Sandy Health and Rehab

Inspectors wroteBased on interview and record review it was determined, for 2 of 41 sample residents, that the facility did not provide the residents with the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have ready and reasonable access to those funds. Resident identifiers: 30 and 295.

Inspectors wroteBased on interviews and observation, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, the shower rooms were in disrepair and one shower room was malodorous. Resident identifier: 37, 46 and 89.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature. Specifically, for 14 out of 41 sample residents, salad was not kept at the correct temperature while serving tray line, residents complained of food quality, a test tray not attractive or palatable and resident council minutes and grievance forms revealed complaints of food quality. Resident identifiers: 2, 7, 18, 21, 30, 33, 46, 49, 60, 66, 89, 70, 73, and 145.

Inspectors wroteBased on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was offered the influenza, pneumococcal, and the coronavirus disease 2019 (COVID-19) vaccines. In addition, residents that accepted the vaccines did not have those vaccines administered. Specifically, for 3 out of 5 sample residents, two residents had signed consent forms where they had accepted to receive the 2024/2025 COVID-19 booster, and the booster was not administered. In addition, one resident did not have documentation that they were offered vaccines for the 2024/2025 season. Resident identifiers: 4, 28, and 55.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 41 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident had a delay in getting sutures removed. Resident identifier:

Inspectors wroteBased on interview and record review it was determined. for 1 out of 41 sample residents, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier:

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, for 1 out of 41 sample residents, a resident's x-ray report was not located in the medical record. Resident identifier:

Inspectors wroteBased on observation, interview, and record review it was determined that, for 1 of 41 sample residents, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences. Specifically, a resident was provided food that was listed as an allergy. Resident identifier: 46.

Inspectors wroteBased on observation and interview, it was determined that the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities. Specifically, the 200 and north 300-hall shower rooms each had one call light that did not work and there were no cords attached to the call lights in the 100, 200, and north 300-hall shower rooms. Resident identifier: 46. On 4/14/25 at 1:17 PM, an interview was conducted with resident 46 and she stated that the 300-hall shower room's call light did not work and that she could get stuck in the shower.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 28 sampled residents, one resident eloped from the facility and sustained 2nd and 3rd degree burns. Additionally, another resident was found outside the facility doors while wearing a wander guard. Resident Identifiers: 10 and 26. Findings Included: 1. Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of left side hemiplegia, epilepsy, bipolar type schizoaffective disorder, cognitive communication deficit, burn of second degree of lower back, burn of second degree of buttock, burn of third degree of lower back, and personal history of traumatic brain injury. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 of 28 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident did not receive treatment to a right foot full thickness laceration and another resident's wounds had no documented measurements. Resident Identifiers: 15 and 26.

Inspectors wroteBased on observation and interviews, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, black spots were observed in the resident showers. Findings Included: On 8/13/24 at 12:10 PM, an observation was made of the 200-hall resident shower room. Black spots were observed on the lower corner base board left of the shower entrance. On 8/13/24 at 11:50 AM, an interview was conducted with Housekeeping (HK). HK stated the certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms. HK stated the certified nursing assistants were given the supplies to clean the shower rooms. HK stated they only cleaned resident room and resident common areas. On 8/13/24 at 2:06 PM, an interview was conducted with CNA 1. [...]

Inspectors wroteBased on interview and record review, it was determined that for 1 of 28 sampled residents, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility did not have evidence that the violations were thoroughly investigated. Specifically, an allegation of neglect was not thoroughly investigated to determine if neglect had occurred. Resident identifier: 7.

Inspectors wroteBased on interview and record review, it was determined that for 2 of 28 sampled residents the facility did not ensure that the residents were free from significant medication errors. Specifically, a resident was not administered antibiotics as ordered that resulted in a treatment of an autolytic debridement and prophylactic medications were not administered to a resident who had 3rd degree burns to her buttocks and back. Resident identifiers: 15 and 26.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were 2 freezers in the kitchen that did not maintain appropriate temperatures to keep food items frozen. These findings resulted in immediate jeopardy. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (Admin 2), Administrator (Admin 1), and a the Director of Leadership Development (DLD) on 7/30/23 at 12:56 PM. [...]

