Riverside Health and Rehabilitation Center LLC

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 04/15/2026 from 9:27AM to 10:41AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD):In the Stand Up/Cold Prep refrigerator, a partially empty jar of applesauce observed with no opened date or use by date. The FSD acknowledged it should be dated. On the floor beside the ice machine, debris was observed on the floor. In the dry storage room, the surveyor observed two boxes containing single-serve cereal bowls stacked directly on the floor. The FSD acknowledged the boxes should not be on the floor and relocated the boxes to the shelf unit. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 4 units (Second and Fourth Floor). The deficient practice was evidenced by the following: During the initial tour on 04/15/2026 at 9:30 AM, surveyor #1 observed the following: room [ROOM NUMBER]: A chair in the bathroom had a brown stain on the seat. room [ROOM NUMBER]: The bathroom wall had large scuff marks that penetrated through the drywall. room [ROOM NUMBER]: A foul odor was present, and the unmade bed had stained sheets and pillowcases. 3rd Floor Shower Room: A patch in the tiled wall had not been retiled. Additionally, the floor molding was peeling off and was held in place with tattered blue tape, which was also peeling. During follow-up rounds on 04/20/2026 at 10:50 AM, surveyor # 1 observed: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately account for the administration, disposition, and reconciliation of 3 controlled medications for 3 sampled resident (Resident #47, Resident #58 and Resident #69) identified upon inspection of 2 of 3 medication carts (second floor low-side cart and high-side cart). The evidence was as follows: On 4/15/2026 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the second-floor high end medication cart. A review of the narcotics located in the secured and locked narcotic box revealed Resident 58's Chain-of-Custody Record (a declining inventory record) for methadone 100 mg (milligram) oral solution, a medication used to treat opioid use disorder, did not match. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to 1 of 3 residents (Resident # 56) reviewed under Beneficiaries Task. The deficient practice was evidenced by the following: A review of Resident # 56's Electronic Medical Record revealed the resident was admitted with Medicare A as the primary payer source. A review of the Beneficiary Notification Review completed by the facility revealed that Resident # 56's Medicare Part A skilled services episode start date was 09/04/2025. The last covered day of Part A service was 12/1/2025. A review of the Beneficiary Notification Review revealed that the SNF ABN, Form CMS 10055 was not provided to the resident. No explanation was provided on the SNF Beneficiary Notification Review form. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to implement care consistent with the resident's care plan by failing to order and implement Enhanced Barrier Precautions (EBP). This deficient practice was observed for 1 of 1 resident (Resident #3) reviewed for Tube Feeding. The deficient practice was evidenced by the following:On 04/15/2026 at 12:12 PM during initial tour, Resident #3 was observed lying in their bed attached to an enteral feed pump (a device used to deliver liquid nutrition directly into a person's stomach or small intestine through a tube). At that time, the surveyor observed no EBP signage outside the resident's doorway. At the same time the surveyor observed Resident #3s identification sign at the top of the doorway with no colored mark next to his/her name. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide pain management that met professional standards of practice related to pain management. Specifically, by giving pain medication outside of the window of administration. This deficient practice was identified for 1 of 1 resident (Resident # 106) investigated for pain. The deficient practice was evidenced by the following: On 04/15/2026 9:43 AM the surveyor spoke to Resident #106 who stated that they received pain medication late. A review of Resident #106's admission Minimum Data Set (MDS) an assessment tool dated 03/20/26 reflected that they received routine pain medication. A review of Resident #106's electronic medical record (EMR) revealed a diagnosis of but not limited to muscle weakness and a lack of coordination. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards of practice to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage areas (first floor nursing office) inspected and was evidenced by the following: On 4/20/2026 at 12:29 PM, the surveyor in the presence of the Director of Nursing (DON), inspected the first-floor medication storage room. There was no medication refrigerator located in that room, the DON stated there was a refrigerator used to store medications located in the first-floor nursing office. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure standardized recipes were utilized to ensure food was prepared to conserve nutritive value and flavor. This deficient practice was identified for 2 of 2 observed lunch meals prepared and the evidence was as follows:On 04/16/2026 at 11:50 AM, Resident #9 stated that they were unsatisfied with the food they were served. Resident #9 stated that they did not receive the food listed on their ticket and the portions were small. On 04/17/2026 at 11:10 AM during the resident council meeting, 5 out of 5 members in attendance stated that the food was not appealing and was not palatable. On 4/16/2026 at 12:02 PM during an interview, the Food Service Director (FSD) stated the menu is a set daily menu with a main entree and alternate entree. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that infection control practices were followed to prevent the potential spread of infection for a resident on contact isolation. This deficient practice was evidenced for 1 of 10 residents (Resident # 65) reviewed under the Infection Control Task. The deficient practice was evidenced by the following: A review of Resident # 65's EMR revealed under orders that he/she has an E.Coli/UTI (a bacterial infection in the urinary tract). The order clarifies that the precaution type is contact. The order was started on 4/16/2026. A review of Resident # 65's Care Plan located in the EMR revealed the resident was on isolation contact precautions. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain an environment free of pests. The deficient practice was identified by observation of a live pest on 1 of 4 floors (2nd Floor) in the facility. The deficient practice was evidenced by the following: On 04/16/2026 at 10:40 AM while touring the 2nd floor in the hallway near the nurses station, the surveyor observed a brown insect crawling across the wall near the hand rail. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) also observed the insect when the surveyor brought it to his attention. He then used a disposable glove to dispose of the insect. The LPN/UM informed the surveyor that he will document the occurrence in the Pest Control Log. [...]

