Rochester Residence and Care Center

Inspectors wroteBased on review of facility policy, reports submitted to the State, and staff interview it was determined that the facility failed to report allegations of abuse for two of two residents (Resident R2, and R3).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on one of two nursing units (3rd floor nursing unit).

Inspectors wroteBased on a review of regulations, documents submitted to the State Agency and staff interviews it was determined that the facility failed to notify the State Agency of a change in the facility's Nursing Home Administrator (NHA) at the time of the change, and ensure that a qualified NHA was assigned to the facility for two of 31 days (3/28/26, and 3/29/26).

Inspectors wroteBased on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure a safe, and functional environment for one of two Entry Doors (Employee Entrance).

Inspectors wroteBased on review of facility documents, vendor interview, and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units (Third Floor).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seventeen residents (Resident R77) identified as having a high risk for wandering.

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of three floors (Third and Fourth Floor).

Inspectors wroteBased on facility policy, observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the Main Kitchen, by failing to properly label and date food products, and failing to properly store serving scoops, and also failed to maintain sanitary conditions on the third-floor kitchenette which created the potential for cross contamination in one of two kitchenettes (Third floor).

Inspectors wroteBased on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (Third and Fourth Floor Crash Carts).

Inspectors wroteBased on a review of facility policy, observations, and staff interview, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on two of two nursing units (Third and Fourth Floors).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Resident R2, R6, R52, R84, and R89), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Resident R2, R6, R52, R84, and R89 ).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of five residents (Resident R2, R4, and R60) and failed to follow physician orders for weights for one of two residents (Resident R16).

Inspectors wroteBased on review of facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for three of four residents (Resident R3, R9, and R55).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of six residents (Resident R2, R29, R34, R60 and R65).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of two treatment carts (4th Floor Treatment Cart), failed to properly secure lab work supplies while not in use for one of two nursing units (4th Floor), and failed to properly store medication in two of three medication carts (Grandview Medication Cart and Riverview Medication Cart).

Inspectors wroteBased on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the former Nursing Home Administrator (NHA) Employee E31 and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained for three of three residents reviewed for hospice services (Resident R9, R23, and R65).

Inspectors wroteBased on facility policies, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene on six of six nursing units (Lilac Lane, Rosewood, Vineyard, Riverview, Hilltop, and Grandview), failed to prevent cross contamination during a dressing change for one of two residents (Resident R9), failed to properly monitor a resident's refrigerator temperature for one of two residents (Resident R44), and failed to monitor the results of blood cultures (a blood test used to determine if infection is present in blood stream) for one of three residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely offer and provide the COVID-19 vaccination for three of five residents (Residents R16, R71, and R72).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R23 and R55).

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary psychotropic drugs used without adequate indications for use for one of three residents (Resident R77).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state certification/license check prior to hire for two out of five personnel records (Nurse Aide (NA) Employee E19 and Licensed Practical Nurse (LPN) Employee E20).

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of five residents (Residents R26).

Inspectors wroteBased on review facility policies, observations, clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter (closed sterile system inserted into the bladder to allow for urine drainage) as required for two of three residents (Resident R34 and R88).

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a midline catheter (a thin flexible tube inserted into a vein in the upper arm with the tip positioned just below the armpit) for one of two residents (Resident R5).

Inspectors wroteBased on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for one of three nurse aide (NA) personnel records (NA Employee E28).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident R55).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of five staff members (Registered Nurse (RN) Employee E29, and E30).

Inspectors wroteBased on observations, facility policy, resident interviews, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents. Findings Include:Review of the facility policy Safe and Homelike Environment dated 12/11/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. This includes ensuring that the residents can receive care and services safely. [...]

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation.

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on three of four medication carts (Vineyard, Rosewood, and Rosewood 2).

Inspectors wroteBased on facility policy, observations, and staff interviews, the facility failed to ensure the outside environment was free of potential accidental hazards, failed to evaluate the snow hazard, and failed to implement a plan for snow removal for two of two parking lot areas, walkways and surrounding grounds three days after a snowstorm (Front Parking and Rear Parking Area).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart while not in use for three of four medication carts (Vineyard, Rosewood, and Rosewood 2).

Inspectors wroteBased on review of job descriptions, clinical records, observations, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.

Inspectors wroteBased on facility policy, review of facility documents, and resident records, resident council group interview, review of resident representative concern, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of two residents (Resident R18 and R51), failed to assist a resident to eat in a timely manner and failed to ensure that food was provided in a manner which maintained resident dignity for one of four residents (Resident R67), and failed to provide a dignified dining experience for all residents for three out of six months (July, August, and September 2025).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to accommodate the proper linen needs for two of two units (third and fourth floors) and provide a clean, safe, comfortable and homelike environment on one of two nursing units (Third Floor).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation.

