Rock River Nursing & Rehab

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R3 and R13) of 3 residents reviewed for pressure injuries. *R3 was admitted to the facility with a pressure injury to the sacrum. The pressure injury healed on 2/9/26. On 3/2/26, R3's sacrum pressure injury reopened. The facility Wound MD recommended a treatment and the order was not entered into R3's medical record. From 3/3/26 through 3/8/26, R3 did not have a treatment completed to R3's pressure injury. R3's pressure injury healed on 4/2/26. *R13 is at risk for pressure injuries. R13 was observed multiple times without R13's heels being offloaded per R13's care plan intervention.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R21) of 4 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R21 is assessed as having functional limitations in range of motion for bilateral lower extremities. The facility has not implemented any interventions to prevent decline in R21's range of motion.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R21 & R7) of 2 residents environment remained free of potential accident hazards. R21 and R7 were observed with an elopement device attached to the metal portion of their wheelchair. The facility was purchasing the incorrect device to be attached to the wheelchair and the device was not two inches away from the metal portion.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R13, R7, & R17) of 6 residents were free from unnecessary medications. *R13 and R7 were administered an antibiotic when they did not meet the criteria for treating an urinary tract infection. *R17 is taking an anticoagulant medication and did not have a care plan.

Inspectors wroteBased on interview, observation, and record review, the facility did not assist 1 (R2) of 1 resident reviewed for obtaining routine dental care. *The dentist recommended R2 be evaluated by an oral surgeon as soon as possible for two teeth to be extracted due to a cavity and broken tooth. The facility did not ensure a physician order to follow up and schedule an appointment was documented until 16 days after the recommendation.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 2 of 2 residents receiving a pureed diet. *The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance.

Inspectors wroteNumber of residents sampled:1Number of residents cited:1Craig- his certification of terminal illness and care plan not available until yesterday. No process in building. Based on interview and record review the Facility did not ensure hospice services were coordinated for 1 (R6) of 1 residents reviewed for hospice care.*R6's certification of terminal illness was not updated and there was not an updated plan of care from hospice.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, to the state survey agency for 1 (R1) of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated to resolve the allegation and staff education provided to prevent further incidences for 1 (R11) of 1 facility reported incidents reviewed. R11 made an allegation of misappropriation of property that was not followed up on to resolve the missing computers allegation and no staff education was provided to prevent further misappropriation.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 (R2) of 12 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. R2 receives Spironolactone for diuresis. R2 does not have a comprehensive care plan that addresses diuretic therapy.

Inspectors wroteBased on interview and record review, the facility did not ensure that pharmacy recommendations reported to the physician were not acted upon for 2 (R6 and R17) of 5 residents reviewed for pharmacy recommendations. R6 and R17's monthly pharmacy medication regimen reviews included recommendations that were not acted upon.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R2, R3, R8 and R11) reviewed for smoking. The failure to prevent and assess a residents risk for injury related to smoking and not ensuring smoking materials are contained to prevent injury created a finding of Immediate Jeopardy beginning on 7/10/25. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R3, R8, R11 and R2) reviewed for supervision with smoking. R3 was observed with cigarette ashes on his person, going through smoking receptacle taking out cigarette butts to smoke and asking other residents for cigarettes. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 2 of 2 non nursing staff chosen at random receive behavior health training. Cook-L and Housekeeping-M did not receive annual behavioral health training.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (R2 and R3) reviewed out of a total sample of 13 residents. R2 reported that he no longer smoked then was observed by Surveyors going through the smoking receptacle removing cigarette butts to smoke. The facility did not offer R2 any alternatives for smoking such as smoking cessation options. R3 is noted to have documented behaviors of going to smoking receptacles to pull out cigarette butts to smoke, asking other residents and staff or cigarettes and taking cigarettes out of other residents hands. The facility failed to offer R3 smoking alternatives such as smoking cessation options. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received resident rights and facility responsibilities training. Cook-L did not receive resident rights and facility responsibilities training annually.

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received abuse, neglect, exploitation, and dementia training. Cook-L did not receive annual abuse, neglect, exploitation, and dementia training.

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 2 non nursing staff chosen at random received QAPI (quality assurance performance improvement) training. Cook-L did not receive annual QAPI training.

Inspectors wroteBased on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 24 out of 24 residents residing at the facility. Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. Evidenced by:Facility policy entitled 'Nurse Staffing Posting Information,' dated 01/2025, states in part: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time.1. The Nurse staffing sheet will be posted on a daily basis and will contain the following information: a. Facility name. b. The current date c. Facility's current resident census. D. [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a thorough investigation of alleged staff abuse. The facility did not report an allegation of physical abuse to the local law enforcement. This was observed with 1 (R20) of 2 Facility Reported Incidents (FRI) reviewed. R20 alleged a staff member hit them on the head. The facility's completed 5-day investigation did not include that law enforcement was notified. The facility's policy and procedure titled, Abuse/Neglect/Exploitation, undated documents: The definitions of physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The procedure document: . Section VII. Reporting/Response; A.1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 12 residents (R25 and R19) reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R25 has a history of depression and receives medication to treat depression. The facility did not have a care plan, with resident specific interventions in place, upon R25's admission to the facility. R25 displayed multiple behaviors of depression including social isolation, refusals of care, refusal of multiple meals, and meal intake was low since R25's admission. R25's primary Nurse Practitioner (NP)-H, was not notified of R25's low meal intake. Fifteen days after admission, facility staff documented R25 had a 30.4-pound weight loss which is 15.7% of R25's body weight. NP-H was not notified of R25's significant weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 of 3 residents (R10 and R25) reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. *On 3/11/25, R10 developed a Deep Tissue Injury (DTI) to the right heel. R10 was assessed to be at risk for pressure injuries. R10's Treatment Administration Record (TAR) documents an order dated 2/19/25, to float R10's heels when in bed as needed (PRN) with no documentation noted in February or March 2025, indicating R10's heels were floated. R10's care plan was updated on 4/8/25, to include bed extenders which is 48 days from when R10 was noted to have an open wound on the right foot on 2/20/25 that developed into a DTI on 3/11/25. [...]

