Shelton Health and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and limit the spread of a gastrointestinal (GI) illness and Norovirus (a virus causing acute GI outbreaks in long-term care facilities, resulting in symptoms such as nausea, vomiting, and diarrhea, which rapidly spread from person to person) by ensuring GI Contact Precaution(limiting direct or indirect contact with the resident or environment by wearing gown and gloves during resident care for residents requiring transmission based precautions and washing hands with soap and water) were followed for 23 of 34 (1, 2, 5, 6, 7, 8, 9, 11, 13, 15, 17, 18, 19, 20, 24, 25, 26, 27, 30, 31, 33, 35, and 36) residents reviewed for a GI or Norovirus illness. The facility failed to cohort (a group of residents with similar symptoms) and isolate residents with the illness and protect residents exposed to the illness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include resident risk for bruising 3 of 4 (3, 4, 5) resident reviewed for bruising and for infection control measures for 14 of 21 sampled residents (1, 2, 6, 8, 13, 15, 17, 19, 20, 24, 25, 26, 30 & 31) reviewed for care plans. The failure placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to thoroughly investigation and implement interventions for allegations of injuries of an unknown origin for 3 of 4 residents (3, 4, 5) residents reviewed with allegation of injuries of unknown origin. The failure left residents at risk for unidentified abuse and/or neglect, recurrence of events, and a decreased quality of life.

Inspectors wroteBased on record review and interview the facility failed to ensure discharge planning included providing recent information related to an abuse allegation and recent fall for 1 of 3 (Resident 1) reviewed for admission, transfer and discharge. This failure placed residents at risk for unmet care needs and decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to protect residents receiving narcotic medications from misappropriation on two of three medication carts (Team 2 & Team 3 Carts) from 12/09/2026-03/26/2026, when staff identified concerns that a registered nurse was diverting narcotic medications; however, the facility failed to report, investigate, or take action on the allegations, allowing the suspected diversion to continue. This failure resulted in residents not receiving prescribed pain medications and the potential misappropriation of medications for which residents were financially responsible.

Inspectors wroteBased on interview and record review the facility failed to implement a system to consistently and accurately reconcile controlled medications, using acceptable standards of practice for controlled substances for 3 of 6 residents (Residents 1, 5 and 6) reviewed for medication administration. This failure placed residents at risk of unmet care needs, unrelieved pain and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the administrator implemented and enforced facility policies and procedures related to the reporting and investigation of allegations and the safeguarding of controlled substances, when the administrator was made aware of potential narcotic diversion but failed to report the allegation, conduct a thorough investigation, or implement measures to prevent ongoing access to controlled substances. This failure resulted in a breakdown in administrative oversight and placed residents at risk for not receiving prescribed medications, unrelieved pain, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide behavioral health services to 1 resident of 3 residents (Resident 7) reviewed for behaviors. The facility's failure to provide behavioral health services placed residents at risk for increased behaviors and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored and documented on, including the interventions, for 5 of 5 sampled Residents (6, 7, 9, 45, and 50) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (resident advocates) occurred for residents transferred to the hospital for 3 of 3 sampled residents (Residents 3, 6, & 67) reviewed for hospitalization and 1 of 1 Resident (Resident 69) reviewed for Against Medical Advice (AMA) discharge. This failure placed residents at risk of a lack of advocacy and possible unidentified or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include, resident behavior monitoring and specific interventions, and guardianship for 6 of 16 sampled Residents (6, 7, 54, 9, 45, and 50) reviewed for comprehensive care plans. This failure to establish care plans that were comprehensive placed residents at risk of receiving inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 entries or 2 of 4 residents (Resident 80 & 39) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to implement a system that ensured a copy of a residents advanced directives (AD, written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney for health care) were requested/obtained upon admission and residents without ADs were provided written information about and informed of their right to formulate one, for 2 of 4 residents (Resident 11 & 8) reviewed for ADs. This failure placed residents at risk of not having their health care goals and treatment choices honored in the event they were incapacitated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure potential restraints were assessed for safety, risks versus benefits associated with the device were discussed with the resident and/or representative and consent was obtained prior to device implementation for 1 of 2 residents (Resident 6) reviewed for physical restraints. This failure placed