty with brown, black and red stains. The top of the packaged terminal air conditioner (PTAC) was noted with a dry black substance. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure information was provided to the receiving provider to ensure continuity of care when the resident was transferred to the hospital. This was found for one (1) of three (3) discharged residents reviewed. Resident identifier: #108. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the ombudsman was notified of the transfer to the hospital for one (1) of three (3) Resident's reviewed for transfer/discharge from the facility. Resident identifier: #108. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a copy of the bed hold notice was provided to the Resident/Medical Power of Attorney (MPOA) upon transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization. Resident identifier: #108. Facility census: 106.

Inspectors wroteBased on record reviews and staff interviews the facility failed to implement the comprehensive person-centered care plan for an altered nutritional status for Resident #40. For Resident #67 the care plan was not developed for coordination of hospice services. This deficient practice was true for two (2) of 28 sample resident care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #40 and #67. Facility census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to revise the care plan regarding behaviors and the use of styrofoam dinnerware and plastic utensils. This was a random opportunity for discovery. Resident Identifier: Resident #106. Facility Census: 106. Findings Included: a) Resident #106 On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed why is Resident #106 being served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things. On 12/11/23 at 10:20 AM, the Director of Nursing in Training was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and as free from accidents as possible. These were random opportunities for discovery. Facility Census: 106. Findings Included: a) room [ROOM NUMBER] On 12/10/23 at 12:17 PM, upon initial observation of room [ROOM NUMBER], three (3) medication cups with a thick, white substance were noted sitting on the over the bed table which was pushed against the wall. Licensed Practical Nurse (LPN) #87 was notified and confirmed the thick, white substance in the medication cups was zinc oxide cream, which is used to prevent skin irritation during incontinence episodes. On 12/10/23 at 12:19 PM, LPN #87 stated, that shouldn't be sitting there. LPN #87 removed the three (3) medication cups from the room. On 12/10/23 at approximately 1:00 PM, the Director of Nursing (DON) was notified of the above issue. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #61 and #93. Facility Census: 106. Findings Included: a) Resident #61 On 12/12/23 at 8:32 AM, an observation was made during Resident #61's medication administration. The resident was ordered a breathing treatment of Albuterol Sulfate. Upon entering the room, the nebulizer was observed laying in the floor with the respiratory tubing wrapped around a chair arm near the resident's bed. The respiratory tubing was not stored in a respiratory bag. On 12/12/23 at 8:33 AM, Licensed Practical Nurse (LPN) #121 confirmed the nebulizer was laying in the floor and the respiratory tubing was not stored correctly. LPN #121 stated, we will get you some new tubing. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to assess and monitor pain every shift per the physician orders for Resident #106, #93 and #67. This was true for three (3) of three (3) residents reviewed under the care area of pain management. Resident Identifiers: #106, #93, and #67. Facility Census: 106. Findings Included: a) Resident #106 On 12/12/23 at 1:30 PM, a physician's order dated 04/03/23 for monitor pain every shift was noted. Upon reviewing the December, 2023, medication administration record (MAR), the notations for each shift were check marks. However, the notations did not include if the resident was having pain, a pain rating or the location of pain. [...]

Inspectors wroteBased on employee record reviews and staff interviews the facility failed to ensure nurse aides had annual performance evaluations completed. This was true for three (3) of five (5) employees reviewed for the facility task of sufficient and competent nurse staffing. Employee identifiers: #1, #96, and #36. Facility census: 106.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to monitor the medication refrigerator temperatures, store a schedule IV medication in a double lock system, remove personal food and drinks from the medication refrigerator and maintain a clean medication refrigerator on the [NAME] Court unit. These were random opportunities for discovery. Facility Census: 106. a) Temperature Logs On 12/12/23 at approximately 10:00 AM, a tour of the medication room on [NAME] Court was completed. The tour of the medication room found the medication refrigerator temperature logs had not been completed for the months of October, 2023, November, 2023 and December, 2023. The following is a list of the missing temperatures and dates for each month: [...]

Inspectors wroteBased on resident interview, observation and staff interview the facility failed to accommodate a Residents' food allergy. This was true for one (1) of seven (7) residents reviewed for food during the long term survey process. Resident Identifiers: #103 Facility Census: 106 Findings Included: a) Resident #103 On 12/10/23 at 12:19 PM it was observed that Resident #103 had baked apples on his lunch tray. He stated he is allergic to cinnamon as he smells the cinnamon on the apples. He also states he continues to get food with cinnamon on it even after he has told dietary staff that he is allergic to it. On 12/11/23 at 08:23 AM record review shows his allergies are documented as cinnamon being one of his two allergies. Review of his meal ticket for 12/10/23 shows as follows: Rosemary Roast Beef Au Jus, Baked Potato, Margarine, Sour Cream, Sliced Parsley Carrots, Dinner roll, Margarine. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to obtain daily temperature checks on residents' personal refrigerators. This was true for three (3) of three (3) personal refrigerators observed during the Long Term Care Process . Resident Identifiers: #34, #35, #23. Facility Census: 106 Findings Included: a) Resident #34 On 12/10/23 at 12:45 PM it was observed that Resident #34 has a personal refrigerator in his room that had no temperature log located at the refrigerator. According to the facility Policy #IC 1021-02 states Procedure: daily refrigerator temperature checks must be performed: d. Record and Log temperatures daily on a log kept at the refrigerator. On 12/10/23 at 1:58 PM, this was confirmed with the Director of Nursing #118 who stated they did not have any logs due to new maintenance personnel. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain the garbage and refuse container in good condition. During a random opportunity for discovery, it was noticed one (1) of the two (2) dumpsters had only a partial covering. This practice did not allow for garbage and refuse to be disposed of properly. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence Quality Assessment and Assurance (QAA) meetings were held and required members were in attendance for the first and second quarter of 2023. This had the potential to affect all residents that resided at the facility. Facility census: 106.

Inspectors wroteBased on employee record review and staff interview, the facility failed to ensure nurse aides received the requied annual in-service training to include dementia management and abuse pervention training. This was true for one (1) of five (5) employees records reviewed for sufficient and competent nurse staffing. Resident identifier: #96. Facility census: 106.

Inspectors wroteBased on staff interview and resident interview, the facility failed to 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. Staff failed to don appropriate Personal Protection Equipment (PPE) when providing care for residents placed in Droplet Precautions. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census: 112.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents receiving a shower in the Long Hall Shower Room on [NAME] Court were afforded full visual privacy. The shower curtain was torn in multiple areas and half of the shower curtain was hanging down from the ceiling track. This was a random opportunity for discovery. Facility census: 112.

Inspectors wroteBased upon record review and staff interview, the facility failed to document accurately in the resident's medical record. Resident #102. Facility census 113.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for the residents. Fecal matter was not cleaned from the shower room floor following resident showers. This had the potential to affect a limited number of residents. Facility census: 112.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the daily posting of nursing staff working was completed and placed in an area accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 112.

Inspectors wroteBased on record review and staff interview the facility failed to ensure medical records were complete. Resident #113's medical record did not contain information from psychiatric visits. This was a random opportunity for discovery. Facility census: 112.