Inspectors wroteBased on facility policy, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene, failed to prevent cross contamination during a dressing change for one of three residents (Resident R74), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections, identify floor mapping for three of five months (July, August, and September 2025) and failed to implement Covid outbreak response timely for one of three residents (Resident R72).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for three of eleven residents (Resident R4, R26 and R61).

Inspectors wroteBased on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect and verbal abuse for three of three residents (Resident R13, R26, and R32).

Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for four of five residents (Residents R1, R6, R28, and R33).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for four of four residents (Residents R7, R10, R29, and R56) reviewed.

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R4, R10, and R17).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents (Residents R10, R34, and R72), and failed to develop a comprehensive person-centered care plan to address resident needs for one of three residents (Resident R72).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being on four of five days (9/15/25, 9/16/25, 9/17/25, and 9/18/25).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) were completed at least monthly for four of five sampled resident records (Resident R1, R3, R28, and R33).

Inspectors wroteBased on review of facility documents, resident council group interviews, and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for of one of two Nursing Units (Fourth Floor).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of five months (July, August, and September 2025).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza vaccine for three of five residents (Resident R1, R4, and R72) and related to the pneumonia vaccine for four five residents (Resident R1, R4, R29, and R72).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R10).

Inspectors wroteBased on review of facility policy, Resident Group interviews, Resident Council meeting minutes, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for three of four months (July, August, September 2025).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post complete contact information for Adult Protective Services as required, on two of two nursing units (Third Floor, and Fourth Floor Nursing Units).

Inspectors wroteBased on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for one of two residents (Resident R48).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R5), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of three resident hospital transfers (Resident R5).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident communication care needs for one of five residents (Resident R10).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents (Resident R10).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate monitoring of elopement (leaving an area without permission) prevention devices for one out of three residents (Resident R5).

Inspectors wroteBased on review of facility policy, observation and staff interviews, it was determined the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medications rooms (Fourth Floor Medication Room), and one of three medication carts (Lilac Lane Medication Cart).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents (Resident R33). Findings Include: A review of the facility Laboratory Services and Reporting reviewed 1/7/25, indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory to meet the needs of its residents. The facility is responsible for the timeliness of the service. A review of the facility Provision of Physician Ordered Services last reviewed 1/7/25, indicated the facility will provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. [...]

Inspectors wroteBased on facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to provide food in a form to meet an individuals' needs in one of three residents ordered a regular diet (Resident R28), and failed to provide drinks in a form to meet individuals' needs in one of three residents (Resident R76). Review of the facility policy Therapeutic Diets dated 1/7/25, indicated that the facility provides all resident with food in the appropriate form and the appropriate nutritive content as prescribed by a physician to support the resident's treatment, plan of care with his or her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. [...]

Inspectors wroteBased on observations, family interview, and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, and functional environment on the nursing unit for one of two floors (Fourth Floor).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E20).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).

Inspectors wroteBased on a review of facility menu, and resident and staff interviews, it was determined that the facility failed to follow the facility menu, and serve palatable food for the lunch meal served on 8/7/25, breakfast meal served on 8/9/25, and dinner meal served on 8/9/25.

Inspectors wroteBased on observations and resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for two of two nursing units (The Gardens, and Scenic Heights).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to address weight loss for one of three residents (Residents R1).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to the notify resident representative of a change in condition or care for one of three residents (Resident R1).

Inspectors wroteBased on facility policy, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with an insulin pump (wearable device that delivers insulin continuously to people with diabetes), and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted.

Inspectors wroteBased on observation, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received treatment and care in accordance with professional standards of practice which resulted in actual harm to Resident R1, who received a medication that was not given according to the physician's orders, resulting in Resident R1 being overdosed on insulin (injectable diabetic medication) overdose and required treatment in an acute care emergency department.

Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of three residents which created an actual harm of an accidental insulin overdose and acute care emergency room visit for Resident R1.

Inspectors wroteBased on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment on two of two nursing floors (Second floor).

Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of three residents reviewed (Resident R1), relating to use of an insulin pump (wearable device that delivers insulin continuously to people with diabetes).

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289). This failure created an immediate jeopardy situation for two of 11 residents (Resident R79 and R289).

Inspectors wroteBased on a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly maintain kitchen equipment and one unit pantry in a sanitary condition creating the potential for cross contamination and food-borne illness (Main Kitchen and 3rd floor).

Inspectors wroteBased on review of facility policies, documentation, observations, resident and staff interviews and state and federal guidance it was determined that the facility failed to fully implement COVID monitoring, tracking, and testing in accordance with state and federal guidance for outbreak response, placing residents at risk for potentially acquiring communicable disease, failed to follow enhanced barrier precautions for one of three residents reviewed (Residents R51), and failed to prevent cross contamination during a medication pass for one of three residents (Resident R88).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for three of three residents (Resident R26, R37, and R56 ).

