Sapphire Rehabilitation and Care Center

Inspectors wroteBased on medical record review, hospital medical record review, staff interviews, interview with dialysis center, and policy review, the facility failed to ensure a resident had a safe discharge from the facility. This affected one (Resident #99) of three residents reviewed for discharge. The facility census was 96.

Inspectors wroteBased on observations, resident interviews, staff interviews, and facility policy, the facility failed to maintain resident use shower rooms in a clean, sanitary, and safe condition. This is affected three of three showers rooms located in the facility. This had the potential to affect all 64 residents who utilize the shower rooms. The facility census was 94.

Inspectors wroteBased on review of the facilities Self-Reported Incidents (SRI) and investigations, policy review, and staff interview, the facility failed to conduct thorough investigations into allegations of physical abuse, neglect, and misappropriation were thoroughly investigated. This affected three of three SRIs reviewed. This affected five resident, Residents #40, #41, #43, #74, and #76. The facility census was 94.

Inspectors wroteBased on medical record review and staff interview, the facility failed to properly provide bathing/shower services and oversite for residents that were dependent on staff for care. This affected one (Resident #27) of three residents reviewed for bathing/showering. The census was 96. Findings Include:Resident #27 was admitted to the facility on [DATE]. Her diagnoses were depression, anxiety disorder, hyperlipidemia, atherosclerotic heart disease, dementia, adult failure to thrive, hypertension, hypo-osmolality and hyponatremia, and non-traumatic intracerebral hemorrhage in hemisphere. Review of her minimum data set (MDS) assessment, dated 04/04/26, revealed she had a severe cognitive impairment. Review of Resident #27 MDS Assessment, section GG, dated 04/04/26, revealed she required substantial physical assistance with her baths/showers. [...]

Inspectors wroteBased on observation, interview and facility policy review the facility failed to maintain infection prevention and control during medication administration. This affected two (Resident #62 and #64) of three residents observed during medication administration. The census was 98.

Inspectors wroteBased on resident record review, interviews, and policy review, the facility failed to administer a SARS-CoV-2 (COVID-19) vaccination as requested by Resident #59. This affected one out of three residents reviewed for vaccinations. The facility census was 96.

Inspectors wroteBased on resident and staff interview and record review, the facility failed to provide a resident's 30-day discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. This affected one (Resident #11) of one resident reviewed for discharge notices. The facility census was 95.