Inspectors wroteCOMPLAINT#: NJ0018543 Based on interview and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to implement the facility's Abuse, Neglect and Exploitation policy to ensure that existing staff received annual education for 1 of 2 employee files reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the Social Worker Assistant's (SWA) employee file, which included a General Orientation Checklist for All Employees dated 12/15/09. The checklist indicated that the SWA had an in-service on Resident Neglect and Abuse as part of her orientation. The employee file did not contain any additional in-services regarding this topic. [...]

Inspectors wroteCOMPLAINT#: NJ00184543 Based on interview, medical record review, and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to: a.) immediately initiate an investigation of an allegation of verbal abuse, and b.) implement the facility's Abuse, Neglect and Exploitation policy. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for abuse and was evidenced by the following: Resident #2 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: paraplegia, acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), anxiety, and depression. [...]

Inspectors wroteBased on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/18/2024 from 9:25 AM to 10:14 AM, the surveyor, accompanied by the Dietary Director (DD), and observed the following: 1.) In the refrigerator referred to as the reach in cooler, there were two egg salad sandwiches labeled with a use by date of 11/16/2024, but no made on date. The DD said that egg salad sandwiches should be discarded because sandwiches can cause illness. 2.) In the dry storage area, there were four bags of unopened marshmallows with a manufacture's expiration date of 07/2024. The DD said that marshmallows should be discarded because of the expiration date. [...]

Inspectors wroteBased on observations and interviews on 11/20/2024 and 11/21/2024 in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the resident call bell system properly functioned by a.) ensuring the call bell system volume was set to a level to be heard and b.) devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at on 12/20/2024 at 12:55 PM revealed the call bell light outside of room [ROOM NUMBER] turned on when tested by the DOM, but there was no audible notification and the activation did not register at the nurse's station call bell annunciator. [...]

