Rock Hill Health & Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by an alleged unidentified male staff member for 1 of 3 sampled residents (Resident 1) reviewed for abuse. Resident 1alledged an unidentified male staff member twisted their hand and caused bruising, swelling and pain to their left pinky. The failure to protect the resident from an unidentified staff member placed the resident at risk for potential ongoing abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse including an injury of unknown origin and of an injury to an area not vulnerable to trauma for 1 of 3 sampled residents (Resident 1) reviewed for allegations of abuse. The failure not to conduct a thorough investigation, and correct actual or potential alleged violations left residents at risk for unidentified and/or repeated incidents, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) responsible for the facility's Infection Control Program met the education qualifications for certification prior to accepting the role as the IP in a long-term care facility. This failure placed residents at risk for not having an adequate oversight of infection control issues specific to long-term care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility environment was clean, sanitary and orderly for 3 of 3 halls and rooms [ROOM NUMBER]. The facility failed to identify and provide the necessary maintenance and housekeeping in resident rooms and common areas. These failures placed residents at risk for decreased quality of life and potential infection control issues.

Inspectors wroteBased on interview and record review the facility failed to have a system in place to ensure information was readily available and posted in prominent places for residents on how to file grievances or complaints for 1 of 1 resident groups and grievances were addressed and resolved in response to residents' concerns for 2 of 2 residents (Residents 7 and 47) who voiced grievances. These failures placed residents at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings Included . Review of the facility policy titled Grievances/Complaints Policy, revised 07/27/2022, documented residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (State Ombudsman). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with bathing for 4 of 5 residents (Residents 3, 5, 7 and 50) reviewed who were unable to carry out their ADL's (activities of daily living) independently. Failure to provide bathing assistance according to the resident's needs and preferences placed the residents and others at risk for poor hygiene, diminished dignity and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 3 of 5 certified nursing assistants (CNA) (Staff G, U and V) reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 6 of 7 sampled staff (Staff B, G, H, T, U and W) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of expired medications in 2 of 2 medication rooms (Forest and Artist Medication Rooms), failed to properly label and discard open vials of Tuberculosis solution (TB solution - used to test for persons with possible Tuberculosis - an infectious respiratory disease), and failed to correctly monitor temperatures of vaccines in 1 of 2 medication refrigerators (Forest Medication Room). These failures placed residents at risk of receiving compromised or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was not greater than 14 hours between the evening meal and breakfast in the main resident dining room without the approval of the resident group and with the provision of a substantial evening snack. This had the potential to affect all residents who received their meals in the main dining room and impact resident quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dishwashing temperatures met the requirements in the facility kitchen. Failing to ensure proper dish sanitation placed residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 6 of 6 residents (Resident's 4, 17, 23, 30, 44, and 50) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected weight and sleep monitoring and alert charting after an allegation for Resident 50 and a discharge note for Resident 4. Further, Residents 4 and 23 had other resident records in their medical record. The failure to maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 5 of 5 nurse aides (Staff G, H, T, U, and V) had their required 12 hours of in-service training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview and record review, the facility failed to address the required documentation for advance directives (AD) for 3 of 6 residents (Residents 4, 7 and 8) reviewed for advance directives. This failure placed residents at risk for not having their preferences and decisions honored for end-of-life care.

