Scioto Rehabilitation & Care Center

Inspectors wroteBased on observations, staff interviews, review of freezer temperature logs, review of work orders, and review of facility policy, the facility failed to ensure food was stored and prepared in a clean and sanitary manner related to labeling/dating opened foods and utilizing wet equipment to prepare food, failed to maintain safe food storage temperatures for the freezer, and failed to maintain effective dishwashing temperature levels for sanitary dishwashing. This had the potential to affect 92 out of 102 residents who received food/beverages from the facility's kitchen. The facility census was 102 residents.1. Observations on 06/08/26 from 8:19 A.M. to 8:39 A.M. revealed that there was approximately six inches of stagnant gray water on the garbage disposal near the handwashing sink. The gray water had a layer of dark gray opaque thick substance on the top of the water. [...]

Inspectors wroteBased on observations, review of facility work orders, review of temperature logs, and staff interviews, the facility failed to ensure that kitchen equipment was maintained in a working manner. This had the potential to affect 92 of 102 residents who received food/beverages from the kitchen. The facility census was 102 residents.

Inspectors wroteBased on observations, staff interviews, and review of facility pest control contract and service records, the facility failed to ensure effective pest control in the kitchen. This had the potential to affect 92 of 102 residents who received food/beverages from the kitchen. The facility census was 102 residents.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to ensure Resident #2 and #15's care plans comprehensively addressed their medications and/or medical conditions. This affected two residents (#2 and #15) of five residents reviewed for unnecessary medications. The facility census was 102.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were in place to maintain or improve Resident #38's ability to communicate/hear. This affected one resident (#38) of one resident reviewed for vision and hearing. The facility census was 102.

Inspectors wroteBased on review of a resident record, observations, family interview, staff interview and review of a facility policy, the facility failed to ensure that a resident's nails were filed and maintained in a clean and sanitary manner per his preferences. This affected one resident (#5) of three residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview, record review, and review of hospital documentation, the facility failed to ensure the physician was notified when intravenous access was not able to be obtained during a change of condition for Resident #130. This affected one resident (#130) of one resident reviewed for change in condition. The facility census was 102. Findings Include:Record review for Resident #130 revealed this resident was admitted to the facility on [DATE], and discharged on 05/15/26, with diagnoses including bipolar disorder, dementia, psychotic disturbance, mood disturbance, and anxiety, diabetes, Parkinson's disease and muscle weakness. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. [...]

Inspectors wroteBased on a resident record review, staff interview and review of a facility policy, the facility failed to ensure that a resident's protein supplement was administered per orders to promote wound healing. This affected one resident (#12) out of three residents reviewed for pressure ulcers. The facility census was 102 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #40, who was identified as a supervised smoker, did not have smoking materials on her person. This effected one resident (#40) of four residents reviewed for accident hazards. The facility's census was 102. Findings Include: Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness muscle. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require minimal staff assistance for bathing and dressing. [...]

Inspectors wroteBased on review of resident medical records, observations, interviews, and review of facility policies, the facility failed to meet the nutritional recommendations and had a delay in implementing nutrition recommendations for Resident #89. Additionally, the facility did not provide enteral feedings as ordered for Resident #96. This affected two residents (#89 and #96) out of three residents reviewed for nutrition.

Inspectors wroteBased on medical record review, observations, interviews, and review of facility policy, the facility failed to implement nutritional recommendations to promote weaning off of enteral feedings for Resident #66 and failed to ensure appropriate care of a feeding tube when a water flush was not completed as ordered before and after medication administration for Resident #89. This affected two residents (#66 and #89) out of three residents reviewed for enteral nutrition. The facility census was 102 residents.