Inspectors wroteBased on observation, resident interview, staff interview, sample of a test tray, and review of Resident Council meeting minutes, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all 108 residents that received meals from the kitchen. The facility census was 108. Interview on 12/09/25 at 2:00 P.M. with Resident #44 revealed that the food is never served hot. Interview on 12/09/25 at 2:15 P.M. with Resident #18 revealed the food is never hot. Interviews on 12/10/25 at 1:17 P.M. with Residents #33 and #78 revealed the food is always cold. Observation on 12/09/25 from 11:30 A.M. to 12:51 P.M. of the lunch meal service revealed food was above 165 degrees Fahrenheit (F) on the tray line. A food cart left the pantry at 12:51 P.M. and arrived at the unit within a minute. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 108 residents who received meals in the facility. The facility census was 108. Observation on 12/09/25 at 10:31 A.M. of the kitchen with Dietary Manager #24 revealed about 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents covering food preparation and cook areas. Interview on 12/09/25 at 10:35 A.M. with the Dietary Manager #24 revealed the black stuff would not come off, stating they have tried everything, including a microfiber cloth. Dietary Manager #24 verified the black ceiling tiles and the dust on the ceiling vents and stated they do need cleaned or replaced. Dietary Manager #24 stated there is not a set cleaning schedule for the ceiling or vents. [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected one (#16) of three residents reviewed for call lights, with the potential to affect off residents residing in the facility. The facility census was 108. Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on observation, resident interview, staff interview, review of maintenance repair logs, and review of facility policy, the facility failed to maintain a clean and homelike environment regarding temperature, sanitation and condition of residents rooms. This affected 10 (#8, #16, #21, #26, #79, #83, #87, #96, #97, and #108) of 10 residents reviewed for environment. The facility census was 108. 1. Observation on 12/08/25 at 9:30 A.M. of Resident #83 and Residents #96's room revealed a hole exposing the drywall. 2. Observation on 12/08/25 at 9:36 A.M. of Resident #26 and# 87's room revealed exposed wires hanging from the wall.3. Observation on 12/08/25 at 9:39 A.M. of Resident #21 and #97's room revealed dried feces on the floor and wall and privacy curtain with brown stains and dried feces.4. Observation on 12/08/25 at 9:59 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were assisted and supervised with activities of daily living (ADL), and the facility failed to further ensure the necessary supplies were readily available to staff to ensure residents received timely ADL care. This affected three (#33, #78 and #87) residents received for activities of daily living. The facility census was 108. 1. Review of the medical record for Resident #33 revealed an admission date of 04/17/25, diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic pain, and difficulty in walking. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policies, the facility failed to ensure outdoor lighting was maintained and failed to ensure the proper storage of hazardous maintenance equipment and supplies. This had the potential to effect 14 residents with orders for unsupervised leave of absence (#2, #9, #10, #15, #23, #31, #44, #60, #67, #69, #83, #96, #104, and #107) and seven Residents (#21, #28, #62, #65, #94, #97, and #102) who were identified as cognitively impaired but independently mobile. Facility census was 108. 1. Observation on 12/09/25 at 6:30 P.M. revealed a dark night sky and no functioning lights to the right side or around the back of the building, and no functioning lights in the employee parking lot. Only two of six lights were working in the middle grassy and visitor parking area. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to accommodate a resident preference to have an electronic monitoring device (camera) placed in the resident's room. This affected one (#16) of three residents reviewed for accommodation of needs/preferences. The facility census was 108. Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. Review of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADL) related to dementia, heart failure, chronic respiratory failure, depression, chronic kidney disease, weakness and cancer. [...]

Inspectors wroteBased on observation, resident interview, staff interview and policy review, facility failed to ensure residents had privacy when communicating on the phone. This affected one (#35) of three residents reviewed for communication with privacy. Facility census was 108. Review of the medical record for Resident #35 revealed an admission date of 06/06/22. Diagnoses included anxiety, dysphagia, muscle wasting, vascular dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00, indicating severe cognitive impairment, and revealed the resident was rarely if ever understood. Review of the medical record for Resident #35 revealed she had a guardian and a family member (son) involved with her care. Observation on 12/10/25 at 2:16 P.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure medication error rate was less than five percent. There were three medication errors out of 30 opportunities, resulting in a 10 percent medication error rate. This affected one (#58) out of five residents reviewed for medication administration. Review of the medical record for Resident #58 revealed an admission date 08/22/24 ad diagnoses including rhabdomyolysis, type II diabetes mellitus and hypertension. Observation on 12/09/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #189 completing medication administration for Resident #58 revealed a physician's order dated 08/23/24 for Mucinex 600 milligrams (mg), one tablet twice daily was not administered per order due to not having any supply on hand. [...]

Inspectors wroteBased on observation,medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (#79) of three residents reviewed for medication storage. The facility census was 108. Review of the medical record for Resident #79, revealed an admission date of 11/11/16. Diagnoses included: vascular dementia, cerebral infarction, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79 required minimal assistance with activities of daily living and ambulates independently. Observation on 12/08/25 at 9:50 A.M. revealed Resident #79's had several medications in a medicine cup sitting on his bedside table. [...]

Inspectors wroteBased on medical record review, staff interview, review of the police reports, review of the facility Self-Reported Incidents (SRI), review of the website www.accuweather.com, review of the incident/accident log, review of the hospital discharge record, review of the incident report, review of the staff witness statements, and policy review, the facility failed to provide adequate interventions and/or supervision to prevent a cognitively impaired resident (Resident #10), who was assessed at risk for elopement, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #10 eloped from the facility and the resident was found by the police 0.5 miles from the facility. [...]

Inspectors wroteBased on closed medical record review, hospital record review, review of a facility investigation, review of the facility assessment, policy review, and interview, the facility failed to develop and implement an effective discharge planning process focusing on the safety and total care needs of Resident #23 to ensure the resident was discharged to a safe location with continuity of care post-discharge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death beginning on 08/12/25 when Resident #23, who had been admitted to the facility with a known diagnosis of alcohol abuse, was discharged from the facility without evidence the resident had a safe location in which to go. [...]

