Rowntree Gardens

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 7 and 36) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure the monitoring for Resident 7's behavior for the use of the divalproex (anticonvulsant medication used to manage bipolar disorder) and escitalopram (antidepressant) medications were specific. * The facility failed to ensure the monitoring for Resident 36's behavior for the use of aripiprazole (antipsychotic medication) was specific and consistent to the resident's diagnosis. This failure had the potential for Residents 7 and 36 to experience potential harm from adverse consequences and a significant decline in functioning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided as per the physician's order to prevent a decline in ROM (range of motion) functions for one of two final sampled residents (Resident 41) reviewed for range of motion. * The facility failed to follow a physician's order to apply the PRAFO boot (a specialized medical brace that stabilizes the ankle and foot, primarily to prevent and treat heel skin breakdown (ulcers) by keeping the heel elevated and offloaded, while also managing conditions like foot drop, contractures, and neurological deficits) to Resident 41's left foot when in bed. This failure had the potential for Resident 41 to sustain a decline in ROM functions.

Inspectors wroteBased on interview, facility P&P review, and facility document review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for the residents. * The facility failed to conduct the staff competency check for the use of PureWick external catheter (a non-invasive device for managing urinary incontinence). This failure placed the residents at risk for unsafe practices and adverse outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the NPI (nonpharmacological intervention) was implemented for three of five final sampled residents (Residents 7, 10, and 36) reviewed for unnecessary medications. * The facility failed to ensure the licensed nurses implemented the NPI and documented its effectiveness for Resident 7's observed behaviors related to the use of the divalproex (anticonvulsant medication) and escitalopram (antidepressant) medications. * The facility failed to show documentation for NPI for Resident 10's use of the Depakote (medication for mood stabilizer), quetiapine (medication to control aggressive behavior), bupropion (antidepressant medication), and buspirone (antianxiety medication). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment were kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. * The facility failed to ensure the food was past the use-by date were discarded. * The facility failed to ensure the food brought from outside was properly labeled and stored as per the facility's P&P. * The facility failed to ensure a food preparation sink had an air gap for back flow prevention. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 42 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from January 2025 through November 2025. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement the antibiotic stewardship program in accordance with their P&P. * The facility initiated McGeer's criteria after the residents' physician prescribed antibiotics rather than attempting to make the determination whether a resident who exhibited signs and symptoms of infection, had met McGeer's criteria before contacting the physician. This failure posed the risk for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure accommodation of needs for one final sampled resident (Resident 43) reviewed for accommodation of needs. *The facility failed to ensure Resident 43's bed controller (used to reposition the bed) was within reach. This failure placed the resident at risk for not having her needs met.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 13 final sampled residents (Resident 2). * The facility failed to implement the care plan for the safe storage of Resident 2's nasal cannula. Resident 2's nasal cannula was observed lying directly on top of the oxygen concentrator. This failure posed the risk for Resident 2's nasal cannula to become contaminated with pathogens, which posed the risk for infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three residents (Resident 51) reviewed for closed records. * The facility failed to ensure Resident 51 was administered the budesonide (steroid medication) medication as per the physician's orders and failed to notify the physician when the medication was not available for administration to Resident 51. Resident 51 was transferred to the acute care hospital. These failures had the potential for Resident 51 to not receive the necessary care and services to maintain the highest physical well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 26) reviewed for falls were provided the necessary services after a fall. * The facility failed to ensure Resident 26's fall risk evaluation was completed accurately after Resident 26 had a fall on 11/19/25, and failed to monitor Resident 26 for episodes of getting out of bed, as per the care plan. These failures had the potential risk of inaccurate fall risk score, the failure to implement the appropriate fall risk interventions, and risk of injury for Resident 26.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility to provide the necessary respiratory care for two of two final residents reviewed for respiratory care (Residents 2 and 22). * The facility failed to obtain a physician's order for the administration of oxygen and failed to ensure the nasal cannula was stored in a sanitary condition, for Resident 2. * The facility failed to ensure Resident 22's nasal cannula was stored in a sanitary condition. These failures posed the risk for the residents' oxygen equipment to become contaminated with pathogens and had the potential to negatively impact the residents' medical condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 5 and 10) reviewed for pain management. * The facility failed to ensure Resident 5 received the appropriate intervention for pain, when a pain level of 5 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) was reported and stronger pain medication meant for severe pain level of 7-10 was administered to the resident. * The facility failed to ensure the NPI (nonpharmacological intervention) was provided and documented prior to Resident 10 receiving a pain medication. These failures had the potential to put Residents 5 and 10 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility P&P for one of ten residents (Resident 43) reviewed for pharmacy services. * The facility failed to ensure Resident 43's new order for levetiracetam (antiseizure medication) oral solution was obtained from the pharmacy in a timely manner. (The pharmacy was notified at approximately 0800 hours and the medication was obtained at approximately 1430 hours). * The facility failed to transcribe Resident 43's physician's order for levetiracetam accurately. The physician ordered levetiracetam 1000 mg oral solution medication to be administered twice daily, however, the LVN transcribed the order in error, indicating the levetiracetam 1000 mg oral solution medication was to be administered once daily. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for three of 13 final sampled residents (Residents 10, 29, and 43). * The facility failed to ensure the episodes of crying spells documented on the MAR were accurate for Resident 10. * The facility failed to ensure the skin assessment was documented accurately to reflect the bruising identified for Resident 29. * The licensed nurse documented Resident 43 received levetiracetam (antiepileptic mediation) 1000 mg tablet orally on 12/10/25 at 0900 hours, however, Resident 43 had refused the medication. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the plan of care for one of 13 final sampled residents (Resident 36) was revised to address the resident's specific care needs. * Resident 36's care plan addressing the episodes of bladder and bowel incontinence was not revised when the resident was determined as not a candidate for B&B (bowel and bladder) retraining or toileting program. This failure posed the risks for the resident to not receive the care and services required to attain or maintain the highest level of physical and mental well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to send the required discharge referral documents to the HHA for one of three sampled residents (Resident 1). This failure resultedin Resident 1 not receiving the ongoing care needs.