Inspectors wrote3.) R24 was originally admitted to the facility on [DATE] with diagnosis that included unspecified convulsions, Schizophrenia, Depressive Episodes, Anxiety Disorder, Cognitive Communication Deficit and Chronic Artial Fibrillation. A review of the most recent quarterly MDS ( Minimum Data Set), dated 3/21/25 documents that R24 has a BIMS ( brief interview for mental status) score of zero ( severe cognitive impairment). R24 has also had a fall at the facility without injury and is frequently incontinent of urine and always incontinent of bowel. R24's individual plan of care documents that he is at risk for falls related to history of falls, use of medication, diagnosis history that includes HTN, CVA, seizure, schizophrenia, a-fib and insomnia. Use of Psychotropic medications. Require staff assist with ADLS/mobility, incontinence cares. Impaired range of motion. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had low staffing on the evening (PM) shift on 4/2/25, while having a census of 30 residents. 2 Certified Nursing Assistants (CNA)s called in on the PM shift on 4/2/25 which left 1 Licensed Practical Nurse (LPN) alone for a census of 30 residents. The facility has made recent staffing changes at the end of March 2025, that allow one dietary staff member on the PM shift, 2.5 Certified Nursing Assistants (CNA)s on the days shift, and 1.5 CNAs on the night shift. This change in staffing puts 1 CNA from 10:00 PM until 2:00 AM with a census of 30 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement an effective Infection Prevention and Control Program (IPCP). This has the potential to effect all 30 residents in the facility. The facility did not ensure medication was administered in a sanitary manner. This was observed with 1 (R29) of 1 resident receiving eye medication. * The IPCP did not have documentation of an effective water management program (WMP) to prevent the spread of Legionella. * The facility did not have documentation of identifying infections and completing corrective actions to prevent their spread. * The facility did not utilize preventative potential infection measures when administering eye medications to R29.

Inspectors wroteBased on record review and interview, the facility not have a designated, and qualified Infection Preventionist (IP), responsible for the facility's Infection Prevention and Control Program (IPCP). This has the potential to affect all 30 residents in the facility. The Facility Assessment does not include the role of the Infection Preventionist. The Director of Nurses (DON)-B has not completed training in infection prevention and control. The facility's policy and procedure titled, Infection Preventionist, dated 10/1/22, was reviewed. The policy documents: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program.; Policy Explanation and Compliance Guidelines: 2. The facility will ensure the IP is qualified by education, training, experience or certification. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe, and protected, area for smoking. This has the potential to effect all 5 (R30, R27, R29, R31 and R33) residents that smoke at the facility. The facility's designated smoking area is not protected from weather events. The area is adjacent to the facility parking lot, and a facility circle driveway that leads to the front entrance.

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 1 (R15) of 12 residents reviewed to participate in the development and implementation of their person-centered plan of care. *R15's Activated Healthcare Power of Attorney (HCPOA) was not formally invited by the facility to participate in R1'5s Quarterly care conferences Findings Include: 1.) R15 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy and Chronic Obstructive Pulmonary Disease. R15's Quarterly Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview for Mental Status (BIMS) score to be a 10, indicating R15 is moderately cognitively impaired and unable to conduct daily decision making. R15 has an Activated HCPOA. On 4/07/2025, at 2:29 PM, Surveyor conducted a family interview via telephone with R15's Activated HCPOA. [...]

Inspectors wroteBased on observation, staff interviews, and record review the facility did not ensure they provided ongoing-re-evaluation of the need for a seatbelt while seated in a wheelchair for 1 (R24) of 1 residents reviewed for physical restraints. R24 uses a seatbelt to aide in positioning while seated in his wheelchair. The facility initially assessed the use of the restraint on 10/11/23 and has not re-evaluated the use of the seatbelt since then. Evidenced by: The facility policy, entitled Restraint Free Environment, (no date), states Each resident shall attain and maintain his; her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident had medical symptoms that warrant the use of the restraint. Physical restraints may include, but are not limited to: . [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care for 1 (R25) of 1 residents reviewed. *R25 was admitted to the facility on [DATE] and did not have a baseline care plan initiated within 48 hours of admission.

Inspectors wroteBased on interview and record review, the facility did not ensure adequate monitoring for adverse reactions of high-risk medications for 3 (R4, R19, & R27) of 6 residents reviewed for unnecessary medications. *R4 has a physician's order for Eliquis (an anticoagulant) for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. The facility did not implement medication monitoring for any adverse side effects that could result from taking an anticoagulant. *R19 has a physician's order for Eliquis (an anticoagulant) for cerebral infarction. The facility did not implement medication monitoring for any adverse side effects that could result from taking an anticoagulant. *R27 has a physician's order for Eliquis (an anticoagulant) for cerebral infarction. implement medication monitoring for any adverse side effects that could result from taking an anticoagulant.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R25) of 6 residents reviewed for medications were free from unnecessary psychotropic medications. *R25 was admitted to the facility with a diagnosis of Major Depressive Disorder and was actively taking psychotropic medication, Fluoxetine, as treatment. R25 did not have a care plan addressing R25's depression or psychotropic medication use. R25 did not have side effect monitoring for Fluoxetine in place.

Inspectors wroteBased on interview and record review, the facility did not ensure residents immunizations were offered, or refused, as eligible. This was observed with 2 (R32 and R9) of 5 residents immunization record reviewed. * R32 did not have documentation of any pneumococcal vaccines. * R9 did not have documentation of the influenza vaccine 2024-2025 timeframe.