Inspectors wroteOn 11/18/2024 at 10:34 AM during the initial tour on the second floor in the low side shower room, Surveyor # 3 observed a trash can without a bag liner. The surveyor observed disposable gloves discarded in the whirlpool tub. The sharps bin on the wall was full and not emptied. The plastic lid indicated, Full. On 11/20/2024 at 10:09 AM in the second floor shower room, Surveyor # 3 observed the sharps bin still indicating, full. On 11/20/2024 at 10:10 AM in room [ROOM NUMBER], Surveyor # 3 observed the plastic on the foot board of Resident # 229's bed separated. Resident # 229 was asleep in the bed at that time. On 11/20/2024 at 10:13 AM, Surveyor # 3 observed the high side medication cart on the second floor. At that time, Surveyor # 3 observed hair tangled in the wheels of the cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by 1). failing to wear a gown when providing wound care, and 2). Performing hand hygiene for residents and staff during meal service. The deficient practice was identified for 1 of 1 (Resident # 22) residents reviewed for Pressure Ulcer/Injury, and 1 of 3 floors observed for dining. (4th Floor) The deficient practice was evidenced by the following: 1.) A review of Resident # 22's diagnoses located in the Electronical Medical Record (EMR), revealed a diagnosis of but not limited to a pressure ulcer of the sacral region. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain an environment that protected and valued a residents' private space along with their personal property. This deficient practice was identified for 1 of 28 residents reviewed for Resident Rights (Resident #77). During initial tour of the Fourth Floor on 11/18/2024 at 10:55 AM, the surveyor observed a housekeeper wiping the inside of Resident #77's bedside drawer that was located across from the resident's bed. The surveyor immediately requested the assistance of the Registered Nurse Unit Manager (RN/UM#1) and upon the return to the resident's room, the surveyor and RN/UM#1 heard Resident #77 yell to the housekeeper to get out of the drawer and that they didn't give permission to go in there. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the call bell within reach for 1 of 28 sampled residents, (Resident #90). This deficient practice was evidenced by the following: On 11/18/2024 at 10:49 AM, upon initial tour of the Fourth Floor, the surveyor observed Resident #90's call bell on the floor under the bed. When asked about their call bell, Resident #90 was unsure where it was and if they had one. On 11/19/2024 at 11:17 AM, the surveyor observed the call bell on the floor underneath the resident's bed. On 11/20/2024 at 12:26 PM, the surveyor observed the call bell on the floor underneath the resident's bed. The surveyor reviewed the medical record for Resident #90. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had a witnessed fall. This deficient practice was identified for 1 of 4 Residents (Resident #8) reviewed for accidents and was evidenced by the following: On 11/19/2024 at 12:PM, the surveyor requested all accidents and/or investigations during the timeframe of 10/14/2024 to 11/17/20204. The facility provided information related to Resident #8 sustaining a fall without injury on 11/9/2024. Upon review of the fall investigation titled, Witnessed Fall with Head Injury dated 11/9/2024 at 2:19 PM revealed under Incident Description: Heard a noise from the hall and got up to check and saw resident sitting on the floor. [...]

Inspectors wroteComplaint # 172764 Based on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool used to facilitate care. This deficient practice was identified for 2 of 31 residents (Residents #98 and #41) reviewed and was evidenced by the following: 1. On 11/21/2024 at11:49 AM, the surveyor observed Resident #98 with a Wander guard to his/her left ankle. According to the admission Record, Resident #98 was admitted to the facility with diagnoses including but not limited to dementia and cerebral vascular accident (stroke). Resident #98 had a Physician Order (PO) dated 04/10/24 to apply a Wander guard to the left ankle. A review of the April 2024, June 2024, and September 2024 Medication Administration Record reflected that the Wander guard was signed out as completed. [...]