Inspectors wroteBased on interview, medical record review, and review of facility policy and procedure, the facility failed to timely administer ordered pain medications for Resident #117. Additionally, the facility failed to implement nurse practitioner pain recommendations in a timely manner and failed to timely reschedule pain management appointments for Resident #61. This affected two residents (#61 and #117) of three residents reviewed for pain management. The facility's census was 102. Findings Include: 1. Record review for Resident #117 revealed the resident was admitted to the facility on [DATE] with diagnoses including pain in right leg, displaced fracture of the right tibia, unspecified mood disorder, bipolar disorder, anxiety disorder, gastroparesis and muscle weakness. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure Resident #2 had an appropriate indication for long term antibiotic use. This affected one resident (#2) of five residents reviewed for unnecessary medication. The facility census was 102.

Inspectors wroteBased on observation, interview, medical record review, facility policy review, and review of medication labels, the facility failed to ensure a medication error rate below 5 percent (%). Out of 27 opportunities for error, two errors were made to equal a medication error rate of 7.4%. This affected two residents (#29 and #89) of two residents observed for medication administration. The census was 102.

Inspectors wroteBased on observation, interview, medical record review, review of resident meal tickets, review of food ingredients, and facility policy review, the facility failed to ensure Resident #54 was not provided food they were allergic to. This affected one resident (#54) of one resident reviewed for food concerns. This facility census was 102.

Inspectors wroteBased on observation, interview, record review, review of the controlled medication log, and review of facility policy, the facility failed to ensure residents Medication Administration Records (MAR) were accurate. This affected two residents (#29 and #79) of five residents reviewed for unnecessary medications. The facility census was 102.

Inspectors wroteBased on medical record review, observation, interview, and facility policy review, the facility failed to maintain infection control when Resident #42's urinary catheter bag was on the floor. This affected one resident (#42) of two residents reviewed for urinary catheters. The facility census was 102.

Inspectors wroteBased on interview, medical record review, review of facility infection control log, and review of facility policy, the facility failed to ensure antibiotic stewardship was followed. This affected 2 of 4 residents (6 and #28) reviewed on the infection control log for the months of December 2025 through May 2026. The facility census was 102. Findings Include:Review of the infection control log for December 2025 through April 2026 revealed the facility tracked the residents who received antibiotics during the months. It included the residents' name, room number, date, type of infection, antibiotic, nosocomial, and community acquired. The facility utilized an Infection Screening Evaluation for each resident who received an antibiotic treatment for an infection. The form determined whether the clinical findings of the resident met either McGeer's or Loeb's criteria for antibiotic use. [...]

Inspectors wroteBased on closed medical record review, interview and facility policy review, the facility failed to ensure the physician and the resident representative was notified of a change in condition. This affected one resident (#30) of three residents reviewed for change in condition. The facility census was 116. Findings Include:Review of the closed record for Resident #30 revealed an initial admission date of 01/22/26 with the diagnoses including but not limited to protein calorie malnutrition, depression, congestive heart failure, obstructive sleep apnea, metabolic encephalopathy, anemia, atrial fibrillation, pleural effusion, acute respiratory failure with hypoxia, hypertension, hyperlipidemia, myotonic muscular dystrophy and rheumatoid arthritis. [...]

Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to ensure one resident who was dependent on staff received routine nail care. This affected one resident (#100) of three residents reviewed for activities of daily living. The facility census was 116. Findings Include:Review of the medical record for Resident #100 revealed an initial admission date of 09/23/25 with the latest readmission of 01/10/26 with the diagnoses including but not limited to end stage renal failure, congestive heart failure (CHF), diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea, major depressive disorder and fracture of lower end of right femur. [...]

Inspectors wroteBased on closed medical record review, interview and facility policy review, the facility failed to obtain physician ordered diagnostic laboratory tests. This affected one resident (#40) of three residents reviewed for diagnostic laboratory test. The facility census was 116. Findings Include:Review of the closed record for Resident #40 revealed an initial admission date of 12/24/25 with the latest readmission of 01/05/26 with the diagnoses including but not limited to acute and chronic respiratory failure, need for assistance with personal care, hyperlipidemia, congestive heart failure, atrial fibrillation, nicotine dependence, anxiety disorder, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease and benign prostatic hyperplasia. [...]