Inspectors wrote3.) R10 was admitted to the facility on [DATE], with diagnoses that include Metabolic encephalopathy, Atrial Fibrillation (irregular heart rate) and Bradycardia (slow heart rate.) R10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R10's cognition is intact. R10's active MD order dated [DATE], documents: Please notify MD or [Nurse Practitioner] if [heart [NAME]] is less than 45. Every shift for Bradycardia . Surveyor reviewed R10's Treatment Administration Record (TAR) from October through [DATE]. Surveyor noted that staff did not document a heart rate on the following times: AM shift [DATE], PM and Night shift on [DATE], AM shift on [DATE], PM shift on 11//12/24, Night shift on [DATE], and AM shift on [DATE]. Surveyor noted 7 opportunities when facility staff did not document a heart rate for R10. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for 3 (R5, R4, and R3) of 6 residents. On [DATE], R5 experienced a seizure, which was a change of condition for R5. On [DATE], R5 received a physician order for Lorazepam 0.5 mg (milligrams) every 4 hours as needed for comfort medication. This order was not picked up by the facility until [DATE]. R5 experienced another seizure on [DATE]. Following the seizure on [DATE], Lorazepam 0.5 mg every two hours as needed for seizure activity was ordered. This order was not picked up until [DATE]. On [DATE], R5 received an order for Levetiracetam 500 mg (an anti-seizure medication): Give 1 tablet by mouth two times a day for seizures. R5 did not start receiving this medication until [DATE]. R5 continued to have seizures on [DATE], [DATE], and [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of 4 of 5 Certified Nursing Assistants (CNA's) reviewed. This had the potential to affect all 35 residents who reside in the facility.

Inspectors wroteBased upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing and implementing policies and procedures regarding the operations of the facility. The facility's governing body did not ensure that proper resources were allocated to ensure that the HVAC (Heating, Ventilation, and Air Conditioning) system providing heat to the entire facility was maintained in a functioning manner. This created the likelihood where services necessary to maintain operations of the facility along with the care and treatment of all residents may be impacted by the failures of the governing body. This deficient practice has the potential to affect all residents present in the facility at the time of the survey that were affected by not having heat.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE, CNA-FF) reviewed received the annual required Effective Communication training. This practice had the potential to affect all 35 Residents in the facility receiving care from these 5 CNAs. The facility did not provide staff with the required annual effective communication training for 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE, CNA-FF). Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 5. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE, CNA-FF) received the annual required QAPI (quality assurance performance improvement) training on the elements & goals of the Facility's QAPI program. This practice had the potential to affect all 35 Residents in the facility. The facility did not provide staff with the required annual QAPI training for 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE and CNA-FF). Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 5. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received the annual Compliance and Ethics training. This practice had the potential to affect all 35 Residents in the facility. The facility did not provide staff with the required annual Compliance and Ethics training for 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE, CNA-FF) on an annual basis. Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 5. The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. a. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure direct care staff 5 of 5 Certified Nurse Aides (CNAs)(CNA-H, CNA-J, CNA-DD, CNA-EE, CNA-FF) reviewed received behavioral health training to care for Residents diagnosed with mental, psychosocial, a history of trauma, or substance use disorder as indicated on the facility assessment. This deficient practice has the potential for all staff to lack current knowledge to work with the unique challenges mental health illnesses present. The facility did not provide staff with required annual training on the facility's behavioral health services. Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the residents environment was comfortable and homelike. The heating unit that supplied heat to the north side of the facility was not fully operational and did not maintain a comfortable, homelike environment with comfortable living temperatures for residents. This has the potential to affect the 14 residents who were residing in the north hallway of the facility when the heating unit went down on 11/21/24. *Temperatures in the north hallway of the facility were below 71 degrees Fahrenheit. This affected resident rooms, hallways, and a common area on the north side of the building.

Inspectors wroteBased on interview and record review the facility did not ensure a residents physician and/or resident representative was notified for 2 (R4 & R3) of 6 residents reviewed. * On 11/14/24 R4's guardian was not notified of a KUB (kidney, ureter and bladder) x-ray, stool culture & labs ordered for R4. R4's physician was not notified when R4 received medication late for medication received BID/TID (two times a day/three times a day) daily from 10/27/24 to 11/30/24, with the exception of 11/8/24. * R3's physician was not notified when R3 received medication late for medication received BID/TID on 9/7/24 & 9/8/24 and on 11/1/24 to 11/11/24.

Inspectors wroteBased on interviews and record review, the facility did not ensure a resident-to-resident altercation was thoroughly investigated for 2 (R14 and R15) of 4 residents reviewed for an allegation of abuse. *R14 and R15's Facility Reported Incident (FRI) dated 12/24/24 documents R15 was in a wheelchair in the middle of the hallway. R14 was trying to get by R15 in his wheelchair but was unsuccessful. R15 became upset that R14 was not moving fast enough and kicked R14 in the left shin. The FRI does not contain statements from other residents to determine if other residents feel safe or if other residents have had interactions with R15. The FRI does not contain staff statements that speak to R14 and R15's pattern of behavior/agitation prior to the Resident-to-Resident altercation. Education was not provided to staff after the altercation to prevent future Resident-to-Resident altercations.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that they provided adequate supervision and assistance to prevent accidents for 1 out of 1 residents (R6) reviewed for falls. During a bed bath, R6 was rolled in bed from one side to another when the bed moved away from the wall and R6 fell to the floor. R6 immediately complained of pain and was sent to the emergency room for further evaluation. R6 was to have had all his cares done with 2 staff members present and R6 should have been rolled towards the staff member, not away from them to provide adequate assistance to prevent a fall from bed.

Inspectors wroteBased on interview and review of HR (human resource) records, the facility did not ensure 1 of 3 nursing staff competencies were completed after being hired. LPN (Licensed Practical Nurse)-K was hired on 9/15/24. A Licensed Nurse Competency was not completed for LPN-K.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 34 opportunities which resulted in a medication error rate of 5.88%. Medication errors were identified for R2 & R16. * R2's Lispro insulin bottle was not dated. * R16's blood pressure & heart rate was not checked prior to receiving Metoprolol Succinate ER 25 mg (milligrams) on [DATE].