Inspectors wroteBased on interview, record review, and pertinent facility documentation, it was determined that the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives to meet the resident's medical, nursing, mental, and psychosocial needs specifically by failing to include what the Care Plan focuses are related to. The deficient practice was identified for 2 of 3 residents (Resident # 124 & 21) reviewed for Development/Implementation of Care Plans. A review of Resident # 124's admission Record located in the Electronic Medical Record (EMR) revealed that he/she had a diagnoses including but not limited to Major Depression Disorder and Anxiety. [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to maintain thorough documentation following a witnessed fall according to professional standards of clinical practice. This deficient practice was identified for 1 of 4 Residents (Resident #8) reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to ensure that residents with indwelling urinary catheters received appropriate treatment and services to prevent urinary tract infections to the extent possible specifically by leaving the urinary catheter drainage bag in contact with the floor, unsecured to a bed, resting on top of a mattress while a resident was lying in bed, and failing to document whether the urinary catheter output was collected as ordered by the physician. The deficient practice was identified for 2 of 2 residents (Resident # 120 & 21). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to properly store respiratory equipment, specifically a nebulizer, in accordance with professional standards of practice by leaving it unsecured, open to air. The deficient practiced was identified for 2 of 3 residents (Resident # 72 & 19) investigated under Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 72's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Oxygen Tubing Change: Please change oxygen tubing and Nebulizer mask weekly for infection prevention and patency. Label and date. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident # 81). reviewed for medication management. The deficient practice was evidenced by the following: A review of the admission Record for Resident # 81 revealed the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily tasks), and Protein-Calorie Malnutrition (a nutritional status in which poor intake of nutrients lead to changes in body composition and function). [...]

Inspectors wroteBased on observation, interview, and review of documentation, it was determined that the facility failed to store, label, and date potentially hazardous food and maintain kitchen sanitation in a manner intended to limit the spread of food-borne illnesses. The deficient practice was evidenced by the following: On 08/28/23 at 09:55 AM, the surveyor entered the kitchen and toured with the Certified Dietary Manager (CDM). The surveyor observed several items throughout the kitchen that were not labeled properly to include a full case of bacon, several loaves of bread, boxes of tea bags, crackers in a yellow box, a bag of chips, and a metal container of grape jelly that was unlabeled. The jelly container contained peanut butter inside the jelly. The meat slicer was stored on the counter uncovered. [...]

Inspectors wroteComplaint number: NJ00158868, NJ00159302, and NJ00158245 Based on observation, interview, and review of facility documentation it was determined the facility failed to maintain a clean, safe, and sanitary environment for the residents. This deficient practice was identified on the a.third and b.fourth floor of the facility and was evidenced by the following: a. On 08/29/23 12:09 PM, the surveyor toured the third-floor unit, the high and low side. During the tour the surveyor observed the following: In rooms 303, 304, 309, and 315 the surveyor observed cracks in the glass windows. The cracks were covered with silver tape; they were semi-private rooms. room [ROOM NUMBER] had brown substance spots on the floor which appeared dry. room [ROOM NUMBER] there was a nightstand with a broken door handing from the hinge. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by incorrectly transcribing a physician's order for the appropriate dose of insulin medication. This deficient practice was identified for 9 out of 10 administered insulin doses for Unsampled Resident #1 observed during medication administration. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to: 1.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and 2.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 3 of 3 medication carts and was evidenced by the following: 1. On 9/1/23 at 11:19 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) and a second surveyor, reviewed the narcotic logbook for the fourth floor's low side medication cart. The Record of Narcotic Count shift log revealed the following incomplete or blank sections: 8/1/23 - 7 AM incoming nurse and outgoing nurse signature and total number of narcotics remaining - cards, bottles, gels, and patches. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to 1.) properly store medications including controlled substances, 2.) maintain clean and sanitary medication storage areas, and 3.) properly label opened multidose medications. This deficient practice was observed in 2 of 2 medication storage rooms and 3 of 3 medication carts reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 10:06 AM, the surveyor, in the presence of Licensed Practical Nurse Unit Manager #1 (LPN/UM #1) and a second surveyor, observed the fourth-floor medication storage room. The following observations were made: The medication storage refrigerator had a locking mechanism on the door which was left unlocked allowing the refrigerator door to be opened. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to promote dignity. This deficient practice was identified for 1 of 1 resident (Resident #287) reviewed for dignity. This deficient practice was evidenced by the following: On 08/09/22 at 7:18 AM, admission records revealed that Resident #287's family member had concerns about Resident #287's Texas catheter (a urine collection device that fits like a condom over the penis) was removed without his/her permission and Resident #287 was placed in a diaper the first night at the facility. On 09/11/23 at 12:15 PM, the surveyor reviewed Resident #287's Quarterly Minimum Data Set (MDS), an assessment tool revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choices to have personal needs allowance (PNA) and to have use of the laundry room during the evening hours and on the weekends. This deficient practice was identified for 6 of 6 residents. This deficient practice was evidenced by the following: On 08/31/23 at 10:30 AM, the resident council meeting was held and 6 out of 6 residents stated there was no PNA available in the evenings during the week and not available at all on the weekends, and the resident laundry room on the first floor was not available in the evenings during the week or on the weekends. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Annual Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 3 residents (Residents #51 ) reviewed for timing of assessments and was evidenced by the following: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that at a minimum, facilities are required to complete a comprehensive assessment for each resident not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. This deficient practice was evidenced by the following: On 8/29/23 a review of the electronic health record (EHR) reflects that resident #51 was admitted to the facility in July 2017. [...]