Inspectors wroteBased on interview, medical record review, policy review, review of an Ohio Department of Health (ODH) educational pamphlet, and facility policy review, the facility failed to ensure Resident #107 was adequately supervised while outside and had a way to summon staff assistance. Actual Harm occurred on 08/16/25 when Resident #107, who had been outside in 88 degree Fahrenheit (F) weather, had a change in condition and had a body temperature of 106 degrees F (normal body temperature 98.6 degrees F) and was subsequently hospitalized for heat exhaustion. An additional finding that did not rise to Actual Harm but had the potential for more than minimal harm occurred when the facility failed to ensure Resident #15's fall was thoroughly investigated and accurately documented. This affected two (Residents #107 and #15) of five residents reviewed for accidents. The facility census was 96.

Inspectors wroteBased on record review, interviews, police report review, self-reported incident review, policy review, and facility assessment review, the facility failed to identify, address, and obtain appropriate services to meet the behavior health care needs of Resident #5 and failed to develop and implement an individualized comprehensive care plan to address and support the behavioral health care needs of Resident #5. Actual harm occurred on 08/03/25 when Resident #5, who had diagnoses of anxiety, intellectual disability, traumatic brain injury (TBI) and a history of self-injurious behavior of cutting, became agitated with staff during care and brandished a knife and threatened Certified Nursing Assistant (CNA) #350 that he was going to gut her. The police were contacted and Resident #5 was subsequently removed from the facility and placed in jail after a warrant was issued for his arrest. [...]

Inspectors wroteBased on observation, interview, review of staff time punches, and review of facility policy, the facility failed to have sufficient staffing in the kitchen to maintain a clean kitchen and to serve residents on appropriate dishware. This had the potential to affect all 96 residents residing in the facility who consumed food by mouth from the facility kitchen.

Inspectors wroteBased on observation, interview, and review of facility policy revealed the facility failed to maintain a clean and sanitary kitchen and serve beverages in clean cups for the B Unit. This had the potential to affect all 96 residents who consumed food from the kitchen and the 47 residents residing on the B unit (#4, #5, #7, #8, #9, #11, #12, #14, #17, #19, #22, #24, #26, #28, #30, #31, #33, #35, #36, #37, #38, #40, #41, #47, #54, #59, #61, #65, #70, #75, #76, #80, #81, #85, #86, #87, #89, #93, #96, #98, #99, #101, #102, #103, #105, #106, #107). The facility identified all residents received meals/beverages from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure kitchen trash cans were appropriately contained. This had the potential to affect all residents residing in the facility. The facility census was 96.

Inspectors wroteBased on staff interview, review of the surety bond, and review of facility resident financial account balances, the facility failed to ensure that their surety bond was sufficient to cover the highest resident daily funds balance. This had the potential to affect 45 resident accounts that were managed by the facility. The facility census was 96.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were filled out accurately and timely. This affected four residents (#4, #10, #19 and #64) of 40 sampled for the annual survey. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to have comprehensive care plans were in place for Residents #5, #14, and #23. This affected three residents (#5, #14, and #23) out of 40 residents reviewed for care planning. The facility census was 96.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Residents #38 and #93 received medications timely and as ordered, failed to ensure Resident #15's laceration was monitored, and failed to apply Resident #11's ace wraps per physician orders. This affected four residents (#11, #15, #38, and #93) out of 40 residents sampled for quality of care and treatment. The facility census was 96.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were dated and expired medication was discarded. This affected five (Resident #2, #50, #55, #57, and #116) residents but had the potential to affect newly admitted residents. The facility census was 96.