Inspectors wrote3. Medical record review for Resident 10 was initiated on 10/22/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 9/12/24, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 10's Order Summary Report dated October 2024 showed a physician's order dated 9/11/24, for bilateral 1/4 side rails up when in bed as enabler for bed mobility. Further review of Resident 10's medical record showed no documented evidence the side rail entrapment assessment was completed prior to the use of side rails. On 10/22/24 at 0907 hours, Resident 10 was observed laying in bed with bilateral upper 1/4 side rails elevated. 4. Medical record review for Resident 23 was initiated on 10/22/24. Resident 23 was admitted to the facility on [DATE], and readmitted back to the facility on 9/25/24. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the expired food was discarded. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The ice machine was not clean. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for 13 of 13 residents observed with bed rails (Residents 6, 8, 10, 14, 15, 23, 30, 35, 37, 38, 41, 545, and 602). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one nonsampled residents (Resident 545). * The facility failed to ensure the call light was within reach and accessible for Resident 545. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for one of 13 final sampled resident (Resident 35) and one nonsampled resident (Resident 37). * The facility failed to develop a care plan problem to address Resident 35's use of antibiotic for UTI. * The facility failed to ensure a care plan problem was developed to address the risk of infection prevention and control related to education for Resident 37 and family member to provide the PureWick catheter supplies in a timely manner and cleaning of the collection canister, collector, and pump tubing. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury and promote healing of existing pressure ulcer for one of one final sampled resident (Resident 41) reviewed for pressure injury. * Resident 41 developed a Stage 3 pressure injury to the coccyx after admission to the facility. The facility failed to ensure Resident 41 was provided with high protein snacks at bedtime as recommended by the RD. In addition, LVN 3 failed to provide protective barrier to protect the wound during wound care per facility P&P. These failures posed Residents 41 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent urinary tract infections for two of three sampled residents (one final sampled resident, Resident 41; and one nonsample resident, Resident 37) reviewed for urinary catheter care. * The staff failed to ensure proper monitoring and care for Resident 37's Pure Wick collection canister. Resident 37's Pure Wick collection canister was observed to have dry, dark green residue. * The facility failed to ensure Resident 41's indwelling urinary catheter drainage bag was positioned below the resident's bladder and prevent tugging of the catheter for adequate urinary drainage and resident discomfort. Resident 41's indwelling urinary catheter tubing was observed on the floor under the resident's bed. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of seven final sampled residents (Residents 38) reviewed for respiratory care was provided the appropriate respiratory care. * The facility failed to ensure Resident 38's storage bag for the Yankauer suction tip was changed weekly. This failure had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the specific competencies and skill sets necessary to care for the residents' needs. * The facility failed to ensure the Certification of Infection Preventionist Training Course was updated for the DSD/Acting IP. * The facility failed to ensure the nursing staff' competency on how to care for Resident 37's pure wick canister, collector and tubing. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration as evidenced by: * The facility failed to ensure administration of the controlled medications for one nonsampled resident (Resident 42) was accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. This failure had the potential for medication administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes).