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R5) of 21 residents reviewed was maintained in accordance with accepted professional standards and practices. R5's July 2024, August 2024, & September 2024 TAR (treatment administration record) had multiple dates which were blank. These blank areas are not explained in the medical record as to whether R5 refused the treatments, the treatments were not completed or the licensed nurse did not document the treatment was completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 of 5 Certified Nurse Aides (CNAs)(CNA-H and CNA-DD) received the required annual Resident Rights and the responsibility of the facility to properly care for the Residents trainings. This practice had the potential to affect all 35 Residents in the facility. The facility did not provide staff with the required annual Resident Rights training for 2 of 5 Certified Nurse Aides (CNAs)(CNA-H). Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 5. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 of 5 Certified Nurse Aides (CNAs)(CNA-H) received the annual require Abuse/Neglect and Dementia training which includes education on abuse, neglect and exploitation, activities that constitute abuse, neglect, exploitation, and misappropriation procedures for reporting incidents of abuse, neglect, exploitation and misappropriation and dementia management and Resident abuse prevention. This deficient practice had the potential to affect all 35 Residents in the facility. The facility did not provide staff with the required annual Abuse and Dementia training for 1 of 5 Certified Nurse Aides(CNA-H). Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 of 5 Certified Nurse Aides (CNAs)(CNA-H, and CNA-DD) received the required annual Infection Control training which includes the written standards, policies, and procedures for Infection Control. This practice had the potential to affect all 35 Residents in the facility. The facility did not provide staff with the required annual Infection Control training for 2 of 5 Certified Nurse Aides (CNAs)(CNA-H, and CNA-DD) on an annual basis. Findings Include: The facility's policy Required Training, Certification and Continuing Education of Nurse Aides dated 10/1/22 documents: .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an effective pest control program to address the flies in the facility. *R4 informed Surveyor that the facility has a problem with flies and R4 had purchased sticky fly strips to place in his room to help with the fly problem. *R6 informed Surveyor that the facility has a problem with flies and R6 has started to keep a fly swatter with him while in bed. *The facility did not have a pest control company to service the facility for the months of June and July of 2024. *Surveyors observed flies in resident unit hallways, the common dining room for residents, the conference room and in a resident's bathroom. This deficient practice has the potential to affect all 58 of 58 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview, the facility did not ensure a clean, comfortable, and homelike environment which had the potential to affect 1 (R12) of 9 resident's rooms observed and a sample of residents that go outside on the facility's grounds. *R12's shared bathroom was observed to have a smeared brown material which appeared to BM (bowel movement) on the wall close to the call light and the bathroom floor was sticky. R12's room was observed to have paint scrapings and plaster gouges behind the headboard of R12's bed. *Surveyor observed the environment outside on facility grounds to be littered with various items and an abandoned wheelchair.

Inspectors wroteBased on observation and interview the facility did not ensure sufficient nursing staff to meet resident care needs. This has the potential to affect R11, R2, R1, R12, R4, R6, and multiple residents residing on the north unit. On 9/9/24 CNA (Certified Nursing Assistant)-F was pulled from her CNA assignment to pass medication. The facility did not reassign staff to CNA-F's assignment resulting in R11's call light being on for over two hours. When R11's call light was answered & her needs addressed R11 was visibly upset & crying. On 9/9/24 R1's call light was observed on for over 30 minutes. Pulling CNA-F to pass medications rather than care for the residents impacted the residents residing on the north wing of the facility. R12, R4, and R6 all described waiting long lengths of time waiting to have call lights answered and needs met due to lack of staff in the facility.

Inspectors wroteBased on observation, interview, and record review the facility did not have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related nursing services to assure resident safety. This deficient practice had the potential to affect all 16 residents residing on the unit. An unqualified medication aide (Certified Nursing Assistant) was observed administering medications to residents.

Inspectors wrote3.) On 9/11/24, at 7:55 a.m., a Surveyor interviewed RN (Registered Nurse)-I regarding the events which occurred on 9/6/24. RN-I informed the Surveyor she worked the day shift, was then called to come back to the Facility and arrived at the facility at approximately 9:00 p.m. to work as LPN-P was unable to return to work. RN-I informed the Surveyor she did not administer any Resident's medication when she returned to the facility as she was unsure what medication LPN-P had administered as medication had not been signed out. R5's diagnoses includes edema, congestive heart failure, atrial fibrillation, peripheral vascular disease, and diabetes mellitus. Surveyor reviewed R5's September MAR (medication administration record) and noted the following PM (evening) medications are not initialed as being administered on 9/6/24: [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents the right to be informed of, and participate in, his or her treatment for 2 of 2 (R7 and R1) residents who received changes in medication. R7 was not informed of a newly ordered psychotropic medication. R1 was not informed of a change in their prescribed Oxycodone dosage and frequency.

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 1 (R1) of 2 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R1 in the care planning process. R1 was admitted on [DATE], and R1's last documented care conference was on 9/22/22. Findings Include: The facility's policy entitled, Care Planning-Resident Participation, implemented 3/1/23 documents: Policy .This facility supports the Resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform the Resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. 3. [...]

Inspectors wroteBased on observation and interview the Facility did not ensure 1 (R1) of 1 Residents were provided with reasonable accommodations of Resident needs and preferences. The air conditioning unit located in R1's room was removed without explanation when R1 was at the emergency room on 5/5/24. R1 then purchased R1's own air conditioner. Findings Include: R1 was admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Personality Disorder, Malingerer, Somatization Disorder, Morbid Obesity, Other Intervertebral Disc Displacement, Low Back Pain, Chronic Pain Syndrome, Chronic Kidney Disease, and Neuromuscular Dysfunction of Bladder. R1 is R1's own person. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R1 and R6) of 2 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. R1 was transferred to another room on 8/30/24 and was not given prior written notice, reason for the room change, or given a choice of available rooms. R6 was transferred to another room on 6/11/24 and was not given prior written notice, reason for the room change, or given a choice of available rooms.

Inspectors wroteBased on interviews and record review, the facility did not ensure the right of a Resident to receive visitors and at the time of their choosing for 1 (R8) of 1 Resident reviewed for visitation rights. The facility restricted a friend immediate access to R8 without any explanation to R8 or developing any strategies to continue safe and enjoyable visits for R8.

Inspectors wroteBased on interview and record review the Facility did not ensure 1(R2) of 10 Resident's resident representative was notified when there was a need to alter treatment and transfer to the hospital. On 9/1/24, R2 had a change of condition and the NP (Nurse Practitioner) ordered CBC (complete blood count), CMP (comprehensive metabolic panel), BNP (B type natriuretic peptide), UA (urinalysis) with c/s (culture/sensitivity) and chest x-ray for R2. R2 was then subsequently transferred to the hospital on 9/1/24. R2's guardian was not notified of the labs & chest x-ray ordered and was not notified of R2's transfer & admission to the hospital until 9/2/24 when a family member for R2 came to visit and R2 was not in the facility.