Inspectors wroteBased on resident observation, interview and record review, it was determined that the facility failed to complete a significant change in status assessment (SCSA) for a hospice resident. This deficient practice was identified for 1 of 1 residents (Resident #93) reviewed for hospice and was evidenced by the following: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan for Resident #23, 1 of 29 residents reviewed for care plans and was evidenced by the following: On 08/29/23 at 12:29 PM, during the initial tour of the facility Resident #23 told the surveyor that he/she fell out of bed about week ago because the bed is small, and they were used to a king-sized bed. The surveyor asked if there was a floor mat next to the bed at the time of the fall and resident said, I don't want a mat, I have rails on the side of the bed. Resident #23 denied any major injuries from falls and said he/she already had hip damage. On 09/06/23 at 10:00 AM, the surveyor observed Resident #23 in bed. The bed was in the low position. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications were administered without an error of 5% or less. During the medication observation on 7/21/23, the survey team observed two (2) nurses administer medications to three (3) residents. There were 25 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 8%. This deficient practice was identified for 1 of 3 residents (Unsampled Resident #1) that were administered medications by 1 of 2 nurses on the second-floor low side nursing unit. On 8/31/23 from 8:18 AM through 9:47 AM, the surveyor, in the presence of a second surveyor, during medication pass observation of the Licensed Practical Nurse (LPN) made the following observations: [...]

Inspectors wroteBased on interview and document review of pertinent facility documentation, the facility failed to have the medical director present for two out of six Quality Assurance and Performance Improvement (QAPI) meetings as evidenced by the following: On 08/29/23 at 11:49 AM, the Director of Nursing (DON) provided the surveyor with six quarterly sign in sheets for the four most recent quarterly meetings which revealed: -Reporting Month of June 2022 Quality Assurance Performance Improvement (QAPI) Quarterly Meeting dated July 21, 2022, Medical Director's (MDs) signature was blank. - Reporting Month of December 2022/4th Quarter 2022 (QAPI) Sign In, the Medical Director's (MDs) signature was blank. During an interview on 09/01/23 at 12:56 PM, the DON stated the Medical Director did not attend the July 21, 2022 meeting and she did not attend the December 2022 meeting because she left the company. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to 1.) follow appropriate infection control practices and perform hand hygiene as indicated during a medication pass, and 2.) ensure respiratory equipment was kept in a clean and sanitary condition and stored properly to reduce the risk of infection. This deficient practice was identified for 1 of 3 residents reviewed for medication pass (Unsampled Resident #1), and for 1 of 1 resident reviewed for respiratory care (Resident #337). 1.) On 8/31/23 from 8:18 AM through 9:47 AM, the surveyor, in the presence of a second surveyor, during medication pass observation of Licensed Practical Nurse (LPN) made the following observations: [...]