Inspectors wroteBased on closed medical record review, interview and facility policy review, the facility failed to notify the physician of diagnostic radiology results. This affected one resident (#40) of three residents reviewed for diagnostic laboratory tests and x-rays. The facility census was 116. Findings Include: Review of the closed record for Resident #40 revealed an initial admission date of 12/24/25 with the latest readmission of 01/05/26 with the diagnoses including but not limited to acute and chronic respiratory failure, need for assistance with personal care, hyperlipidemia, congestive heart failure, atrial fibrillation, nicotine dependence, anxiety disorder, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease and benign prostatic hyperplasia. [...]

Inspectors wroteBased on medical record review, resident representative interview, resident interview, staff interview, and facility policy review, the facility failed to investigate an allegation of abuse thoroughly. This affected one (Resident #39) of three residents reviewed for abuse. The census was 111. Findings Include:Resident #39 was admitted to the facility on [DATE]. Her diagnoses were seizures, chronic embolism and thrombosis, osteoarthritis, peripheral vascular disease, hyperlipidemia, dementia, major depressive disorder, anxiety disorder, and Parkinson's disease. Review of her minimum data set (MDS) assessment, dated 11/20/25, revealed she had a mild cognitive impairment. Review of Resident #39's progress notes, dated 12/02/25, confirmed an incident that happened between Resident #39 and Resident #79. Resident #79 became agitated and grabbed Resident #39, but did not strike her. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to implement physician orders to care for an indwelling urinary catheter. This affected one resident, (Resident #72) of three residents reviewed for urinary catheters. The facility census was 111. Findings Include:Record review for Resident #72 revealed this resident was admitted to the facility on [DATE] with diagnoses including: chronic obstructive pulmonary disorder, tracheostomy, obstructive sleep apnea, muscle wasting and atrophy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require assistance with self-care activities. Review of the care plan dated 12/09/26 revealed Resident# 72 was at risk for a urinary tract infection. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #9 received adequate monitoring as ordered by the physician prior to the administration of a cardiovascular medication to ensure the medication was administered only when necessary. This affected one resident (Resident #9) of two residents reviewed for medication administration. Facility census was 109.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to follow appropriate transmission-based precautions for a resident on contact precautions. This affected one resident (Resident #41) of three residents reviewed for infection control. The facility census was 109. Review of Resident #41's medical record revealed an admission date of 09/23/25 with diagnosis of osteomyelitis.

Inspectors wroteBased on medical record review, staff interview, observations, and facility policy review, the facility failed to ensure infection control measures were in place including ensuring dirty linen was off the facility hallway floors, ensuring the Glucometer machine was cleaned between resident use, ensuring sterile techniques was used and maintained during trach care and ensuring Enhanced Barrier Precautions were implemented for residents who required this form of precaution. This affected seven (Resident #13, #20, #60, #70, #92, #250, and #275) of the ten residents reviewed for infection control with the potential to affect all residents residing at this facility. The facility census was 91.

Inspectors wroteBased on interview, record review and policy review, the facility failed to notify the transfer of Resident #10 to their Power of Attorney (POA). This affected one (Resident #10) of three residents reviewed for transfers and notification to their POAs. The facility census was 91.

Inspectors wroteBased on interviews, observations, record reviews and facility policies, the facility failed to notify the physician of weight gain for a congestive heart failure resident. This affected one (Resident #10) of three residents reviewed. The facility also failed to ensure non pressure skin alterations were treated per physician orders. This affected two (resident #20 and resident #300) of three residents reviewed. The facility census was 91.

Inspectors wroteBased in on interviews and record reviews, the facility failed to accurately document and treat pressure ulcers for three residents (#20, #60, and #70) out of four residents reviewed for pressure ulcer care. The facility census was 91.