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 8%. One licensed nurses (LVN 1) observed administering the medications was found to have errors while administering the medications to two nonsampled residents (Residents 11 and 29). * The facility failed to ensure Resident 11 received the prescribed eye drops and in accordance with the facility's P&P. * The facility failed to ensure Resident 29 received the prescribed medication with food as ordered by the physician. These failures had the potential for the residents developing complications and ineffective therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to dispose of the prescription medications as nitroglycerine tablets in Medication Cart A. * The facility failed to store the external and internal medications separately. *The facility failed to accurately monitor the Glucose Quality Control of the glucometer in Medication Cart A. * The facility failed to disposed of the opened sterile dressings, expired dressings, indwelling catheters in the treatment cart. *The facility failed to appropriately label multiple ointments with open date. * The facility failed to ensure accuracy and complete records in the facility's Medication Room temperature log and Medication Refrigerator temperature log. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to follow the food preferences for one nonsampled resident (Resident 25) observed during the dining observation. * The facility failed to ensure Resident 25 received a chocolate shake as shown on the meal ticket as the preferred drink. This failure had the potential to affect the resident not receiving food as per their preference.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the facility's P&P for the resident's food brought by the visitors was followed. * The facility failed to show evidence of safe food handling instructions provided to the residents' family or visitors bringing food to the resident from outside. * The facility failed to ensure the resident refrigerator was clean. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure infection prevention and control program were maintained per facility's P&P as evidence by: * The facility failed to ensure the clean linen folding table in the laundry was free from personal items. * The facility failed to ensure LVN 2 completely wipe off the entire BP cuff, pulse oximeter, and thermometer prior obtaining one nonsampled resident's (Resident 595) vital signs who was on EBP observed during the medication administration. * The facility failed to ensure LVN 2 performed hand hygiene before and after removing gloves prior to changing to new pair of gloves during the medication administration for one final sampled resident (Resident 38), who was on EBP. These failures had the potential to cause safety hazards and the spread of infection to staff and residents.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for four sampled residents (two final sampled residents, Residents 23 and 30; and two nonsampled residents, Residents 9 and 397). * The facility failed to assess for the McGeer's criteria for Residents 9, 23, 30 and 397 with prescribed antibiotics in the month of September. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to promote the dignity and respect for one of 13 final sampled residents (Resident 3). * Resident 3 was observed waiting for someone to assist him to eat his meals and CNA 3 was standing over Resident 3 while assisting the resident to eat his meal. This failure posed the risk of not treating the resident with respect.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 to one nonsampled resident (Resident 22) reviewed for beneficiary notification. The SNF ABN Form CMS-10055 was used to inform the residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. This failure had the potential for not allowing Resident 22 to make an informed decision regarding their Medicare services.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper hand washing was performed when preparing food. * The facility failed to ensure the wiping cloths used to sanitize the kitchen surfaces were stored in the sanitizing solution. * The facility failed to ensure the use of a cool down procedure for Time/Temperature Control for Safety Foods for the food that required time and temperature controls to limit the growth of pathogens. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer was properly labeled. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the use hair restraints was implemented to the dietary staff working in the kitchen. [...]

Inspectors wroteBased on interview, medical record, facility P&P review, and facility document review, the facility failed to ensure the staff provided care and promoted dignity and respect for one of 14 final sampled residents (Resident 16) and one nonsampled resident (Resident 7). * CNA 1 was observed going into Rooms A, B, C, and D without knocking during a dining observation. * RNA 1 was observed assisting Residents 7 and 16 with meals at the same time. RNA 1 was also observed standing over Resident 16 while assisting the resident with meals. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to determine if it was safe for one nonsampled resident (Residents 405) to self-administer the medications. * Resident 405 was observed with a cup containing several Lactaid (enzyme supplement) medication at bedside. Resident 405 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medications. This had the potential for Resident 405 to administer medications inaccurately.