residents at risk for feelings of powerlessness, restrained or inhibited movement, physical injury, psychosocial harm and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medication related to excessive duration for 1 of 6 residents (Resident 19) reviewed for medications. This failure placed residents at risk of medication complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to assess food preferences and provide food that met preferences for 3 of 7 residents (Residents 75, 76, and 11) reviewed for food. These failures placed residents at risk for hunger, nutrient deficiency and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of their inter-disciplinary team (IDT) who would be responsible for working with the hospice representatives to ensure effective coordination of care between the facility and hospice staff and to have documentation in residents' Electronic Health Records (EHR) that showed when hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) participated with care and what care was provided for 1 of 1 sampled resident (Resident 3) reviewed for hospice services. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate staff supervision to ensure fall prevention interventions were adequate, effective, and/or implemented for residents assessed at high fall risk for 3 of 4 residents (Resident 1, 2 and 4) reviewed for falls. Resident 1, who had eight unwitnessed falls from their bed, experienced harm when two of the unwitnessed falls resulted in injury that required transportation to the hospital for treatment. Resident 1 sustained a fracture of the lumbar (lower back) spine during one of the falls and sustained facial fractures in a separate fall occurrence. These failures placed residents at risk for further falls, injury, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing levels were met to follow the plan of care and services for 5 of 10 residents (1, 2, 4, 5 & 6) reviewed for staffing. This failure placed residents at risk for unmet physical, mental and psychosocial needs, a decline in health status and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with respect and honor privacy while having private conversations for 1 of 1 sampled resident (1) reviewed for privacy. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered laboratory values were obtained for 1 of 3 residents (Resident 14) who was declining, found unresponsive and had to be hospitalized , and failed to ensure the bowel protocol was followed for 2 of 7 residents (Residents 13 & 49) reviewed for bowel protocol. Resident 14 experienced actual harm when the facility failed to follow physician orders, failed to provide adequate hydration and failed to consistently monitor and document resident's change in condition and the resident developed altered mental status and sepsis (infection of the blood) and urinary tract infection (infection in the urine) and required intensive care level hospitalization. This failure placed residents at risk for unidentified and untreated sepsis, dehydration, constipation, decline, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident meal intake was accurately recorded, nutritional supplements were provided as ordered, weights were timely obtained and evaluated, significant weight loss was identified, and nutritional interventions were implemented and evaluated for effectiveness for 3 of 5 sampled residents (Residents 14, 49, & 29) reviewed for nutrition. Resident 14 experienced harm when they had a severe weight loss of 14.89% over six months. Resident 49 experienced harm when they had a 11.09% weight loss in 34 days before it was identified by staff. This failure placed all residents at risk of malnourishment, weakness, unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer oxygen (O2) in accordance with physicians' orders, to monitor and replace humidifier bottles when empty, and to ensure O2 concentrator filters (used to protect the resident from inhaling dust and particulate matter) were routinely cleaned and maintained for 3 of 3 residents (Residents 51, 38 & 32) reviewed for respiratory care. These failures placed residents at risk for respiratory compromise, dry nares and other negative healthcare outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) were reviewed in a manner that explicitly informed the resident or their representative of their right not to sign the binding arbitration agreement and/or to explain what a binding arbitration agreement was in a manner they could understand, for 3 of 3 sampled residents (Residents 32, 51, & 54) reviewed for binding arbitration agreements. This failure placed residents at risk for legal complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when the facility failed to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions used when someone has confirmed or suspected infections) for 3 of 5 (Residents 13, 14, & 12) reviewed for infection control. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer of funds, from a resident trust account, was completed within 30 days following their discharge for 2 of 5 residents (Residents 165 and 166) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse, neglect, or mistreatment that was identified by staff was reported to the Administrator and/or the state agency as required for 1 of 3 residents (Resident 18) reviewed for allegations related to abuse/neglect. This failure prevented the facility from conducting an immediate investigation, taking steps to protect residents from further abuse/neglect if necessary, conducting a thorough investigation and monitoring and treating residents as needed for potential harm.