Inspectors wroteBased on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a resident was forced to do Activities of Daily Living (ADL's), a male resident did not have the mental capacity to consent prior to moving in with a female resident, a resident was transferred inappropriately resulting in a femur fracture, and a Certified Nursing Assistant (CNA) was allowed to work with a specific resident after the CNA caused the resident to fall. This resulted in a finding of HARM for 3 residents. Resident identifiers: 16, 20, 22, 44 and 78.

Inspectors wrote7. Resident 35 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, weakness, and repeated falls. Resident 35's medical record was reviewed from 7/30/23 through 8/16/23. A Minimum Data Set (MDS) assessment dated [DATE] documented, resident 35 required a one person extensive assistance for transfers including to or from: bed, chair, wheelchair, standing position. A care plan dated 2/13/23, a focus care area documented Resident is at risk for falls r/t (related to) impaired mobility, altered ADL (activities of daily living) ability, advanced age, EOL (end of life) process. A goal developed was Resident shall be free from injury daily. Interventions: a. 2/13/23 Assist with ADL's PRN (as needed). Evaluate physical abilities at least qtrly(quarterly), fall risk assess upon admission and qtrly and prn. [...]

Inspectors wroteBased on interview, record review, and observation, multiple system failures were identified during the survey, and the facility was found to be in non-compliance at a harm level with F600, F644, F679, F686, F689, F692, F726, F742; and F812 at an Immediately Jeopardy level, indicating substandard quality of care. Resident identifiers: 16, 18, 20, 22, 35, 39, 40, 44, 49, 50, 51, 54, 62, 65, 78, 88, 156, and 158.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, and act on available data to make improvements. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of prevention of accident hazards, develop and or implement comprehensive care plans, provide activities of daily living (ADLs) care for dependent residents, maintenance of nutrition, label and store drugs and biologicals, maintaining identifiable information in the resident records, infection prevention, and Food storage. Resident identifiers: 16, 18, 20, 22, 35, 39, 40, 44, 49, 50, 51, 54, 62, 65, 78, 88, 156, and 158.

Inspectors wroteBased on interview and record review, it was determined for 1 of 68 sampled residents, the facility did not incorporate the recommendations from the Pre-admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for this deficiency were determined to have occurred at a harm level. Resident identifier: 62.

Inspectors wroteBased on observation, interview and record review it was determined, 6 out of 68 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, residents complained about not having activities, observations were made of less than 10 residents per activity, and one on one activities were not being provided. The findings for one resident were determined to have occurred at a harm level. Resident identifiers: 16, 20, 49, 51, 54 and 62.

Inspectors wroteBased on interview, observation and interview, the facility did not ensure that for 2 of 68 sample residents without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed a pressure ulcer during his stay, and did not receive timely skin checks or wound treatments. The findings for this resident were determined to have occurred at a harm level. In addition, a resident was not repositioned appropriately. Resident identifiers: 65 and 158.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 4 of 68 sampled residents maintained acceptable parameters of nutritional status. Specifically, residents experienced weight loss and pressure sores without timely and appropriate interventions. This will be cited at a harm level for resident 65. In addition, residents were not provided interventions to prevent weight loss further weight loss. Resident identifiers: 16, 44, 65 and 88.

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 of 68 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, facility staff transferred a resident who required a two person physical assist resulting in a femur fracture. Also, a resident who sustained a fall was not assessed by the nurse or monitored after the fall. The findings for resident 22 were determined to have occurred at a harm level. Resident identifier: 18 and 22.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with a mental disorder or a psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practical mental and psychosocial well-being. Specifically, a resident with suicidal ideation and a Pre-admission Screening Resident Review (PASRR) Level II evaluation identified that a resident needed mental health services and the facility did not arrange for those services. The findings for resident 62 were found to have occurred at a harm level. Resident identifier: 62.

Inspectors wroteBased on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility shower rooms were dirty; the temperature in a resident's room was repeatedly below 71 degrees Fahrenheit (F); the exit door to the resident smoking area would not open without getting caught on the sidewalk resulting in an injury to a resident; the wheelchairs were in disrepair for two residents; areas of the facility were dirty and in disrepair; and the paint, nightstands and clothing wardrobes in numerous rooms in the 200 and 300 hallways were in disrepair. Resident identifiers: 16, 27, 40, 50, 51, 54 and 88.