Inspectors wroteBased on interviews, observations, record review and policy review, the facility failed to implement fall preventions for Resident #30 and Resident #90. The facility also failed to ensure two staff members were used when transferring Resident #30 with a Hoyer lift resulting in a fall. This affected two ( Resident 330 and Resident #90) of three residents reviewed for accidents/falls. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, and hospital paperwork review, the facility failed to ensure the medication Gabapentin, Oxycodone, and Tylenol was administered as per physician order for Resident #60. This affected one (Resident #60) of the four residents reviewed for accurate medication administration. The facility census was 91.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to ensure residents medical records accurately reflected current health status, care and treatments including an accurate Advanced Directive (code status), wound notes and assessment completed by a Certified Wound Nurse Practitioner, and ensure staff did not continue to chart on a residents daily health status days after being discharged from the facility. This affected three (Resident #30, #50, and #70) of the ten residents reviewed for accurate medical record information. The facility census was 91.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to to ensure residents received meals as ordered/needed. This had the potential to affect 105 out of 110 residents residing in the facility. The facility census was 110.

Inspectors wroteBased on medical record review, staff interview and internet resource, the facility failed to ensure residents who received nutritional support through a Nasogastric (NG) Tube received the proper care including ensuring the proper placement of tubing prior to administration of fluids and/or medication. This affected one (Resident #111) of the five resident reviewed for care with a feeding tube. The facility census was 106.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, promote optimal healing, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection. Actual Harm occurred beginning on 11/19/24 when Resident #54, who had moderate cognitive impairment and was at high risk for pressure ulcer development, was assessed to have a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the right buttocks that originated from Moisture Associated Skin Damage (MASD). [...]

Inspectors wroteBased on observations, staff interviews and review of facility policy, the facility failed to store and prepare food under sanitary conditions. This had the potential to effect 108 of 109 residents in the facility. One resident was identified as not eating by mouth. The facility census was 109.

Inspectors wroteBased on review of Resident Council meeting minutes, staff interviews, review of previous job description, review of the Social Services Designee (SSD) #320's current resume, and review of the job description for Social Services Director, the facility failed to ensure a qualified social worker was on staff due to the facility having over 120 certified beds. The deficient practice had the potential to affect all 109 residents in the facility. Findings Include: Review of the Resident Council Meeting Minutes dated from 06/24/24 through 11/25/24 revealed SSD #320 was introduced as the facility's new social worker. SSD #320 was noted as a Licensed Social Worker (LSW) in the monthly meeting minutes. Interviews on 12/16/24 at approximately 9:00 A.M. and 12/18/24 at approximately 2:00 P.M. [...]

Inspectors wroteBased on observations, staff interviews and review of facility policy, the facility failed to have effective pest control in the kitchen. This had the potential to effect 108 of 109 residents in the facility. One resident was identified as not eating by mouth. The facility census was 109.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment remained free of accident hazards by providing adequate supervision and assistance devices to prevent accidents for three of three residents (#17, #56, and #163) reviewed for accidents. The facility also failed to ensure a wanderguard alarm (alarm used to temporarily lock an exterior door and sound an audible alarm alerting staff that a resident is close to the door) was functioning for two ( #27 and #87) of two reviewed . The facility census was 109. Findings Include: 1. Resident #17 had an admission date of 12/11/23 with diagnoses including: [...]

Inspectors wroteBased on observation, staff interview and policy review the facility failed to ensure medications were not left unattended and the medications and medical supplies were not expired. This had the ability to affect all 29 residents in the 100 unit and three (27, #62, and #88) who lived on the 400 hall who were identified as being cognitively impaired and independently mobile. The facility census was 109. Findings Include: 1. Observation [DATE] at 3:05 P.M. in the medication room on the 100 unit revealed a box of vacutainers 22 gage needles, the box expired in 2023 and REF number on needles did not match the reference number on the box. The individual needles did not have expiration dates on them. The prefilled sodium chloride syringes expired [DATE]. Interview on [DATE] at 2:10 P.M. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, medical record review, and review of facility policy, the facility failed to provide dignified living conditions for two residents. This affected two (Resident #49 and #81) residents out of three residents (#49, #81, and #220) reviewed for dignity. The facility census was 109 residents.