Inspectors wroteBased on interview and record review, the facility failed to provide the Ombudsman with transfer notification for 2 of 5 sampled residents (Residents 7 & 14) reviewed for hospitalization. The failure to ensure required notifications were completed, prevented the Office of the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes) the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wrote2) Resident 49 admitted to the facility on [DATE]. Review of the 02/14/2024 admission MDS, dated [DATE], showed the resident did not use a wander/elopement alarm. Review of the electronic health record showed an order was obtained and consent provided for placement of a wander guard to Resident 49's left wrist. On 03/18/2025 at 8:02 AM, Staff B, DNS, confirmed Resident 49's wander guard should have been coded on the admission MDS. Based on interview and record review, the facility failed to accurately assess Minimum Data Sets (MDS, an assessment tool) for 4 of 18 sampled residents (Resident 29, 49, 13 & 14) reviewed. Failure to ensure accurate assessments regarding Wander guard (alarm), resident refusals, and signficant weight loss placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wrote<Resident 49> Resident 49 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident's diagnoses included non-Alzheimer's dementia, psychotic disorder (severe mental illness that causes abnormal thinking and perceptions) and depression, and the resident was treated with antipsychotic and antidepressant medication during the assessment period. Review of Resident 49's Level I PASRR, dated 02/04/2025, showed the resident had a diagnosis of major depressive disorder, but not a diagnosis of psychotic disorder. The assessment determined Level II PASRR evaluation for serious mental illness (SMI) was not indicated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised and accurately reflected resident care needs for 5 of 18 sampled residents (Resident 51, 41, 49, 38 & 14) reviewed for care plans. This placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wrote2) Resident 51 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and required substantial to maximal assistance with bathing/showering. On 03/10/2025 at 3:19 PM, Resident 51 reported they were supposed to be bathed every Monday and Thursday, but staff don't show up. Review of Resident 51's bathing flowsheet showed the resident was scheduled to be bathed every Thursday and Sunday on evening shift. Review of the bathing record showed for the 30-day period from 02/13/2025 - 03/13/2025, showed the resident was offered/provided bathing 02/23/2025, 03/02/2025 and 03/09/2025. On 03/18/2025 at 11:02 AM, when asked if Resident 51 was consistently offered/provided bathing per their bathing schedule Staff D, Resident Care Manager (RCM), stated, No. 3) Resident 41 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently document pre and post dialysis (a treatment to filter wastes and water from the blood) assessments and medications received, by making sure there was consistent ongoing follow-up with the dialysis center regarding the dialysis care and services for 1 of 1 sampled resident (Resident 163) reviewed for dialysis. This failure placed the resident at risk for unmet care needs and medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent, when 15 of 32 medication administration opportunities resulted in a 46.88% error rate due to late administration and omitting administration for 3 of 4 sampled residents (Residents 6, 12, and 57) reviewed for medication administration. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects, and other potential negative outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secured in a locked storage area and inaccessible to unauthorized staff and residents, for 1 of 2 medication carts (Team 3 Med Cart) observed for medication cart review and 1 of 4 residents (Resident 12) observed for medication administration. These failures placed residents at risk for unauthorized access to medications, medical complications, and a diminished quality of life.

Inspectors wrote2) Resident 35 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 35 was severely cognitively impaired and needed set up assistance for being independent with ADLs. A review of the EHR showed a progress note, dated [DATE] at 7:35 PM, documented Resident 35 was taken to the hospital. There were no other progress notes that documented when Resident 35 returned to the facility from the hospital. On [DATE] at 1:47 PM, Staff C, RCM/RN, confirmed Resident 35 was sent to the hospital on [DATE] and he said they returned to the facility on [DATE]. Staff C said he did not see a progress note in the EHR and he had to look at the census to see when Resident 35 returned to the facility from the hospital. Staff C said his expectation was for staff to write a progress note when a resident came back from the hospital. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff performed complete Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and failed to assure required staff had unexpired CPR certifications for 1 of 1 resident (Resident 2) who was found unresponsive and had a physician's order for CPR. The failure of facility staff to initiate respirations during CPR placed all residents who chose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 4:25 PM, the facility was notified of an IJ at CFR 483.24 (a)(3), F678 CPR, the IJ was determined to have begun on [DATE] when the facility failed to perform complete CPR with respirations. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely physician visits were within the first 30 days after admission for 2 residents of 5 sample residents (Resident 11 and 14) reviewed for physician visits. This failure placed residents at risk of being denied face to face contact with a physician, during comprehensive review and for assessment of their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to update care plan and/or implement new interventions after resident had a fall for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for injury and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an abuse allegation was reported timely for 1 of 3 residents (Resident 2) reviewed for abuse. This failure placed residents at risk for abuse, neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to or a statement of the resident's appeal rights for 3 of 5 sampled residents (Resident 8, 12 & 9) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was followed up with a Level II screening for 3 of 6 residents (Resident 3, 12 & 27) reviewed for PASRR. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing. The facility's failure to follow written recipes for preparation of pureed food placed residents at risk for decreased satisfaction with meals.