Inspectors wroteBased on observation, interview and record review the Facility did not ensure 1 (R2) of 17 residents reviewed had a comprehensive care plan that was reviewed and revised by the interdisciplinary team as determined by the resident's assessed needs. R2's care plan was not revised to accurately identify R2's fall prevention interventions. Evidenced by: * R2's diagnoses include atrial fibrillation, congestive heart failure, bipolar disorder, dementia, schizophrenia, depression, and diabetes mellitus. The quarterly MDS (minimum data set) with an assessment reference date of 6/12/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R2 is assessed as requiring substantial/maximal assistance to roll left & right and partial/moderate assistance for chair/bed to chair transfer. R2 has not fallen since prior assessment. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they develop and implement an effective discharge planning process focusing on the Resident's discharge goal, ensuring discharge needs are identified and incorporated into a discharge planning care plan in preparation for transition for 1 (R1) of 1 Residents reviewed for discharge plans to effectively transition R1 to post-facility care. Findings Include: The facility's undated policy Discharge Planning Process documents: .It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the Resident's discharge goals, the preparation of Residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Procedure: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R6) of 1 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene. R6 prefers showers weekly and did not receive weekly showers during the months of June, July, and August 2024.

Inspectors wroteBased on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 2 (R2 & R1) of 3 residents reviewed for ADL's (Activity of Daily Living). R2 & R1 did not consistently receive showers.

Inspectors wroteBased on interview and record review the facility did not ensure residents received treatment and care in accordance with assessment and medical recommendations for 3 (R2, R5, & R1) of 11 residents. * R2 had a colonoscopy performed on 6/18/24. The facility did not follow up regarding the results of this colonoscopy when a large polyp was removed. R2 was transferred to the hospital on 9/6/24 and returned on the same day. The facility did not follow the hospital discharge recommendations and did not update the care plan with these recommendations. R2 also had a diagnosis of cellulitis as a change in condition the facility did not follow discharge recommendations for orders to monitor. * R5's physician orders were not consistently being followed. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure each Resident received adequate supervision to prevent accidents for 1 (R2) of 3 Residents. * On 9/9/24 CNA (Certified Nursing Assistant)-K did not use a gait belt when transferring R2 from the bed to the wheelchair.

Inspectors wroteBased on interview and record review the Facility did not comprehensively assess 1 (R1) of 1 Residents for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. *R1 was admitted [DATE] and during R1's admission psychosocial assessment, the facility did not identify R1 as having a history of post traumatic stress disorder (PTSD). On 12/7/23, R1 had an initial psychiatric evaluation that identified R1's PTSD to be physical and sexual trauma. The facility completed Trauma Informed Care Assessments for all high risk residents on 5/20/24. R1's past history of physical and sexual trauma was not addressed with person centered interventions. A care plan and approaches to mitigate any triggers to prevent re-traumatization was not put in place after the assessment for R1 had been completed. Findings Included: [...]

Inspectors wrote2.) R7 admitted to the facility on [DATE] and has diagnoses that include: Intercranial injury with loss of consciousness, nontraumatic intracerebral hemorrhage, hemiplegia affecting left non-dominant side, hypertension, anemia, major depressive disorder, anxiety, chronic pain, and dysphagia. R7's Quarterly Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 11. R7's care plan initiated 3/21/24 documents: I sometimes have behaviors which include name calling to staff, yelling at staff; refuses vital signs, states the machine is not accurate; Inappropriate comments and inappropriate racial comments towards staff; Resident has conversations with people who are not there, answers the conversations as well; Is not an accurate historian when recalling events; Perseverates on topics, statements, stories; [...]

Inspectors wroteBased on comprehensive assessment of a resident, the facility did not ensure that residents were not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 1 (R7) residents reviewed for unnecessary medications. R7 was prescribed Seroquel without clear indication for use.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 53.33%. The Facility Policy titled Medication Administration implemented 3/1/19 documents (in part) . . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 11. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R11 & R5) of 2 Residents. * Staff did not wear appropriate PPE (personal protective equipment) when placing R11 on a bed pan. R11 is on EBP (enhanced barrier precautions). * Appropriate hand hygiene was not observed during incontinence cares and staff was not wearing a gown during this care observation for R5 who is on EBP.

Inspectors wroteBased on observation and record review the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 58 residents residing at the facility.

Inspectors wroteBased upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing and implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 53 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or invoiced amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body.

Inspectors wroteUNCORRECTED ON REVISIT Based on interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R6 and R51) of 3 residents reviewed for pressure injuries. *R6 did not have an ordered treatment in the Treatment Administration Record (TAR) for the sacral pressure injury from 4/10/2024 through 6/11/2024. *R51 had a pressure injury to the right metatarsal identified on 6/10/2024 and was not assessed until 6/12/2024 when Wound Nurse Practitioner (NP)-I determined the pressure injury was Unstageable. The air mattress was observed to be at an improper weight during the survey.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R51) of 6 Resident's representative was notified when there was a need to alter treatment. On 6/10/24 R51 was identified with new wounds on left heel & right metatarsal with treatment initiated. On 6/10/24 CBC (complete blood count) with differential and BMP (basic metabolic panel) was ordered along with holding R51's Eliquis for three days. R51's guardian was not notified of these changes in treatment.

Inspectors wroteBased on interview and record review the Facility did not promptly resolve a grievance for 1 (R51) of 5 grievances reviewed. On 5/13/24 R51's guardian sent SSD (Social Service Director)-D an email regarding R51 not being provided incontinence care for approximately 7 hours. On 5/14/24 SSD-D sent R51's guardian an email back indicating she had reported her concerns to NHA (Nursing Home Administrator)-A and NHA-A will be completing a grievance & conducting an investigation. The facility did not resolve the grievance involving R51 with R51's guardian and did not write up the grievance until after Surveyor inquired on 6/11/24.