Inspectors wroteBased on resident and staff interviews, the facility failed to give one resident timely access to her social security benefits and failed to ensure one resident was appointed a legal guardian appropriately. The deficient practices affected two residents (Residents #61 and #163) of three reviewed for accommodation of needs. The facility census was 109 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure an accurate code status was in place for one resident (Resident #97). The deficient practice affected one resident (Resident #97) of one reviewed for advanced directives. The facility census was 109. Findings Include: Review of the medical record for Resident #97 revealed an admission date on [DATE]. Medical diagnoses included Type II diabetes mellitus with diabetic neuropathy, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, encounter for surgical aftercare following surgery on the digestive system, and other intestinal obstruction unspecified as to partial versus complete obstruction. Resident #97's advance directive was noted as full code. Resident #97's daughter was listed as the resident's Durable Power of Attorney (DPOA). [...]

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to notify one resident's (#81) family of a room change. This affected one of 29 sampled residents. The facility census was 109. Findings Include: Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24, diagnoses include but were not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. [...]

Inspectors wroteBased on record review, staff interviews, and resident interviews, the facility failed to provide written transfer notices and inform residents or their families of their rights regarding hospitalization for three (Residents #41, #76, and #106) out of three residents reviewed for hospitalizations. The facility census was 109.

Inspectors wroteBased on record review, staff interviews, and resident interviews, and facility policy, the facility failed to provide a bed hold notice to inform residents or their families of their rights regarding the retention of their room and bed during hospitalizations for two (Residents #41 and #76) out of three residents reviewed for hospitalizations. The facility census was 109.

Inspectors wroteBased on observation,record review, interview, and Resident Assessment Instrument (RAI) manual review the facility failed to conduct an accurate assessment of each resident's functional capacity. This had the potential to affect two residents (#27, and #87), reviewed for accurate, comprehensive assessments, and the facility failed to timely complete a comprehensive assessment for one (#220) of four reviewed for accurate, comprehensive assessments. The facility census was 109. Findings Include: 1. Resident #27 had an admission date of 11/07/19 with diagnoses including: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate significant change Minimum Data Status (MDS) 3.0 assessment was completed for two residents (Residents #97 and #163). The deficient practice affected two residents (Residents #97 and 163) of two reviewed for significant change MDS assessments. The facility census was 109. Findings Include: Review of the medical record for Resident #97 revealed an admission date on 08/14/24. Medical diagnoses included Type II diabetes mellitus with diabetic neuropathy, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, encounter for surgical aftercare following surgery on the digestive system, and other intestinal obstruction unspecified as to partial versus complete obstruction. [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#163) received assistance with meals. This affected one resident of four residents reviewed for activities of daily living (ADL). The facility census was 109. Findings Include: Review of the medical record for Resident #163 revealed an initial admission date of 09/23/24 with the latest readmission of 12/01/24, diagnoses included but were not limited to gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope and collapse, repeated falls, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. Review of the plan of care dated 10/12/24 revealed the resident had a self-care performance deficit related to CVA with hemiparesis. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews and review of facility policies, the facility failed to treat and monitor conditions for two residents within professional standards of practice. This affected two (Residents #85 and #87) of twenty-nine residents reviewed during the survey. The facility census was 109 Residents.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure one resident (#81) received podiatry care. This affected one resident of 29 sampled residents. The facility census was 109. Findings Include: Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24, diagnoses included but were not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. [...]

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to monitor behaviors and side effects for two residents (#9, #81) who received psychotropic and anticoagulant medications. Additionally, the facility failed to complete an abnormal involuntary movement scale (AIMS) when resident #9 was started on an antipsychotic medication. This affected two residents of five residents reviewed for unnecessary medications. The facility census was 109. Findings Include: 1. [...]

Inspectors wroteBased on record review, staff interview, and review of the laboratory contract, the facility failed to ensure prothrombin time (PT) and international normalized ratio (INR) laboratory tests were completed timely as ordered for one resident (Resident #84). The deficient practice affected one resident (Resident #84) of two reviewed for anticoagulant medications. The facility census was 109. Findings Include: Review of the medical record for Resident #84 revealed an admission date on 06/20/24. Medical diagnoses included atrial fibrillation (A-Fib), heart failure, hypertension, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and a personal history of venous thrombosis and embolism. [...]