Inspectors wroteBased on observation and interview the facility failed to ensure the floor and air conditioning units were maintained on the B unit, failed to ensure the floor in Resident #4's room was clean, and failed to ensure the floor and walls of Resident #103 room were clean. This had the potential to affect 47 residents residing on the B unit (#4, #5, #7, #8, #9, #11, #12, #14, #17, #19, #22, #24, #26, #28, #30, #31, #33, #35, #36, #37, #38, #40, #41, #47, #54, #59, #61, #65, #70, #75, #76, #80, #81, #85, #86, #87, #89, #93, #96, #98, #99, #101, #102, #103, #105, #106, and #107). The facility census was 96.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to honor Resident #57's and Resident #68's bathing preferences and failed to ensure Resident #12's call light was within reach. This affected three residents (#12, #57, and #68) out of six residents reviewed for accommodations of needs and preferences. The facility census was 96.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to maintain resident privacy during a routine dressing change. This affected one resident (#25) of one resident observed for wound care. The facility census was 96.

Inspectors wroteBased on interview, record review, review of facility self-reported incidents, and review of facility policy the facility failed to ensure Resident #107's injury of unknown origin and an altercation between Resident #5 and a Certified Nursing Assistant (CNA) were reported to the State Agency in a timely manner. This affected one resident (#107) of seven reviewed for accidents and one resident (#5) of one resident reviewed for abuse. The facility census was 96.

Inspectors wroteBased on interview, record review, review of facility self-reported incidents, facility investigation review and review of facility policy the facility failed to ensure Resident #107's injury of unknown origin and an altercation between Resident #5 and a Certified Nursing Assistant CNA) were thoroughly investigated. This affected one resident (#107) of seven reviewed for accidents and one resident (#5) of one resident reviewed for abuse. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to timely complete a Preadmission Screening and Resident Review (PASARR) for Resident #9 and failed to ensure an accurate PASARR was completed for Resident #23. This affected two residents (#9 and #23) out of six residents reviewed for PASARR assessments. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to update the preadmission screening and resident review (PASARR) when Resident #15 received a new diagnosis. This affected one (Resident #15) out of six residents reviewed for PASARR assessments. The facility census was 96.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to provide nail care for Resident #62 and failed to provide bathing as scheduled for Resident #68. This affected two (Resident #62 and #68) of nine residents reviewed for activities of daily living (ADL). The facility census was 96.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #11 and #38 were offered activities and had activity plans of care in place. This affected two residents (#11 and #38) of three residents reviewed for activities. The facility census was 96.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to implement interventions to prevent pressure ulcer development for Resident #21 and failed to ensure Resident #85's pressure ulcer was treated as ordered. This affected two residents (#21 and #85) of four residents reviewed for pressure ulcers. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to ensure documented evidence of Resident #15's bowel movements and failed to ensure documented evidence of Resident #21's catheter care. This affected two (Residents #15 and #21) out of four residents reviewed for bowel and bladder. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to provide documented evidence that Resident #9's ileostomy/urostomy bag was routinely changed. This affected one (Residents #9) out of four residents reviewed for bowel and bladder. The facility census was 96.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to appropriately supervise and position Resident #107 during meals, and timely implement dietitian recommendations for Resident #4 and #21. This affected three residents (#4, #21, and #107) of seven residents reviewed for nutrition. The facility census was 96.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to administer a fentanyl patch as ordered for Resident #38 and failed to ensure parameters were in place for Resident #105's pain medications to administer them appropriately. This affected one resident (#105) of five reviewed for unnecessary medications and one resident (#38) of four people reviewed for pain. The facility census was 96.

Inspectors wroteBased on interview and record review, the facility failed to appropriately document the disposal of fentanyl patches for Resident #38. This affected one resident (#38) of five residents reviewed for pain. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #15's medication was ordered with the proper diagnosis. This affected one (Resident #15) of five residents reviewed for appropriate diagnosis for medications. The facility census was 96.