Inspectors wrote2. Resident 31 was admitted to the facility on [DATE] with diagnoses that included COVID-19, viral pneumonia, chronic kidney disease stage 4, dementia, depression and acute respiratory failure. Resident 31's medical record was reviewed from 7/30/23 through 8/16/23. On 7/31/23 at 11:30 AM, an interview was conducted with resident 31's wife. Resident 31's wife stated that since resident 31 was admitted , 4 pair of pants, 7 pairs of socks, and multiple shorts and shirts had gone missing. Resident 31's wife stated that the resident's name had been put inside his clothing to prevent it from being lost. Resident 31's wife stated that she had informed multiple CNAs, but the CNAs looked but can't find the missing items. Resident 31's wife stated she had not been offered to fill out a grievance form for the missing items. [...]

Inspectors wroteBased on interview and record review it was determined, for 9 out of 68 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Specifically, allegations of verbal and physical abuse were not reported to the State Survey Agency (SSA) within the 2 hour timeframe. Resident identifiers: 4, 12, 22, 29, 38, 51, 54, 78 and 157. Findings Include: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included seizures, dementia in other diseases, type 2 diabetes mellitus, persistent atrial fibrillation, gastroesophageal reflux disease and depression. The exhibit 358 revealed that staff became aware of an incident on 7/14/23 at 1:50 PM. [...]

Inspectors wroteb. Resident 38 was admitted to the facility on [DATE] with diagnoses which included other specified arthritis multiple sites, bipolar disorder, anxiety disorder, borderline personality disorder, unspecified dementia, post-traumatic stress disorder, polyneuropathy, and presence of right artificial hip joint. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 38 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Resident 38's medical record was reviewed 7/30/23 through 8/16/23. On 7/31/23 at 11:53 AM an interview was conducted with resident 38. Resident 38 stated when she is out smoking, she has issues with another resident 54. Resident 38 stated she goes out during supervised smoking times, but she still feels bullied by resident 54. On 8/10/23 at 9:39 AM a follow-up interview with resident 38 was conducted. [...]

Inspectors wrote2. Resident 21 was admitted to the facility on [DATE] with diagnoses which included myocardial infarction, failure to thrive, depression, left ventricular failure, asthma, vascular dementia, and obstructive sleep apnea. Resident 21's medical record was reviewed on 7/30/23 - 8/16/23. On 7/30/23 at 12:03 PM, an interview was conducted with resident 21. Resident 21 stated she didn't feel like her CPAP machine was working correctly. Resident 21 stated she had asked for filters so she cold change them out but she hadn't gotten any from the facility. Resident 21 stated they don't clean her CPAP machine or tubing and she stated she just hasn't had the time to do it. On 7/30/23 at 12:05 PM, an observation was made of no date or time on the CPAP machine or tubing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined, for 3 of 68 sampled residents the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, three residents did not receive assistance with showers. Resident identifiers: 12, 40 and 45.

Inspectors wroteBased on interview and record review, for 3 of 68 sampled residents, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, dependent residents reported not receiving their twice weekly showers. Resident identifiers: 24, 81 and 87.

Inspectors wrote5. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mild cognitive impairment, unspecified dementia, bipolar disorder, type 2 diabetes mellitus with diabetic polyneuropathy, schizophrenia, depression, anxiety, and hypertensive chronic kidney disease. Resident 6's medical record was reviewed 7/30/23 through 8/16/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 6 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. On 6/10/23 at 1:04 PM a Progress Nurses Note for resident 6 revealed that CNA reported to nurse that patient was on the floor in her bathroom .No visible injuries .X-ray ordered .Neuro checks started . A review of the Neurological Flow Sheet dated 6/10/23 for resident 6 releaved the following: a. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 68 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, a resident did not receive a Continuous Positive Airway Pressure (CPAP) machine or care as ordered, and facility staff were not cleaning the resident's CPAP machines, mask and tubing. Resident identifiers: 18, 21 and 47.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 50 medication opportunities, on [DATE], revealed 7 medication errors which resulted in a 14.00% medication error rate. Specifically, a resident's blood pressure medication was administered out of the ordered parameters, a resident was not administered an antibiotic, a resident was administered the wrong dose of Vitamin D, a resident was administered a medication at the wrong time and one resident was administered an expired medication. Resident identifiers: 12, 19, 27 and 91.

Inspectors wroteBased on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, insulin pens were expired, open and available for use, not labeled with an expiration date or resident identifier information, a narcotic box in a medication room was not locked, cream for peri area care was kept in an unsecured cupboard at the nurses station.