Inspectors wrote3.) R303 was admitted to the facility on [DATE] with diagnoses of infection of surgical site and cellulitis of left lower leg, diabetes, squamous cell carcinoma to the face, dementia with psychotic disturbance, depression, anxiety, and encephalopathy. R303's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R303 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and was receiving intravenous (IV) antibiotics. R303 did not have an activated Power of Attorney. R303 did not have a Discharge Care Plan initiated and no records were found of R303 having a care conference to discuss discharge plans. R303 received Occupational, Physical, and Speech Therapy while at the facility but did not reach goals of therapy prior to discharging from the facility. [...]

Inspectors wrote3.) R303 was admitted to the facility on [DATE] with diagnoses of infection of surgical site and cellulitis of left lower leg, diabetes, squamous cell carcinoma to the face, dementia with psychotic disturbance, depression, anxiety, and encephalopathy. R303's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R303 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and was receiving intravenous (IV) antibiotics. R303 did not have an activated Power of Attorney. [...]

Inspectors wrote2.) R51's diagnosis includes diabetes mellitus. The pressure ulcer actual or at risk care plan initiated 3/10/24 documents the following intervention: * Diabetic foot monitoring. Initiated 3/21/24. The nurses note dated 6/10/24 at 14:20 (2:20 p.m.) documents Wounds - new skin issues found on R (right) metatarsal 1 cm x 1 cm abrasion and 4 cm x 4 cm scab on L (left heel). See TAR (treatment administration record) for tx (treatment). Will continue to monitor. This nurses note was written by LPN-F. On 6/10/24 during R51's record review, Surveyor was unable to locate diabetic foot monitoring for R51. On 6/11/24, at 2:50 p.m., Surveyor asked RN (Registered Nurse)-G if diabetic foot checks are completed for residents with diabetes. RN-G replied we check them. Surveyor inquired where this is documented. RN-G informed Surveyor in the TAR (treatment administration record). [...]

Inspectors wroteUNCORRECTED ON REVISIT Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R301 & R51) of 2 Residents during wound care. R301 was on EBP (enhanced barrier precautions). During an observation of wound care on 6/10/24 LPN (Licensed Practical Nurse)-F and CNA (Certified Nursing Assistant)-H did not place on the appropriate PPE (personal protective equipment). LPN-F did not perform appropriate hand hygiene & applied medihoney with her gloved finger. On 6/10/24 LPN-F did not perform appropriate hand hygiene & applied medihoney with her gloved finger during R51's wound observation.

Inspectors wroteBased on record review and interviews, the facility did not provide CPR (cardiopulmonary resuscitation) per a resident directive. This was observed with 1 (R55) of 2 residents reviewed who requested CPR in the facility. -R55 created Advanced Directives documenting the wish to have CPR performed. When staff found R55 pulseless and non-breathing, the facility did not Initiate CPR. R55 was pronounced dead without life-sustaining measures having been implemented. The facility's failure to implement CPR created a finding of immediate jeopardy that began on [DATE]. On [DATE] at 2:12 PM, this Surveyor shared the finding of immediate jeopardy with Nursing Home Administrator-A, (Director of Nurse) DON-B, (Regional Nurse Consultant) RNC-N and RNC-V. The facility had identified the noncompliance and removed and corrected the immediate jeopardy on [DATE]. [...]

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to ensure cold foods were held at an acceptable temperature for 29 of the 29 sampled residents.

Inspectors wroteBased on interviews and record review the facility did not have evidence an allegation of misappropriation of narcotics was thoroughly investigated for 1 (R28) of 1 residents reviewed for misappropriation. A reported allegation of misappropriation of Oxycodone for R28 by a staff nurse the week of 3/18/24 was not thoroughly investigated by the Facility.

Inspectors wroteBased on interviews and record review the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 1 (R28) residents reviewed. Oxycodone was removed from the pharmacy Alixa (contingency) system for R28. There was no record of the medication having been administered.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the diet card for one of 29 sampled residents (Resident (R) 51) included information regarding a physician ordered fluid restriction.

Inspectors wroteBased on observations, interviews and record review the facility did not maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect all residents residing in the facility. After providing cares to residents, staff did not change their gloves or wash their hands and proceeded to touch items and surfaces in the residents rooms. Dirty linen and incontinence products were observed on the floor of resident's rooms. Staff were observed carrying dirty linen and garbage against their body in the hallway. Clean items were observed stored in the soiled linen room and oxygen room. [...]

Inspectors wroteBased on observation, interview, record review, review of a police incident report, and facility policy review, the facility failed to provide one (Resident (R)1) of three sampled residents who were dependent on staff for bed mobility with timely assistance to reposition her in bed in a total sample of seven.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide pain medication in a timely manner, as ordered to one (Resident (R) 3) of three sampled residents reviewed for pain management in a total sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 12 sampled residents (R7). R7 was ordered to have mineral oil applied to his legs daily and then bilateral Velcro wraps applied; however, observation revealed this was not being administered as ordered by the physician.

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT. See SOD for ID: HZ2U11 Based on observation, policy review, and interview, the facility did not ensure food was stored, prepared, and served in accordance with professional standards. This deficient practice has the potential to affect 51 of the 51 residents currently residing in the facility. * The floor behind the steamer & stove was observed with food particles, dirt particles, a french fry, & plastic bag. * The slicer was observed with food particles. * Dietary staff with facial hair were observed not wearing facial hair restraints. * The facility does not have a system to check the internal water temperature in the dish wash machine to ensure the digital reading is correct. * Cook-S did not clean the thermometer with a probe cleaner in between food items. [...]

Inspectors wroteBased on record review and interview, the facility did not always provide orally and in writing, in a language that Residents can understand the notice of rules and services prior to or upon admission. This practice had the potential to affect a pattern of residents who bring in food from outside sources. * The facility does not allow direct care staff to heat or reheat food for residents brought in from outside sources. Although residents have been verbally informed of this rule by staff, this rule is not in writing and is not within the facility's admission agreement. There is no written acknowledgment of resident receipt of this information.

Inspectors wroteBased on interview and record review the Facility did not notify a Resident's representative when there was change of condition or a change and/or new medication involving 1 (R42) of 5 Residents reviewed for notification of a representative. * R42 was receiving hospice care while being a resident at the facility. R42 had received a new order from the facility's Nurse Practitioner for Remeron 15mg (milligrams)/daily related to weight loss. There was no documentation R42's representative was aware of R42's weight loss and the facility did not have documented consent from R42's representative for the use of Remeron.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 (R41) of 1 resident had a Do Not Resuscitate (DNR) order signed by the physician on file at the facility.