Inspectors wroteBased on review of facility policy and documentation, resident and staff interview it was determined that the facility failed to respond the residents concerns from resident council for five of six month reviewed (September, October, November and December of 2024, and February of 2025).

Inspectors wroteBased on review of facility documentation, resident and staff interview it was determined that the facility failed to provide ongoing program of activities to meet the interest of and support the physical, mental, and psychosocial well-being of each resident for four of four residents:

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to develop an individualized care plan for the use of a urinary catheter (insertion of a tube into the bladder to remove urine) for one of six residents (R64) and failed to provide privacy for the collection bags for four of six residents reviewed (Residents R32, R34, R51, and R64).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to identify and address significant weight loss in a timely manner for one out of seven residents (R38), failed to develop or update an individualized nutrition care plan for two out of seven residents (R1 and R38), and failed to timely assess the nutritional status of four out of seven residents (Residents R1, R9, R38, and R64).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen and nebulizer management for four of four residents (Residents R15, R36, R80, and R84).

Inspectors wroteBased on review of facility policy, resident observations, and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five days (3/10/25, 3/17/25, and 3/18/25). Findings Include: Review of the facility policy Nursing Services and Sufficient Staff dated 1/7/25, indicated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical records, and interview with staff, it was determined that the facility failed to make certain that PRN (as needed) orders for psychotropic medications are limited to 14 days for three of five residents (Residents R30, R32, and R41).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in three of six medications carts (Grandview medication cart, Riverside medication cart and Rosewood medication cart) and failed to properly secure treatment medication in one of four treatment carts (Fourth floor Rosewood hall treatment cart) and failed to secure one of two medication rooms (fourth floor medication room).

Inspectors wroteBased on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to notify the physician of a change in treatment in a timely manner for one of three residents (Resident R290).

Inspectors wroteBased on review of facility policy, resident clinical record, documentation provided by the facility, and staff interview it was determined that the facility failed to report an allegation of possible neglect within 24 hours to the local state field office for one of seven residents (Resident R30).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an incident to rule out possible neglect for one of seven residents (Resident R30).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to document assessment and notify the physician of a change in condition for one of four residents (Resident R80).

Inspectors wroteBased on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of four residents (Resident R32).

Inspectors wroteBased on review of policy and clinical records, staff and resident interview, it was determined that the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R290).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide care and services for the provision of hemodialysis (treatment that helps body remove extra fluid and waste products) consistent with professional standards of practice for one of two residents (Resident R80).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a resident with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident R30).

Inspectors wroteBased upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five residents (Resident R30).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents (Resident R290). Findings Include: A review of the facility Laboratory Services and Reporting reviewed 1/7/25, indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory to meet the needs of its residents. The facility is responsible for the timeliness of the service. A review of the facility Provision of Physician Ordered Services last reviewed 1/7/25, indicated the facility will provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. [...]

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of three residents (Resident R15 and R30).

Inspectors wroteBased on review of the facility's policy, plan of correction for previous incident, resident records and staff interview it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed concerns identified during an elopement (2/6/25).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of five residents (Resident R1).

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to have physician order specifications relating to size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) for one of five residents (Resident R4) and failed to provide privacy for the collection bags for three of five residents reviewed (Residents R4, R5, and R6).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide medications within time guidelines for one of five residents reviewed (Resident R5). Findings Include: Review of the facility policy Nursing Services and Sufficient Staff dated 1/7/25, indicated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of admission record indicated Resident R5 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for two of two residents (Residents R2 and R3).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for three of five residents reviewed (Residents R5, R6, and R7).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment on five of six nursing units (lilac lane, rosewood, riverview, hilltop, and grandview) Findings Include: Review of the facility policy Safe and Homelike Environment last reviewed 1/7/25, indicates the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly and comfortable environment. During a facility tour complete on 1/28/25, 10:00 a.m. thru 10:30 am. the following observations were noted: . Third floor lilac lane hallway the ceiling cold air return vents were coved in a dark grey fuzzy substance. . Third floor rosewood hallway the ceiling cold air return vents were coved in a dark grey fuzzy substance and had visible cobwebs hanging down. . [...]

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to maintain and implement an effective Quality Assurance and performance improvement program that focuses on outcome by failing to implement a QAPI for the call bell system pager use.

Inspectors wroteBased on review of facility policy, facility document, staff interviews, and observations, it was determined that the facility failed to ensure that the call bell system was in full working order for six of six units (lilac lane, vineyard, rosewood, riverview, hilltop, and grandview) by ensuring employees were in possession of a pager as indicated in the exemption dated 10/3/19.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment in the laundry room storage area and the large main storage area located on the facilities lower level.