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure a complete and accurate medical record for one (#81) of 29 sampled residents. The facility census was 109. Findings Include: 1. Review of the medical record for Resident #81 revealed an initial admission date of 10/31/24 with the latest readmission date 12/12/24 with the diagnoses including but not limited to pneumonitis due to inhalation of food and vomit, bacteremia, metabolic encephalopathy, severe sepsis with septic shock, intestinal obstruction, dysphagia, severe protein calorie malnutrition, acute respiratory failure with hypoxia, aphasia, anxiety disorder, periodontal disease, seizures, traumatic brain injury, tracheostomy, anemia, gastro-esophageal reflux disease, hypertension, chronic obstructive pulmonary disease, constipation, insomnia and cerebral infarct. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews and review of facility policy, the facility failed to follow infection control policies for two residents. This affected two (Residents #85, and #164) of five (Resident #10, #81, #85, #163, and #164) residents reviewed for infection control. The facility census was 109 residents.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe manner. This affected one (#108) out of 22 residents who smoke in the facility. The facility census was 113.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to maintain a safe accident free environment and prevent a fall with injury for Resident #20. Actual Harm occurred on 05/03/24 when Resident #20 sustained a fracture of metatarsal bone and talus as a result of a fall sustained when the resident stepped from the transportation bus onto an unstable milk crate placed by facility staff, when exiting the transportation bus. Following the incident, Resident #20 complained of left knee and right foot pain and bruising was noted on her right ankle. Nursing noted Resident #20 had right extremity swelling, bruising, and uncontrolled pain, rating her pain an eight on a scale of one to 10 prior to her being sent to the hospital for evaluation and treatment. This affected one resident (#20) of three residents reviewed for accidents. [...]

Inspectors wroteBased on observations, review of facility policy, and staff interviews, the facility failed to ensure garbage and food waste was disposed of in a timely manner. This had the potential to affect all 108 residents residing at the facility.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to complete wound assessments accurately to reflect the residents current wound condition. This affected one (Resident #207) of the three residents reviewed for skin management and breakdown prevention. The facility census was 95.

Inspectors wroteBased on medical record review, X-ray result review, staff interview, and facility policy review, the facility failed to ensure weekly skin observations were completed on residents at risk for skin breakdown. This affected one (Resident #207) of the three residents reviewed for skin management and breakdown prevention. The facility census was 95.

Inspectors wroteBased on medical record review, hospital record review, X-ray result review, staff interview, and facility policy review, the facility failed to ensure residents being transported with the facility's van was properly secured to prevent falls and to report incidents immediately after they occur. This affected one (Resident #231) of the three residents reviewed for falls. The facility census was 95.

Inspectors wroteBased on medical record review, medication administration observation, staff interview, and review of facility Medication Administration policy, revealed the facility failed to ensure hand hygiene was completed between care for each resident during medication administration. This affected two (Resident #129 and #139) of the three residents reviewed during medication administration. The facility census was 95.

Inspectors wroteBased on resident and staff interviews, review of weekly menus, review of substitution log, review of food committee minutes, and facility policy review, the facility failed to ensure menus provided a variety of foods according to resident preferences. This had the potential to affect all 74 residents who received meals from the kitchen. The facility did not have any residents who were unable to eat by mouth (NPO). The census was 74.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure foods were properly dated and were discarded when appropriate. This had the potential to affect all 74 residents who received food from the kitchen. The facility did not have any residents who were unable to eat food by mouth (NPO). The census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy, the facility failed to ensure residents were assisted with meals in a dignified manner. This affected one (Resident #18) of one resident reviewed for dignity. The facility census was 74.

Inspectors wroteBased on medical record review, staff and resident, and policy review, the facility failed to ensure residents were bathed at their preferred time of day. This affected one (Resident #30) of one resident reviewed for bathing. The facility census was 74.