Inspectors wroteBased on interview and record review, the facility failed to prevent Resident #8 from experiencing a significant medication error when he missed his immunosuppressant medication related to a kidney transplant. This affected one resident (#8) of seven residents reviewed for accidents. The facility census was 96.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #10's physician-ordered laboratory testing was completed as ordered. This affected one resident (#10) of five residents reviewed for unnecessary medications. The facility census was 96.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure enhanced barrier precautions were in place as ordered for Resident #4, failed to appropriately sanitize a blood pressure cuff for the B Hall, and failed to maintain infection control procedures by changing Resident #64's incontinence brief in Residents #71's bed. This affected three residents (#4, #64, and #71) out of 10 residents reviewed for infection control, and had the potential to affect 47 residents residing on the B hall, that utilized the facility blood pressure cuff, at the time of the survey. The facility census was 96. Findings Include:1. Review of Resident #64's medical record revealed an admission date of 11/25/24 and diagnoses including, but not limited to, depression, anxiety disorder, Vitamin D deficiency, hypertension, diabetes, and unspecified dementia. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Resident #107's topical antibiotic cream was not provided antibiotic cream past its physician-ordered end date. This affected one resident (#107) of seven residents reviewed for accidents. The facility census was 96.

Inspectors wroteBased on record review and interview the facility failed to provide bed hold notices, and transfer/discharge notices to residents being sent to the hospital and to notify the ombudsman monthly of facility discharges. This affected three residents (#3, #55, and #109) of three reviewed for hospitalization. Findings Include: 1. Review of Resident #109‘s medical record revealed an admission date of 06/18/25, a discharge date of 06/30/25 and diagnoses including, but not limited to, diabetes, chronic kidney disease stage three, Alzheimer's disease, anxiety, hypertension and metabolic encephalopathy. Review of the admission Minimum Data Set (MDS) assessment, dated 06/24/25 revealed a Brief Interview for Mental Status (BIMS) score of six indicating the resident had severely impaired cognition. [...]

Inspectors wroteBased on medical record review, review of hospital records, review of Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure residents were free from physical abuse. This resulted in Actual Harm on 05/27/25 for Resident #12 who was admitted to the hospital and treated for facial bruising and a laceration above the left eye with sutures after being punched in the face by another resident. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 109 residents.

Inspectors wroteBased on closed medical record review, staff interviews, Emergency Medical Technician (EMT) interview, review of Emergency Medical Services (EMS) run report, review of the tracheostomy handbook, and review of the facilities policies and procedures, the facility failed to ensure the proper respiratory support was provided to a resident who was experiencing respiratory distress. [...]

Inspectors wroteBased on observation, resident, resident family member, and staff interview, and medical record review, the facility failed to maintain a homelike environment for one (#13) of three residents reviewed for environment. The facility census was 99.

Inspectors wroteBased on observation, resident, resident family, and staff interview, medical record review, and policy review, the facility failed to ensure residents received assistance with bathing and nail care. This affected three (#13, #21, and #102) of four residents reviewed for activities of daily living (ADLs) for dependent residents. The facility census was 99.

Inspectors wroteBased on medical record review, resident, resident family, and staff interview, policy review, the facility failed to ensure physical therapy was provided as ordered. This affected two (#13 and #102) of three residents reviewed for therapy services. The facility census was 99.

Inspectors wroteBased on medical record review, staff interview, review of infection control logs, and policy review, the facility failed to ensure COVID-19 infections were adequately monitored. This affected one (#102) of three reviewed for COVID-19 infections. The facility census was 99.

Inspectors wroteBased on record review, staff interview, resident interview, guardian interview, record review, policy review, and review of Self-Reported Incident (SRI), the facility failed to timely notify the resident representative following a change in condition. This affected one (#69) of three residents reviewed for notification of change in condition. The facility census was 95.

Inspectors wroteBased on medical record review, hospital record review, orthopedic follow-up note review, and staff interview, this facility failed to ensure follow-up appointments were implemented as scheduled and/or ordered. This affected one (Resident #36) of the six residents reviewed for follow-up care. The facility census was 98.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and fall investigation report review, this facility failed to ensure safety measures were in place during mechanical lift transfers to prevent a fall. This affected one (Resident #108) of three residents reviewed for accidents while receiving staff assistance. Facility census was 98. Findings Include: Review of the medical record for Resident #108 revealed an initial admission date of 10/20/10 and a re-entry date of 03/06/23. Diagnoses included contracture of the left and right ankle, lack of coordination, muscle spasms, and dependence on enabling machines and devices. Review of Resident #108's Fall assessment dated [DATE] revealed a score of 10 indicating a low risk for falls. [...]