Inspectors wroteBased on observation, interview and record review, for 4 of 68 sampled residents, the facility did not have menus that met the the nutritional needs of resident in accordance with established national guidelines. In addition, the menus were not followed. Specifically, watermelon was substituted for sausage for a breakfast, macaroni and cheese was substituted for chicken parmesan, cooked spinach was served verses broccoli. Resident identifiers: 58, 62, 65, and 92.

Inspectors wroteBased on observation, interview and record review it was determined, for 21 of 68 sampled residents, that the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, resident complained of the food quality, the test tray was not palatable and there were complaints in residents council. Resident identifiers: 4, 8, 12, 16, 18, 20, 28, 38, 40, 49, 51, 54, 58, 62, 65, 66, 85, 86, 92 and 148.

Inspectors wroteBased on interview and record review, for 7 of 68 sampled residents, the facility failed to provide a suitable, nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, or outside of scheduled meal service times. Specifically, evening snacks were either not offered, were not nourishing, and were not consistent with the resident's plan of care. In addition, there were 2 snacks available for residents throughout the day. Resident identifiers: 4, 16, 18, 20, 38, 40, and 51.

Inspectors wroteBased on interview and record review it was determined for 4 of 68 sample resident that the facility did not maintain medical records on each resident that were accurately documented. Specifically, a residents sleep study and respiratory therapy notes from a hospitalization were not in their medical records. A resident did not have documentation of an emergency department observation notes in the medical records. A resident had another resident's Advance Beneficiary Notice in their medical records. Resident identifiers: 18, 62, 65 and 162.

Inspectors wroteBased on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, clean linens were stored in the soiled laundry area. Clean linens were not transported in garbage bags through the facility. Staff members were observed to touch the resident's medications with bare hands during medication administration. Also, medications were dropped on the medication cart and then administered to a resident. Resident identifiers: 6 and 19.

Inspectors wroteBased on observation and interview it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff members did not knock prior to entering a resident room, and multiple residents reported that the Dietary Manager did not treat them with respect. Resident identifiers: 38 and 149.

Inspectors wroteBased on observation interview and record review it was determined, for 2 of 68 sample residents, the facility did not ensure the residents' right to retain and use personal possessions. Specifically, residents' clothing was lost. Resident identifiers: 31 and 94.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide each resident with reasonable accommodation of resident needs and preferences. Specifically, a resident was not provided return transportation to the facility on two separate occasions when requested by the resident, after going on a leave of absence. Resident identifier: 9.

Inspectors wroteBased on interview and record review the facility did not allow 1 of 68 sample residents and/or resident representatives to obtain a copy of medical records upon request and 2 days advance notice to the facility. Resident identifier: 156.

Inspectors wroteBased on observation, interview and record review, for 1 of 68 sampled residents, that the facility did not ensure that the residents were free from physical restraints imposed for purposes of convenience, and not required to treat the residents' medical symptoms. Specifically, a resident's left leg was tied to the wheelchair footrest with a cloth strip and the resident was not assessed regularly and evaluated for the continued need of the restraint. Resident identifier: 13.

Inspectors wroteBased on interview and record review, it was determined for 2 of 68 sampled residents, that the facility did not accurately assess residents. Specifically, weightloss was not documented on the Minimum Data Set (MDS) assessments, and the nature of a resident's discharge conflicted with the resident's medical record. Resident identifiers: 87 and 96.

Inspectors wroteBased on interview and record review, the facility did not ensure that for 2 of 68 sample residents the resident had a discharge summary that includes, but is not limited to: a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); [...]

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs and biologicals to 1 of 68 sample residents. Specifically, multiple medications were not available for a resident the day the resident admitted . Resident identifier: 149.

Inspectors wroteBased on interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, a resident's blood pressure (B/P) medication was administered outside of physicians ordered parameters. Resident identifier: 12.

Inspectors wroteBased on interview and record review, it was determined for 1 of 68 sampled residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, there was no behavior monitoring when a resident was administered psychotropic medications. Resident identifier:

Inspectors wroteBased on interview and record review it was determined, for 1 of 68 sampled residents, the facility did not obtain laboratory services to meet the needs of the residents. Specifically, resident 6 had physician's orders to obtain a basic metabolic panel (BMP) for medical monitoring purposes and the labs were not completed as ordered. Resident identifier: 6.

Inspectors wroteBased on interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide or obtain laboratory services only when ordered by a physician. Specifically, laboratory services were provided for resident 6 without physician's orders. Resident identifier: 6.