Inspectors wroteBased on record review and interview, the facility failed to provide 2 of 3 residents (Residents 38 and 51) required notices regarding anticipated Medicare non-coverage. The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for Resident 51. Additionally, the facility failed to provide Resident 38 a Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN), which informs the beneficiary about potential non-coverage and the option to continue services by accepting the cost of continuing the services. These failures had the potential to impact residents and their representative's ability to decide if they wish to continue receiving the skilled services that may not be paid for by Medicare, assume financial responsibility or exercise their right to an appeal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 8 and 23) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to obtain consent, monitor and document behaviors and symptoms, failed to attempt and document non-pharmacological interventions prior to administration and demonstrate adequate indication of use of medications. These failures placed the residents at risk for medication-related complications such as drowsiness, withdrawal from activities and socialization, movement disorders, falls with injury, stroke, and increased risk of death, for receiving unnecessary psychotropic medication.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and report timely an allegation of verbal/mental abuse for 3 of 4 residents (Residents 1, 7, and 38) reviewed for abuse. The lack of thorough investigation prevented the facility from ruling out abuse and failure to report immediately caused a delay in further investigation and protection of the residents. These failures placed residents at risk for harm related to potential unrecognized abuse. Findings Included. Review of the facility policy titled, Abuse dated 10/01/2021 documented each resident had the right to be free from abuse.staff would immediately review and investigate all allegations or observations of abuse.protect the resident .and ensure each mandated reporter reported immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 3 of 3 residents (Residents 1, 4, and 42) reviewed for hospitalization and failed to ensure notification to the Office of the State Long-Term Care Ombudsman (LTCO - resident advocates) occurred for 1 of 3 residents reviewed for hospitalization. Failure to offer bed holds placed residents and/or representatives at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility. Failure to notify the LTCO and ensure written notification was provided to the resident and/or representative placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were referred and followed up on for 3 of 5 residents (Residents 1, 4 and 8) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plans were revised as need for 4 of 5 residents (Residents 7, 8, 38, and 44) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team placed residents at risk for unmet care needs, anxiety, fear, decreased quality of care related to outdated or inaccurate care plans, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for 2 of 3 residents (Residents 8 and 31) reviewed for wandering. The facility failed to ensure adequate supervision to prevent Resident 8 from unsupervised access while entering other resident rooms, prevent unwanted touching, resident to resident altercations and falls. The facility failure to timely document, follow-up, evaluate, and analyze data gathered to establish a root cause after wandering, falls, resident to resident altercations placed the resident at risk for subsequent falls, elopement, avoidable serious injuries, negative health outcome, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication errors when medication was not administered in accordance with provider orders for 1 of 2 sampled residents (Resident 7) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health conditions, anxiety and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the provision and follow-up of dental services for 1 of 2 residents (Resident 3) reviewed for dental care. This failure had the potential to result in a decreased quality of life for Resident 3, who was experiencing dental pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection prevention and control Antibiotic Stewardship Program (ASP, a system-wide implementation of measures for monitoring/tracking of antibiotics along with reducing the risk of unnecessary antibiotic use) was implemented for 3 of 3 residents (Residents 5, 23, and 27). This failure increased the resident's risk for development of multidrug-resistant organisms (a bacteria that are resistant to many antibiotics) along with potential for unidentified nursing care trends that identify risk related to infection prevention. This failure had the potential for adverse outcomes associated with unnecessary or inappropriate antibiotic use and a decrease in quality of life for all facility residents.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide pharmaceutical services (including procedures that interpret prescriber's orders, reflect current standards of practice, assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) in place to meet the needs of each resident for 3 of 3 residents (Residents 1, 2, and 3) reviewed for medication management. Failure to ensure drugs and biologicals were administered per the physician order and standard of nursing practice placed residents at risk medication errors, unmet health care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to have a functioning medication administration system to ensure the licensed nurse (LN) followed professional standards, medications were administered per the providers orders, medications were not omitted, and failed to follow facility policy regarding the ten rights to medication administration for 7 of 8 sampled residents (Residents 3, 11, 5, 6, 9, 8, and 10) reviewed for mediation administration. These failures placed residents at risk for potential negative adverse effects to mediations, complications, not receiving their medications as prescribed by the physician and a decline in their health status.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a treatment cart was locked/secured in the absence of a nurse for 1 of 2 treatment carts ([NAME] Lane treatment cart) observed, and proper labeling and storing of medications for 1 of 3 medication cart (Artist Lane medication cart) reviewed. These failures placed residents at risk of having unintended access and potential for ingestion of medications and biologicals that should be stored and locked.