Inspectors wroteBased on observation and interview, the facility failed to respect and value the residents' private space by knocking and/or announcing themselves prior to entering a Resident's room and honoring residents' food preferences for 2 of 4 sampled residents (Resident 200 & 299) reviewed for resident rights and dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 4 residents (Resident 199) reviewed for showers. This failure placed residents at risk for feeling unclean and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were maintained in good condition for 1 of 3 sampled rooms (room [ROOM NUMBER]) reviewed for homelike environment. This failure placed residents at risk of not having rooms maintained with a comfortable interior and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide residents/residents' representatives written bed hold notices at the time of transfer, or within 24 hours of an emergent transfer for 2 of 5 residents (Resident 12 and 9) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days after the facility determined, or should have determined, that there was a significant change in a resident's physical or mental condition for 1 of 1 resident (Resident 9) reviewed for a decline in activities of daily living (ADLs). Failure to identify Resident 9's decline in ADL function and to complete a SCSA, placed the resident at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess 4 of 22 residents (Residents 12, 27, 21 & 9), reviewed for accurate Minimum Data Set (MDS, an assessment tool). Failure to ensure residents' preferences, customary routine and activities were assessed, and dental status accurately coded, placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed prior to admission as required for 1 of 6 residents (Residents 27) reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet behavioral healthcare needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan with a specific measurable goal for 1 of 6 residents (Resident 31) reviewed for care plans. This failure placed residents at risk for unidentified and unmet care needs and diminished quality of life. Findings Included . Resident 31 was admitted to the facility on [DATE] with diagnosis of hypertension, depression, spinal stenosis (narrowing of spinal column and potential compression of the spinal cord) and muscle weakness. The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/17/2023, documented Resident 31 required extensive assistance with activities of daily living (ADL). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 22 sample residents (Resident 12 & 21) reviewed. The failure to obtain and/or follow physician's orders, and to notify the physician when medications were held, placed residents at risk for medication errors, and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 6 residents (Residents 12 & 21) reviewed for bowel management and 1 of 5 residents (Resident 27) reviewed for positioning. The failure to initiate bowel care in accordance with physician's orders and to implement positioning measures residents were assessed to require, placed residents at risk for pain/discomfort, wound development, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for 1 of 2 residents (Residents 100) reviewed for accidents. The failure to ensure portable liquid oxygen (O2) canisters were secured to residents' wheelchairs and in good repair, placed residents at risk for severe frostbite or cryogenic burns, pain and other potential negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices were assessed and monitored in accordance with professional standards of practice for 1 of 1 resident (Residents 100) reviewed for IV therapy. The facility failed to provide Midline (a catheter is an 8 - 12 centimeter catheter inserted in the upper arm with the tip located just below the armpit) maintenance and monitoring to include changing needleless injection caps and monitoring the external length to verify the line had not migrated. This placed residents at risk for loss of vascular access, infection, and other potential negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice for 1 of 2 sampled residents (Residents 22) reviewed for respiratory care. The facility's failure to ensure physician's orders were in place before administrating oxygen treatment placed residents at risk for discomfort, a potential negative outcome and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for target behaviors for 1 of 5 sampled residents (Resident 199) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made out of 34 opportunities during medication administration for two of seven residents (Resident 38 & 32) who were sampled/observed for medication administration. The facility's medication error rate was 5.8%. This placed the residents at risk of receiving medications that were not effective or less effective.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were kept secure and not left at the resident's bedside for 1 of 3 hallways reviewed for medication storage. This failure placed residents at risk for not receiving the full benefits of the medications or potential overuse of the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure dental services were provided for 1 of 4 Medicaid residents (Residents 12) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to use ill-fitting dentures and/or go without dentures. These failures placed residents at risk for difficulty chewing, oral pain, decreased self-image and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate personal protective equipment (PPE) was donned (put on) timely for 1 of 3 sampled residents (Resident 18) observed on enhanced barrier precautions and failed to ensure staff maintained safe and sanitary food service for 1 of 3 hallways. This failure placed residents at risk for facility acquired or healthcare associated infections and related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the posted menu and/or failed to post an updated menu and notify residents of the change. Failure of the facility to follow written menus and accurately serve planned menu items and/or communicate substitutions to residents, detracted from residents' ability to select an alternative meal if the substitution was not to their liking. This placed residents at risk for dissatisfaction with meals and decreased intake.

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for implementing a facility-initiated discharge for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed residents at risk for homelessness, unmet care needs, and a diminished quality of life.