Inspectors wroteBased on interview and medical record review, the facility failed to maintain a copy of the resident's advance directives in the medical record for one of 14 final sampled residents (Resident 40). This had the potential for Resident 40's decisions regarding her healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the transfer to the acute care hospital for one of three closed record sampled residents (Resident 50). This failure had the potential of not providing Resident 50 with access to an advocate who could inform them of their options or rights related to transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to show an accurate assessment that represented an accurate picture of the residents' status during the observation period of the MDS for one of 14 final sampled residents (Resident 28). This failure had the potential for Resident 28's care needs not being met.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 38) on hospice services attained and maintained the highest practicable well-being. * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visits. This had the potential of a delay in hospice care regarding changes in Resident 38's condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the equipment utilized to provide oxygen and nebulizer treatments for three of the 14 final sampled residents (Residents 5, 28, and 403) and four nonsampled residents (Residents 8, 17, 20, and 25) were changed and/or labeled in accordance with the facility's P&P. * The facility failed to ensure Resident 5's nasal cannula and nebulizer mask were labeled with the date when they were changed. * The facility failed to ensure Resident 17's nasal cannula was labeled with the date when it was changed and failed to ensure Resident 17's oxygen concentrator humidifier bottle and plastic bag were changed every seven days as per the facility's P&P. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide appropriate pain management for one of 14 final sampled residents (Resident 40). * The facility failed to ensure Resident 40 was administered her pain medication promptly after Resident 40 complained of severe pain to her right lower back. The licensed nurses failed to dispense the pain medication which was available in the facility's emergency kit (contains a small quantity of medications that can be dispensed when pharmacy services are not available). This failure resulted in Resident 40's pain left unmanaged and feeling helpless for not receiving her pain medication to manage her severe pain.

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to provide the necessary care for one of 14 final sampled residents (Resident 32). * The facility failed to ensure Resident 32's medication and supplement were administered as ordered by the physician on the days the resident left the facility for dialysis (a process of purifying the blood of a person whose kidneys are not working normally). This had the potential for Resident 32 not getting the appropriate doses of medication and supplement as ordered, resulting in health complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 14 final sampled residents (Residents 14 and 40). * Resident 40 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. * Resident 14 who had bilateral 1/4 (quarter) side rails in bed was not assessed for risk for entrapment. This failure posed the risk for injury for Residents 14 and 40 from side rail use.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 43) and three nonsampled residents (Residents 9, 11, and 30). * Resident 43's Tramadol (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 43's MAR. * Resident 9's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Medication Count Sheet did not match Resident 9's MAR. * Resident 11's hydrocodone-acetaminophen Controlled Medication Count Sheet did not match Resident 11's MAR. * The facility failed to ensure Resident 30's biotin (a supplement) was administered as ordered by the physician. These failures posed the risk for diversion of controlled medications and possible health complications due to not administering a medication as prescribed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 32) was free from the significant medication errors when the facility failed to administer Resident 32's Brilinta (a blood thinner medication to prevent stroke, heart attack, and other heart problems) during dialysis (a process of purifying the blood of a person whose kidneys are not working normally) days and failed to ensure a physician's order was obtained to hold or reschedule the blood thinner medication as ordered on dialysis days. This failure had placed Resident 32 at risk for medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to store and label the medications properly and failed to discard the expired supplies. * Medication Cart 1 had two opened and unlabeled Chloraseptic spray bottles (a medication to treat sore throat or mouth) without resident's name and/or room number. This had the potential for the medication to be used for other residents. * The facility failed to store Resident 17's artificial tears bottle (a medication to treat dry eyes) in a safe manner. This had the potential for the medication to be used for other residents. * Medication room [ROOM NUMBER] drawer had expired port-a-cath needles. This had the potential for use of expired supplies.

Inspectors wroteBased on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree recipes were followed during the puree procedure of the residents food. This failure posed the risk for the inconsistent puree product which could alter the quality and nutrient content of the puree food for seven of 49 residents who received a puree diet.

Inspectors wroteBased on observation, interview, facility P&P, and facility document review, the facility failed to ensure the puree food was prepared to preserve nutritive value as evidenced by: * Excess water and thickener were added to the puree vegetables. * Puree vegetables were cooked more than three hours prior to meal service and held in a hot oven. These failures posed the risk for not meeting the nutritional needs of seven residents who received a puree diet.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the entree substitutes offered were of equal nutritive value when grilled cheese sandwiches were not equal in protein content to the main entrée. This failure had the potential of not meeting the resident's nutritional needs.

Inspectors wroteBased on interview and facility document review, the facility failed to implement their Quality Assessment and Assurance (QA&A) plan of action. There was no documentation to show the facility was monitoring the effects of the corrective action plans to identify if they had achieved and sustained the improvement for the repeated deficient practices cited at F698 and F812 in accordance with their POC for an abbreviated survey completed on 12/9/19. This had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene during wound care treatment for Resident 28. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when three dusty fans were in use in the clean linen area and empty water bottle was in the clean linen area. * The facility failed to ensure RNA 1 performed hand hygiene when assisting meals between two residents (Residents 7 and 16). * The facility failed to ensure the pads used on the bed side rails for one of 14 residents (Resident 403) were cleanable and were not porous, torn and frayed. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death.