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable water temperature throughout resident areas for two of two units on the same boiler line (Third and Fourth floors) and failed to have disposable wash cloths immediately available for staff use for two of two units (Third and Fourth floors). Findings Include: Review of the facility policy Safe and Homelike Environment dated 8/21/24, indicated the facility will provide and maintain bed and bath linens that are clean and in good condition. Housekeeping and Maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. [...]

Inspectors wroteBased on review of facility documentation and staff and resident interviews, it was determined that the facility failed to maintain mechanical systems (boiler system), and three of three facility elevator cars (Two cars on Main, and one car on service elevator) in a safe operating condition resulting in no hot water being available for resident hygiene on two of two units (Third and Fourth floors) and residents unable to the leave the floors (Third and Fourth floors) unless in the event of a necessary medical reason where they would have to be carried down flights of stairs on a bed sled (an emergency type device used to transport residents up and down stairs who are not able to safely navigate on their own).

Inspectors wroteBased on observations, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for resident bathing for five of five nursing staff (Licensed practical Nurse (LPN) Employee E2, Nurse Aide (NA) Employee E1, NA Employee E4, NA Employee E7, and NA Employee E8).

Inspectors wroteBased on observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician's orders for one of two residents (Resident R1) and failed to revise/update a comprehensive care plan to meet resident care needs for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policies, observations and staff interview, it was determined the facility failed to cover food products and properly serve food in a sanitary manner to prevent foodborne illness.

Inspectors wroteBased on facility policy, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for five of nine residents who require care (Residents R1, R2, R3, R4, and R5)

Inspectors wroteBased on review of facility policy, facility document, staff interviews, and observations, it was determined that the facility failed to ensure that the call bell system was in full working order for one of six resident hallways (Lilac Lane)

Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of three residents with facility-initiated transfers (Resident R2, R3, and R4).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for three of three resident records reviewed (Resident R2, R3, and R4) Findings Include: Review of the facility policy Transfer and Discharge dated 5/31/24, indicated that the facility will provide copies of notices for emergency transfers to the Ombudsman. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Resident R2, R3, and R4). Findings Include: Review of the facility policy Transfer and Discharge, dated 5/31/24, indicated that the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to provide goods and services resulting in neglect for one of three residents reviewed (Resident R1), which resulted in an avoidable fall resulting in actual harm causing a skin tear (traumatic wound caused by blunt force, friction, and shear) for one of three residents (Resident R1), and failed to identify Resident R1's concerns as neglect to prevent future incidents.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to document the appropriate assistance level and failed to provide appropriate assistance for one of three residents (Resident R1), to prevent an avoidable fall for one of three residents reviewed (Resident R1) resulting in actual harm of a skin tear (a traumatic wound caused by blunt force, friction, and shear).

Inspectors wroteBased on review of facility policy, resident clinical record, documentation provided by the facility, and staff interview it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment in six of six resident rooms, one of two shower rooms and one of three hallways (Residents R2, R6, R11, R25, R36, R43 and Fourth-floor shower room, Fourth-floor hallway be elevator). Findings Include: Review of the facility policy Safe and Homelike Environment dated 5/31/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the admission record indicated R6 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for six of six months (January 2024 - June 2024), failed to implement enhance barrier precautions for one of three residents (Residents R27), failed to prevent cross contamination during a dressing change for one of three residents (Resident R27), failed to prevent cross contamination during a medication pass for two of three residents (Residents R33, R47), failed to have appropriate isolation signage posted for one of three residents (Resident R88), failed to utilize soiled utility area appropriately, and failed to provide evidence of control measures and testing protocols for water management prevention program for six of [...]

Inspectors wroteBased on review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide palatable meals during lunch for two of two meal observations (Lunch on 6/3/24 and 6/4/24).

Inspectors wroteBased on a review of facility policy, documents, resident medical records and staff interviews it was determined that the facility failed to notify the resident's physician and responsible party of unavailable medication prescribed for one of three residents. (Resident R1)

Inspectors wroteBased on a review of resident medical records and staff interviews it was determined that the facility failed to implement person centered care plans for two of four residents. (Resident R 2 and R4)

Inspectors wroteBased on a a review of resident medical records and staff interviews it was determined that the facility failed to make certain an as needed (prn) pain medication was necessary by failing to attempt and document the effectiveness of non pharmacological interventions prior to the administration of the pain medication for two of two residents. (Resident R2 and R4).

Inspectors wroteBased on a review of facility policy, facility documents, resident medical records and staff interviews it was determined that the facility failed to provide proper medication administration and reaction monitoring for two of three residents as required. (Residents R1 and R3)

Inspectors wroteBased on a review of facility documents, resident medical records and staff interviews it was determined that the facility failed to make certain that documentation of resident medication administration was recorded accurately for one of four residents. (Resident R1)