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT. See SOD for event: HZ2U11. Based on staff interview and record review, the facility did not ensure a safe environment that was free of accident hazards for 1 of 13 sampled residents (R41.) R41, who was assessed to be at high risk for falls, experienced falls on 11/23/23 and on 12/10/23. The facility did not conduct a root cause analysis regarding these falls by interviewing staff pertaining to the circumstances surrounding these falls. Completing a thorough root cause analysis assists in determining whether current fall prevention interventions were implemented, the effectiveness of them, and in developing fall prevention strategies to prevent the potential for further falls. R41's care plan initiated 11/16/23 indicates R41 needs nectar thick liquids. [...]

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID: HZ2U11 Based on observation and interview, the facility did not provide residents with meals that were palatable and at an appetizing temperature. R1, R9, & R16 expressed dissatisfaction with meals, reporting their food was cold and not cooked properly. A sampled lunch tray on the East unit had temperatures that were not hot. This deficient practice has the potential to affect approximately 11 residents residing on the East Unit.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed (R7) for falls and 2 of 18 residents reviewed (R17 and R33) for thickened liquids. R7 has a diagnosis of unspecified convulsions, a history of multiple falls, and is on anticoagulation therapy. R7 is at a high risk for falls and has had two falls with head injuries. The facility failed to find root causes for every fall for R7 and failed to have an RN assess R7 after several falls. R7's falls resulted in 2 head injuries one requiring staples and another requiring glue. With R7's risk of head injury and potential for brain bleeding with anticoagulant therapy the facility failed to implement robust interventions including offering interventions such as a helmet, to prevent further injury from falls. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure Residents were provided with meals that were palatable and at an appetizing temperature for 6 of 37 (R17, R29, R4, R15, R2, and R13) sampled residents and 3 of 3 test trays. Residents were provided with meals that were palatable and at an appetizing temperature. 3 of 3 Test trays were not palatable. R13 & R4 voiced food concerns. R17 and R29 voiced concerns related to their hot meals being served at undesirable/cold temperatures. RR P (Resident Representative) and RR Q voiced concerns regarding R2 and R15 receiving their hot meals at an undesirable/cold temperature R1 voiced concerns of receiving cold food trays. Surveyor observed the facility staff not use the facility plate warmer for resident meals. Facility staff indicated they don't use the plate warmer and are not sure if it is functioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 54 residents who reside in the facility. -Surveyor observed 2 staff serving food without having their hair restrained. -Surveyor observed milk being served past the best by date and milk removed from original carton with no sell by date. -Surveyor observed 3 uncovered garbage cans that were not in use, near uncovered food or in food preparation area. -Surveyor observed scoops lying in contact with food in storage bins. Evidenced by: Example 1: Facility policy, entitled Personal Hygiene, undated, includes: . if hair is long and not covered properly with a cap, a hairnet must be worn . USDA Food Code, 2022, includes, in part: . Hair Restraints . 2-402.11 Effectiveness . [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that garbage is disposed of properly, this has the potential to affect the census of 54. R29 voiced concerns related to the overflowing dumpsters in the facility parking lot. Surveyor observed facility's dumpsters to be overflowing with garbage and having garbage bags sitting on the ground around the dumpster. This is evidenced by: On 10/10/23 at 9:04 AM, Surveyor observed dumpsters in facility parking lot behind the facility were full to the top with several bags of garbage sitting around the dumpster on the ground. On 10/10/23 at 9:30 AM Surveyor observed the facility's dumpster, located in the parking lot behind the facility, to be overflowing with garbage coming out of the top propping up the dumpster lids. Surveyor also observed about 20 garbage bags full of garbage to be sitting on the ground around the dumpster. [...]

Inspectors wroteBased on observation, interview and record review the facility did not provide a safe, clean, comfortable, and homelike environment for 10 of 37 residents (R24, R17, R29, R2, R25, R4, R8, R20, R1, R7). R24, R17, R29 voiced concerns of their rooms being unclean. Surveyor observed these rooms to be unclean. RR P (Resident Representative) voiced concerns of R2's room not being clean. RR U voiced concerns of the cleanliness of R25's room. Surveyor and HD CC (Housekeeper Director) observed R4's room to be unclean. R8's tray table was observed to be sticky with an unknown substance. R20 voiced concerns of her bedside table being sticky. R1 is part of filed complaint that she does not get help to unpack and her belongings are still in the same boxes. R7's room was not home like as it had multiple cardboard boxes stacked. Evidenced by: The facility's housekeeping checklist, undated, includes: 7: [...]

Inspectors wroteBased on interview and record review, the facility did not follow their grievance process for 6 of 37 Residents (R13, R4, R2, R24, R1, R15). R1 and R24 voiced concerns to Receptionist Y related to needing help, long call light wait times and not having enough staff. Receptionist Y did not follow the facility grievance process related to these concerns. R24 voiced concerns to CNA/MT Z (certified nursing assistant/medication tech) related to care provided by CNA F. CNA/MT Z did not report this to anyone and did not fill out a grievance form for R24. RR P (Resident Representative) voiced concerns related to R2 to staff who recorded these concerns in progress notes. The facility failed to follow up on RR P's concerns and communicate with her on a resolution. RR BB and RR Q voiced concerns related to staff treatment, call light wait times, and staff refusing to care for R15 without follow up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure sufficient staff were present to provide nursing and related services to assure they met resident needs in a safe manner to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 12 of 37 sampled residents (R20, R6, R1, R37, R4, R17, R2, R15, R34, R25, R24, and R29). R20 sat in a soiled brief of stool and urine for approximately 14 hours and has concerns with staffing in relation to toileting and call light times. R6 has concerns with staffing in relation to toileting. R1 has concerns with staffing in relation to toileting, showers, and call light times. R37 soiled himself and waited 2 hours to be changed. Surveyor observed R37 repeatedly calling out, Help me, help me. Surveyor notified staff of the situation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater during medication administration. This affected 4 of 4 residents (R1, R20, R35, and R36) observed for medication pass. R1 was administered medication outside the ordered scheduled time window making the medication error a timing error. R20 was observed having her medication administered outside the ordered scheduled time window making the medication error a timing error. R35 was observed having his medication administered outside the ordered scheduled time window making the medication error a timing error. R36 was observed having her medication administered outside the ordered scheduled time window making the medication error a timing error. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review the facility did not provide food prepared in a form designed to meet individual needs for 5 of 5 sampled residents (R30, R10, R17, R31, and R14). R30 received the wrong diet/texture. R10 received the wrong diet/texture. R17 received the wrong diet/texture. R31 received the wrong diet/texture. R14 received the wrong diet/texture. This is evidenced by: Example 1 R30 was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis. R30's physician ordered diet is: Dysphagia 2, No added salt, Controlled carbohydrate, thin liquids ground meats, extra sauce/gravy. Soft foods and easy to chew. R30's meal ticket states in part; Dysphagia 2, No added salt, Controlled carbohydrate, thin liquids ground meats, extra sauce/gravy. Soft foods and easy to chew. [...]