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices by not cleaning and disinfecting resident care equipment to include vital sign (VS) equipment and a glucometer (a small portable medical device used to measure the concentration of sugar in the blood) machine per the manufactures guidelines for 1 of 1 residents (Resident 5), consistently implement hand hygiene when preparing resident medications for 2 of 2 residents (Residents 11 and 5), placing on and removing Personal Protective Equipment (PPE) for 1 of 1 nurses (Staff D) observed for medication administration. These failures placed residents at risk of obtaining infections and a decreased quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed to conduct thorough investigations for 2 of 3 residents (Residents 1 and 2) reviewed for abuse and neglect. The failure to conduct thorough investigations placed all residents at risk for repeat incidents, potential injury, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q4 2024 [October1 through December 31, 2024]), reviewed for PBJ submission. This failed practice resulted in CMS having inaccurate data related to nursing home staffing levels which had the potential to impact on the care and services provided to all the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility Administration failed to ensure the facility's finances were maintained effectively for continuity of resident care and services. The Administration was aware the facility was behind on vendor payments and receiving notices for discontinuation of services. The Administration's failure to ensure the facility met their financial obligations to vendors resulted in the facility laboratory services provider discontinuing services to the facility resulted in four residents (Residents 10, 34, 95, and 7) not receiving timely laboratory services, and placed all 41 residents at risk of not receiving necessary care and services and constituted an Immediate Jeopardy (IJ). On 04/25/2025 at 5:19 PM, the facility was notified of an IJ in F835. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure timely laboratory services were provided for 5 of 5 residents (Residents 7, 10, 15, 34 and 95) reviewed for laboratory services. Resident 15 did not have a urinalysis sample collected for laboratory study per physician order, Resident 7 did not have a Hemoglobin A1C (lab measures blood sugars in the body over a period) test completed as ordered and Resident 95 did not have a metabolic panel and blood count completed timely. Resident 10 and 34's Depakote levels (critical lab test to determine therapeutic drug level in the body and prevent toxicity for seizure medications, reference range 50-100) were not completed timely as ordered and constituted an Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pressure offloading mattress was ordered and implemented timely to prevent pressure ulcer (PU)/pressure injury (PI) development for 1 of 2 residents (Resident 7) reviewed for facility acquired PU. Resident 7 experienced harm when they developed a preventable Stage 3 PU to their coccyx (tailbone), requiring wound vacuum treatment which impacted the resident's rehabilitation and discharge potential. This failure placed residents at risk for adverse outcomes and a decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility Governing Body failed to ensure the facility's finances were maintained. The Governing Body was aware the facility was behind on vendor payments and receiving notices for discontinuation of services. The Governing Body's failure to ensure oversite of the facility Administration to meet their financial obligations to vendors resulted in the facility laboratory services provider discontinuing services to the facility and placed all 41 residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigations for 4 of 6 residents (Residents 5, 6, 10 and 27) reviewed for accidents and potential abuse or neglect. The failure to conduct complete and thorough investigations placed residents at risk for repeat incidents, injury, and lack of appropriate corrective action on the part of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 4 of 5 residents (Residents 6, 10, 15 and 28) reviewed for Pre-admission Screening and Resident Review (PASRR) assessments, were accurately completed prior to or upon admission to facility, or updated if resident's conditions change. This failure placed residents at risk of not receiving timely and necessary mental health services, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that 9 of 9 sampled Certified Nursing Assistant (CNAs) (Staff W, Staff J, Staff X, Staff Y, Staff Z, Staff AA, Staff BB, Staff CC, and Staff K) reviewed for background checks were verified as active on the Omnibus Budget Reconciliation Act (OBRA). This failure placed residents at risk of being cared for by unqualified staff, unmet care needs, diminished quality of life, and possible harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 5 residents (Residents 1, 6, 9, and 15) reviewed for unnecessary medications were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, and to ensure appropriate indications were present for psychotropic medications and that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. consents were obtained prior to administration of psychotropic medications. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on interview and record review the facility failed to ensure a system in which residents' records were complete, accurate, accessible, and systematically organized for 3 of 5 residents (Residents 6, 7, and 10) reviewed for accurate PASRR (Preadmission Screening and Resident Review), Medication Administration Records (MAR) and Treatment Administration Records (TAR). Failure to ensure clinical records were complete and accurate made it impossible to determine what care and services were provided, or should have been provided, and placed residents at risk for medical complications, unmet care need and for diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to immediately report to the state agency potential abuse/neglect of 1 of 4 residents (Resident 10) reviewed for accidents. Failure to report potential allegations of abuse and/or neglect placed residents at risk for unidentified abuse, and therefore, continued mistreatment and a poor quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure written notification of facility-initiated transfer and/or discharge was completed for 3 of 4 residents (Residents 31, 37, and 144) reviewed for hospitalizations. The facility failed to ensure the transfer/discharge notice with all the required information was provided in a timely, practical manner upon an emergency transfer to the hospital. This failure placed residents and their representatives at risk of not receiving accurate information related to resident's discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 3 of 4 residents (Residents 31, 37, and 144) reviewed for hospitalizations. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review the facility failed to ensure care plans were revised as required for 2 of 5 residents (Resident 10 and 15) reviewed for psychotropic medication review. This failure had the potential to impact staff knowledge of resident needs, placing resident's at risk for decreased quality of care and negative outcomes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 of 7 sampled staff (Staff EE) had an active professional Nursing Assistant Certification (NAC).