Inspectors wroteBased on medical record review, observations, staff interview, and facility policy review, this facility failed to ensure proper hand hygiene after glove removal and implement Enhanced Barrier Precautions during wound care and dressing change. This affected one (Resident #36) of the four residents reviewed for wound care. Facility census was 98.

Inspectors wroteBased on observation, staff interviews, resident interviews, and review of the facility meal schedule, the facility failed to ensure meals were served at the scheduled time. This affected all of the residents residing in the facility. The facility census was 102.

Inspectors wroteBased on observations, staff interviews and review of the facility policy the facility failed to ensure food was stored, prepared and distributed in a sanitary manner to prevent food borne illnesses. This had the potential to affect all of the residents residing in the facility. The census was 102 residents.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to maintain a safe, functional, and homelike environment for residents and staff. This had the potential to affect all residents residing in the facility. The census was 102 residents.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure staff treated residents with dignity and respect by knocking on the resident door and waiting to be invited in before entering the room. This affected one (Resident #16) of four residents reviewed for dignity and respect. The facility census was 102.

Inspectors wroteBased on medical record review, resident interview, review of facility grievance log, staff interview, and review of the facility policy, the facility failed to ensure resident complaints and concerns were documented and followed up on in a timely manner. This affected one (Resident #16) of three residents reviewed for follow up on resident concerns. Resident census was 101.

Inspectors wroteBased on medical record review, staff interviews and review of the facility policy the facility failed to ensure a complete and thorough investigation was completed for allegations of abuse, neglect and misappropriation. This affected one (Resident #16) of three residents reviewed for abuse and neglect. The facility census was 101.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility menu, the facility failed to ensure residents received foods that accommodated resident preferences. This affected two (Residents #16 and #22) of six residents reviewed for dietary services. The facility census was 102.

Inspectors wroteBased on medical record review, review of hospital discharge summaries, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #58 was administered diabetic medication as ordered. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #58 was readmitted to the facility from the hospital with orders for Lantus (a long-acting insulin) and Humalog (a fast-acting insulin) and Resident #58 was not administered any diabetic medications or insulin on [DATE] or [DATE]. On [DATE] at approximately 11:30 A.M., Resident #58 was sent back to the hospital when Resident #58's blood sugar was checked and showed high. Resident #58's blood sugar was 624 milligrams per deciliter (mg/dL) at the hospital and Resident #58 was treated for hyperglycemia and diabetic ketoacidosis (DKA). [...]

Inspectors wroteBased on medical record review, review of hospital records, review of dental records, staff interview, and facility policy review, the facility failed to ensure one resident (Resident #72) was provided dental care in a timely manner. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or medical emergency on 03/30/23 when Resident #72 was re-admitted to the facility from the hospital where Resident #72 had been treated with three antibiotics for sepsis (the body's extreme response to an infection) caused by several abscessed teeth. Resident #72 was discharged from the hospital with an order to follow-up with a dentist as soon as possible (ASAP) for tooth extractions. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to ensure one resident's (Resident #74) call light was kept within reach. The deficient practice affected one (Resident #74) of 21 residents observed for call lights. The facility census was 87.

Inspectors wroteBased on medical record review, resident interviews, review of resident council meeting minutes, staff interview, and facility policy review, the facility failed to ensure repeated concerns expressed during resident council were adequately addressed. This affected three (Residents #28, #61, and #68) of five residents reviewed for staffing concerns. The census was 87.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure meals intakes were consistently recorded and monitored as well ensure resident weights were routinely obtained upon admission. This affected one (Resident #87) of four residents reviewed for nutrition. The census was 87.

Inspectors wroteBased on medical record review, review of the menu, review of the substituation log, review of the dietary spreadsheet, observation, staff interview, and facility policy review, the facility failed to serve the appropriate dessert according to the menu. The deficient practice affected two (Residents #10 and #29) of three residents who were on a pureed diet in the facility. The facility census was 87.