Inspectors wroteBased on medical record review, review of a Beneficiary Notice list, review of a SNF Beneficiary Protection Notification Review, staff interview, and facility policy review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage was provided to residents as required. The deficient practice affected one (Resident #8) of three residents reviewed for beneficiary notices. The facility census was 74.

Inspectors wroteBased on medical record review, staff and resident interview, review of facility investigation and self-reported incident (SRI), review of witness statements, and policy review, the facility failed to ensure residents were free from abuse and failed to ensure staff intervened in a timely manner during an instance of abuse. This affected two (#15 and #68) of three residents reviewed for abuse. The facility census was 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected one resident (#45) out of 21 residents reviewed for accurate assessments. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, review of Pre-admission Screening And Resident Reviews (PASARR), and facility policy review, the facility failed to complete an updated PASARR when a new mental health diagnosis was given and failed to ensure PASARR's were accurate. The deficient practice affected two (Residents #6 and #39) of two residents reviewed for PASARR. The facility census was 74.

Inspectors wrote3. Review of the medical record for Resident #53 revealed an initial admission date of 05/03/23. Medical diagnoses included anoxic brain injury, larynx cancer, hemorrhage from tracheostomy stoma, anxiety, major depression, high blood pressure, and laryngectomy. Review of the discharge return anticipated [NAME] Data Set (MDS) assessment, dated 10/08/23, revealed Resident #53 had impaired cognition. Resident #53 required extensive assistance from staff for activities of daily living (ADL) tasks, and had a laryngectomy which required oxygen use and suctioning. Review of Resident #53's care plan, dated 10/14/23 revealed Resident #53 self-removing his tracheostomy cannulas was not addressed in the care plan. The tracheostomy care plan did not reference Resident #53 self-removing his tracheostomy cannulas. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for assistance were provided adequate nail care. This affected two (#18 and #31) of three residents reviewed for activities of daily living (ADL). The facility census was 74.

Inspectors wroteBased on medical record review, review of lab test results, review of weekly wound observation evaluations, staff interview, and facility policy review, the facility failed to provide timely treatment following critical lab results and failed to ensure weekly wound observation evaluations were completed accurately. The deficient practice affected two residents (Residents #23 and #67) of nine residents reviewed for skin impairments and lab test results. The facility census was 74.

Inspectors wroteBased on resident and staff interview, and medical record review, the facility failed to accurately assess a residents hearing and to make a timely referral to an audiologist. This affected one (#30) of one resident reviewed for ancillary services. The facility census was 74.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected two residents (#45 and #49) of four residents reviewed for falls. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure there were physician orders in place to care for a residents an indwelling urinary catheter. This deficient practice affected one resident (Resident #53) out of two residents reviewed for indwelling urinary catheter care. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interviews, review of hospital records, and facility policy review, the facility failed to ensure there were physician orders for heated humidified oxygen for a resident who was receiving heated humidified oxygen. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to ensure pain medication was administered as ordered. This affected one resident (#30) of two residents reviewed for pain management. The facility census was 74.

Inspectors wroteBased on staff interview, medical record review, and review of facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to administering anti-anxiety medications. This affected one resident (#30) of six residents reviewed for unnecessary medications. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to maintain a medication error rate less than five percent (%). There were two medication errors out of 30 opportunity which resulted in a medication error rate of 6.67%. This affected one resident (Resident #53) out of three residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to residents were free from significant medication errors. This affected one resident (Resident #53) out of three residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on medical record review, resident and staff interviews, and facility policy review, the facility failed to ensure medical records were accurate. This affected two residents (Residents #23 and #30) of 21 residents reviewed whose medical records were reviewed. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to follow proper infection control practices during medication administration. This affected one resident (Resident #53) out of three residents observed for medication administration. The facility census was 74.

Inspectors wroteBased on medical record review, review of an emergency room note, review of infection control log, staff interview, and facility policy review, the facility failed to ensure there was appropriate justification for antibiotic use. This affected one (Resident #23) out of six residents reviewed for unnecessary medications. The facility census was 74.