Inspectors wroteBased on interview and record review the facility failed to thoroughly provide professional standards of care and services for 3 of 5 residents (Residents 10, 15, and 27) reviewed for medication management. The facility failed to hold cardiac medications per physician orders, and to reassess abnormal blood pressure (BP) or heart rate (HR) values and notify the provider of abnormal findings. This failed practice placed residents at risk for adverse health effects, medication complications, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 6) reviewed for hydration were consistently monitored and received adequate fluids. This failure placed residents at risk for dehydration, constipation, urinary tract infections (UTI), and other health complications including worsening cognitive impairment and behavioral changes.

Inspectors wroteBased on an interview, observation, and record review, the facility did not adequately reassess, report, or provide effective pain management for 1 of 1 (Resident 1). This oversight resulted in the resident experiencing discomfort during routine tasks such as repositioning and peri-care. Furthermore, the situation may have affected the resident's quality of life and increased the risk of developing bed sores. Findings Included . <Resident 1> Resident 1 was a long-term resident of the facility. According to the admission MDS dated [DATE], Resident 1 was mildly cognitively impaired. Review of policy titled 'Pain Assessment and Management' dated 03/25/2024, documented: Staff will identify situations or interventions that increase resident pain, staff will know why pain medication is being administered, and staff will conduct and document pain levels when residents' pain increases . [...]

Inspectors wroteBased on interview and record reviews, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 5 sampled staff (Staff M), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings Included . Staff M was hired on 12/02/2022 as a nursing assistant certified (NAC). In a review of Staff M's performance evaluation showed it was an annual evaluation but was not dated or signed by the evaluator or the staff. The performance evaluation was one page and at the bottom of the page indicated there was two pages to the evaluation. No other documents were provided for Staff M's performance evaluation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services including all procedures that assured accurate order entry, dispensing and administration of medications in the facility, occurred for 1of 1 resident (Resident 7) reviewed for pharmaceutical services. The failure to ensure accurate orders and administration for Resident 7 resulted in a duplication error and placed residents at risk for adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services including all procedures that assured accurate order entry, dispensing and administration of medications in the facility, occurred for 1of 1 resident (Resident 7) reviewed for pharmaceutical services. The failure to ensure accurate orders and administration for Resident 7 resulted in a duplication error and placed residents at risk for adverse outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 5 nursing assistant certified (NAC) (Staff M) failed to receive the required dementia care, abuse and neglect, communication and quality assurance performance improvement (QAPI) training's and 12-hour training. These failures to ensure NACs received required training placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary supervision and services for 1 of 3 residents (Resident 1), reviewed for elopement. The failure to provide the necessary supervision and services for Resident 1 resulted in an elopement and placed the resident at risk for injury.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, and homelike environment on 2 of 2 resident units and 1 of 1 outdoor space reviewed for the environment. The failure to ensure walls, ceilings, floors, and outdoor spaces were homelike and in good repair, and water temperatures were comfortable, placed residents at risk for diminished quality of life in their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, implement interventions, and update the care plan to prevent accidents/falls for 1 of 1 sampled resident (Resident 31) reviewed for accidents/incidents. This failure caused Resident 31 to have recurrent falls resulting in injury for 5 of 11 falls reviewed, and placed residents at risk for falls, injury, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete required annual performance evaluations for 3 of 3 Certified Nursing Assistants (CNAs) (Staff E, F, G ), who had been employed at the facility greater than one year. Failure to complete annual performance evaluations, and ensure staff members had met yearly performance and competency requirements, placed residents at risk for dimished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens. The failure to ensure they had hot water in the kitchen handwashing sink, to use safe procedures for cooling foods to be re-used at a later meal, to use safe dishwashing procedures, and to do hand hygiene after cleaning counters and before dishing up foods placed residents at risk for foodborne illnesses.