Inspectors wroteBased on medical record review, observation, staff interview, review of the pureed green beans recipe, and review of facility policy, the facility failed to serve palatable pureed green beans. This affected three (Resident #10, #29, and #40) out of three residents who received a pureed diet. The facility census was 87.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents received dessert that was the appropriate texture and consistency. The deficient practice affected one (Resident #40) out of three residents who received a pureed diet. The facility census was 87.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the environment was maintained in a safe, sanitary, and comfortable manner. This affected two (Residents #12 and #50) out of three residents reviewed for environment. The facility census was 87.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure nurse aides received an annual performance evaluation. This affected two (State Tested Nurse Aides #103 and #112) out of two nurse aides reviewed for annual performance evaluations. This had the potential to affect all 87 residents residing in the facility. The census was 87.

Inspectors wroteBased on observation, staff interview and review of the facility's policy, the facility failed to maintain a sanitary kitchen and ensure food proper food storage. This affected 83 of 87 residents who receive food from the kitchen (Residents #4, #23, #68 and #245 receive nothing by mouth). The facility census was 87.

Inspectors wroteBased on facility record review, staff interview, interview with the county health department, review of the memorandum from the Center for Clinical Standards and Quality/Quality, Safety and Oversight Group and review of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidance, the facility failed to develop an adequate water management plan. In addition, the facility failed to ensure proper signage was located on the door of a resident on isolation precautions. This had the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on record review, observation, staff and resident interviews and review of the facility's policy, the facility failed to promote dignity by not removing a hospital band containing private information from Resident #68's wrist and failed to provide dignity to Resident #6, #28 and #51 by standing over the residents and feeding the residents. This affected four (#6, #28, #51 and #68) of six residents reviewed for dignity. The facility identified nine residents who require feeding assistance. The facility census was 87.

Inspectors wroteBased on record review, staff interview and review of the facility's policy, the facility failed to ensure the code status in the electronic medical record was accurate for Resident #36 and failed to obtain a do not resuscitate (DNR) consent nt for Resident #68. This affected two (#36 and #68) of 25 residents reviewed for advanced directives. The facility census was 87.

Inspectors wroteBased on record review, staff interview and review of the facility's policy, the facility failed to notify the physician of Resident #68's abnormal lab values. This affected one (#68) of two residents reviewed for notification of change. The facility census was 87.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a pre-admission screening and resident review (PASARR) after a new mental health diagnosis for Resident #17. This affected one (Resident #17) of five reviewed for PASARR. The facility census was 87.

Inspectors wroteBased on record review, staff interview, review of the facility's policy and observation, the facility failed to develop and implement fall interventions for Resident #7, an oxygen administration care plan for Resident #24, and a wandering care plan for Resident #66. This affected three (#7, #24 and #66) of 23 resident's care plans reviewed during the annual survey. The facility census was 87.

Inspectors wroteBased on record review, observation, staff and resident interviews and review of the facility's policy, the facility failed to provide timely personal hygiene care to a resident who required extensive assistance from staff for personal hygiene. This affected one (#68) of seven residents reviewed for activities of daily living (ADL). The facility census was 87.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to implement fall interventions as indicated in a resident's care plan by not adding non-slip strips to the floor next to the resident's bed or in front of the resident's toilet. This affected one (Resident #61) of three residents reviewed for falls. The facility census was 87.

Inspectors wroteBased on record review, observation, staff interview and review of the facility's policy, the facility failed to administer Resident #68's tube feeding per physicians order. This affected one (#68) of one residents reviewed with a tube feeding care need. The facility identified seven residents receiving tube feed. The facility census was 87.

Inspectors wroteBased on record review, observation, staff interviews and facility policy, the facility failed to obtain an oxygen order and then follow the physician for Resident #24 and failed to properly date and label the oxygen tubing for Resident #24 and Resident #77. This affected two (#24 and #77) of five residents reviewed for respiratory care. The facility identified 14 residents who receive respiratory care. The facility census was 87.

Inspectors wroteBased on record review, review of the facility's policy and staff interview, the facility failed to address monthly pharmacy recommendations in a timely manner. This affected one (Resident #53) of five residents reviewed for unnecessary medications. The facility census was 87.

Inspectors wroteBased on observation, review of the facility's policy and staff interview, the facility failed to ensure drugs and biological were stored in locked compartments when they left a medication cart unlocked on unit A. This had the potential to affect four residents (Resident #6, #37, #81 and #238) who were cognitively impaired and self mobile. The facility census was 87.