Inspectors wroteBased interview and record review, the facility did not ensure therapy services were provided for 4 of 4 residents (R3, R25, R26, R27) reviewed for therapy services. R3 was admitted with Physician orders for Physcial therapy. THe facility failed to provide Therapy per Physician Orders. R25, R26, and R27 had Physician Orders for Physical Therapy. The facility failed to provide Physical Therapy per Physician Orders in house and failed to seek other ways of providing this service to residents. The facility continued to admit residents with orders for Physical Therapy when they could not provide services. Evidenced by: Facility Policy, entitled Rehabilitation Department Procedures, undated, includes, in part: Policy: Screen of a resident's condition is a necessary component of providing consistent quality of care . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that every resident was treated with dignity and respect when entering a resident's private space for 2 of 2 residents (R20 and R1) reviewed. Surveyor observed staff entering R20's room without knocking on her door. Surveyor observed staff entering R1's room without knocking on her door. This is evidenced by: Example 1 R20 was admitted to the facility on [DATE] with diagnoses that include: acute and chronic respiratory failure with hypoxia (low levels of oxygen), seizures, major depressive disorder (a severe and persistent low mood, profound sadness, or a sense of despair), dependence on supplemental oxygen, and intervertebral disc degeneration in the lumbar region (the wear and tear of the intervertebral discs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 2 of 2 (R1 and R22) residents. R1 was observed with a clear medication cup of her morning medications on her bedside table while she was sleeping. R22 was observed to have medication on her bedside tray and in her closet without a physician's order. This is evidenced by: The facility's policy titled Medication Administration-Preparation and General Guidelines, revision dated 10/17, states in part: . B. Administration . 14. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications . 18. The resident is always observed after administration to ensure that the dose was completely ingested . [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain personal privacy for 1 one 1 (R35) reviewed for confidential personal medical records. Surveyor observed the facility's demographic screen on a medication cart in the hallway without staff presence. Surveyor observed R35's Medication Administration Record (MAR) on an open computer located on the medication cart in the hallway. Evidenced by: The facility's policy titled Medication Administration-Preparation and General Guidelines, revision dated 10/17, states in part: . B. Administration . 16. During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident is properly assessed for the use of physical restraints for 1 of 1 resident (R7) reviewed for restraints. R7 has a seatbelt in his wheelchair due to his diagnosis of seizures. The facility did not assess R7's seatbelt for being used as a potential restraint. This is evidenced by: R7 was admitted to the facility on [DATE] with diagnoses that include, in part: Unspecified convulsions, traumatic brain injury, atrial fibrillation (irregular heart beat), cognitive communication deficit, and schizophrenia. R7's most recent quarterly Minimum Data Set (MDS) dated [DATE] documents the following, in part: Section C: A Brief Interview for Mental Status (BIMS) of 2, indicating R7 has a severe cognitive impairment. Section G: . locomotion on and off unit 1/2 (Supervision/1 person physical assist) .mobility device: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, this affected 3 of 5 residents reviewed for wounds (R8, R17, R29) and 1 of 37 sampled residents for provider communication (R5). The facility failed to provide communication with R5's Managed Care Organization (MCO). R8 did not have an initial assessment of her wounds on admission and Surveyor observed multiple poor hand hygiene opportunities during wound care. R17 has wounds to her left leg. RN C (Registered Nurse) did not perform hand hygiene or glove changes at the appropriate times, did not use a barrier under R17's wounds, and did not sanitize her scissors appropriately after wound care. RN C applied the wrong treatment to all of R17's wounds. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Residents are free of significant medication errors, for 2 of 37 resident's reviewed for significant medication errors (R18 and R36). On 9/29/23 the facility prepared R18's Medication Release/Receipt from 9/30/23-10/3/23. The facility transcribed R32's medication orders as R18's medication orders. These medications include the following: Famotidine 20 mg (milligrams) (indigestion), Allopurinol 300 mg (gout), Sertraline 50 mg (depression, obsessive-compulsive disorder, pottraumatic stress disorder, social anxiety and panic disorder), Clozapine 25 mg (schizophrenia), Gabapentin 100 mg (epilepsy and nerve pain), Gabapentin 300 mg. The medication error for Clozapine and Gabapentin are significant medication errors. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility did not provide special assistive eating equipment for 3 of 3 sampled residents (R10, R21 and R32) reviewed for assistive devices. The facility did not provide R10 with a lipped plate (raised plate edges to aid in self-feeding) as indicated per plan of care. The facility did not provide R21 with built up silverware and mug with lid and handle as indicated per plan of care. The facility did not provide R10 and R32 and with a lipped plate (raise plate edges to aid in self-feeding) as indicated per plan of care.

Inspectors wroteBased on observation, interviewt, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment during 2 out of 9 hand hygiene opportunities observed. This affected 2 of 37 sampled residents (R13 and R20). Staff did not complete hand hygiene multiple times during R13's wound care observation and washed scissors used for wound care with soap and water. A Certified Nursing Assistant (CNA) was observed not following hand hygiene procedures during R20's peri care. This is evidenced by: The facility policy entitled, Hand Hygiene, undated, states in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . [...]