Inspectors wroteBased on record review, and interview, the facility failed to ensure 3 of 5 Certified Nursing Assistants (CNAs) (Staff E, F, G), reviewed for training, had the required 12 hours per year of in-service education and the required annual dementia training. This failure placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview, and record review, the facility failed to honor 1 of 2 residents (Resident 21) choices regarding bathing. The facility failed to accommodate resident's preferences for bathing frequency. This failed practice placed residents at risk for unmet bathing needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process (a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings), was followed for 2 of 5 sampled residents (Resident 37 and 8) for medication review. Failure to refer Resident 8 for Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) services as indicated, and implement the Level II recommendations received for Resident 37, placed the residents at risk for not receiving care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on interview, and record review, the facility failed to fully develop a baseline care plan and/or to provide a written summary of the baseline care plan information that included all of the required elements to 3 of 5 sampled residents (Residents 15, 191, and 37) reviewed for baseline care plans. This failure placed residents at risk of not being informed of their medications, dietary instructions, services, and treatments to be administered, or goals of care, and could lead to unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 3 residents (Resident 18) reviewed for nutrition. The facility failure to weigh the new resident and to implement orders for daily weights placed residents at risk for unrecognized weight loss or weight gain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure cleanliness of respiratory care tubing equipment for three of five sampled residents (Residents 31, 33, and 141) reviewed. Failure to replace oxygen administration equipment or nebulized medication equipment placed residents at risk for using soiled equipment and for acquiring infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 8) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure consents were obtained and the resident received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, and interview, the facility failed to store medications in a safe place for 1 of 1 resident (Resident 18) reviewed who had medications stored in their room. This failure placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for 1 of 4 residents (Resident 21) reviewed for skin conditions. The failure to ensure clinical records were complete and accurate placed residents at risk for unmet needs.

Inspectors wroteBased on observation and interview, the facility failed to use adequate infection control practices for 1 of 1 residents (Resident 18) observed for wound incontinent care and wound cares. Staff failed to change gloves and perform necessary hand hygiene during the cares which resulted in contamination of the resident's bedding, clothing, and the light pull cord. Staff also failed to use good principles of infection control when they wiped the resident's groin during incontinent cares, then while still wearing the same contaminated gloves wiped the rash in the resident's abdominal folds. These failures placed residents at risk of communicable diseases and/or healthcare associated diseases, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was free from neglect for 1 of 1 resident (Resident 1) when the facility failed to provide Resident 1 with the routine physician ordered Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) to their left leg. Resident 1 experienced harm when they were found with a Stage 4 (a full thickness tissue loss with exposed bone, tendon, or muscle. Nonviable tissue, dead or devitalized tissue may be present on some parts of the wound bed. Often includes undermining, which was destruction of tissue or ulceration extending under the skin edges, and tunneling, which was a passageway of tissue destruction under the skin surface) which pressure injury they had developed unbeknownst to the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure nursing staff consistently provided the skin integrity and Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) assessment and monitoring as ordered, for 1 of 1 resident (Resident 1) reviewed for pressure ulcer/pressure injury (PU/PI). Resident 1 experienced harm when they developed an avoidable Stage 4 (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle. There may be nonviable tissue, dead or devitalized tissue present on some parts of the wound bed) PU/PI under the resident's knee brace (also known as an immobilizer - a medical device that stabilizes your knee joint and holds it in place). This failed practice placed residents at risk for developing PU/PIs under a brace and/or immobilizers.

Inspectors wroteBased on interview, and record review, the facility failed to provide the resident/resident representative written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to, or a statement of the resident's appeal rights for 1 of 3 sampled residents (Resident 1) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident/resident representative at the time of transfer or within 24 hours of transfer, a written notice that specified the bed hold policy for 1 of 3 residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk of being unaware of the right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 Halls (Forest Hall). The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. The facility failed to ensure staff used personal protective equipment (PPE) in accordance with national standards. [...]

Inspectors wroteBased on observations, interviews, record review, the facility failed to develop and/or implement policies and procedures for ensuring a communicable disease outbreak for Coronavirus Disease 2019 COVID-19) was reported to the state reporting agency (Complaint Resolution Unit - CRU) 1 of 1 disease outbreaks reviewed. The facility failed to report a communicable disease outbreak in the facility for five days after the outbreak was identified and failed to log the outbreak on the state reporting log. This failure to report to the required state agency and log the outbreak on the state reporting log placed all residents at risk for unidentified and uninvestigated exposure to a communicable disease.