Inspectors wroteBased on interview and record review, it was determined for 1 out of 68 sampled residents that the facility did not file in the resident's clinical record laboratory (lab) reports. Specifically, resident 6 had multiple laboratory results that were not located in the medical record. Resident identifier: 6.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 68 sampled residents, that the facility did not provide or obtain outside resources for routine and emergency dental services to meet the needs of the residents. Specifically, a resident was not provided dental services for dentures. Resident identifier: 20.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 49 sampled residents, a resident that had multiple falls with injuries was not provided interventions or adequate supervision to prevent falls from occurring. In addition, the resident had a fall that resulted in a major injury and the resident was hospitalized . Resident identifier: 54.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, observations were made of trays delivered later than posted meal times.

Inspectors wroteBased on observation and interview, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, including properly preventing and/or containing Coronavirus disease 2019 (COVID-19). Specifically, observations were made of eye protection not worn by staff, vendors or visitors, facial masks were not worn over the mouth and nose by staff, and N95 masks were not worn by third party vendors during an outbreak. Staff were observed to not perform hand hygiene while assisting residents with eating and between residents, during the passing of meal trays to residents, and during dressing changes. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. In addition, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, for 3 out of 49 sampled residents, there was debris on the floor of resident rooms, in the resident hallways and common areas, and the resident hallways and common areas were not vacuumed. Additionally, a resident who was missing a personal item did not have the missing item located or replaced. Resident identifiers: 13, 17, and 22.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, for 4 out of 49 sampled residents, following witnessed and unwitnessed falls and a documented significant weight loss the facility did not maintain and update the comprehensive care plan of a resident to include the services that were to be furnished. In addition, two residents were not provide showers per the developed and initiated comprehensive care plan and a resident that was hospitalized for aspiration pneumonia did not have a comprehensive care plan developed and implemented. Resident identifiers: 22, 32, 54, and 289.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, for 6 out of 49 sampled residents, residents were not provided assistance with showers. Resident identifiers: 17, 22, 29, 32, 51, and 288.

Inspectors wroteBased on observation and interview it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, multiple vials of insulin were open and available for use without an expiration date and without resident identifier information and multiple bottle/packages of medication were expired and available for use.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not have menus which must be followed. Specifically, during tray line service, dietary staff provided incorrect meals and serving sizes for physician prescribed therapeutic diets.

Inspectors wroteBased on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cross contamination through hand hygiene and use of a sanitation rag were observed during tray line, and the resident communal refrigerator located between the 200 and 300 resident hallways was found to include unlabelled, undated items with some items remaining within the fridge past the facility policy length of 3 days.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not maintain medical records on each resident that were complete, accurate, and readily accessible. Specifically, for 2 out of 49 sampled residents, a residents hospital records were not in the individual medical record and a residents hospice plan of care, nurse assessments or Certified Nursing Assistant (CNA) visit notes were not in the individual medical record. Resident identifiers: 38 and 187.

Inspectors wroteBased on interview and record review, it was determined the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment, and at the residents' option formulate an advance directive. Specifically, for 1 out of 49 sampled residents, the facility did not accurately document the resident's life-saving preferences. Resident identifier: 76.

Inspectors wroteBased on interview and record review it was determined, the facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. Specifically, for 1 out of 49 sampled residents, no documentation was found in the resident's medical record to indicate the basis for the transfer or that the receiving provider was provided contact information of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, all special instructions for care, a discharge summary, and any other documentation necessary for a safe and effective transition of care. Resident identifier: 288.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that the resident received proper treatment and assistive devices to maintain vision abilities. Specifically, for 1 out of 49 sampled residents, a resident received a new prescription for eye glasses and the new glasses were not ordered as the resident believed they had been. Resident identifier: 15.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers (PU) and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 49 sampled residents, a resident developed an unstageable pressure ulcer on the second metatarsal-head pad of the plantar surface and interventions were not implemented specific to the prevention of its development. Resident identifier: 288.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 49 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 54.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not ensure each resident received drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, for 1 out of 49 sampled residents, a resident with a physician's order for nectar thick liquids was provided with thin liquids from care staff and was provided thin liquids on a meal tray. Resident Identifier: 33.

Inspectors wroteBased on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the resident census, and the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses, and Certified nurse aides. The facility must post the nurse staffing data on a daily basis at the beginning of each shift. Specifically, the nurse staffing data was not posted on a daily basis.