Skies Healthcare & Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to notify the facility provider (Physician's Assistant) and the Director of Nursing (DON) for 1 (R #1) of 1 (R #1) resident with an abnormal urinary analysis (UA; a laboratory test on urine to detect infection) and dark colored urine. If the facility does not notify providers and clinical leadership of abnormal health related findings, residents are at increased risk for deterioration in condition, delayed medical intervention, hospitalization, or additional complications.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident, when:Facility staff did not complete a urinary analysis (UA; a laboratory test on urine to detect infection) or a culture and sensitivity (C and S; a test used to detect urinary tract infections and determine effective antibiotics) test as intended and per professional standards. Facility staff did not review and implement the appropriate plan of care for R #1's abnormal UA test results for approximately seven days. If ordered laboratory tests are not completed as intended and staff delay implementing an appropriate plan of care for abnormal health related findings, residents may receive substandard care and treatment, placing them at risk for preventable harm

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, #2 and #3) resident, when:The facility failed to ensure R #1 continued to receive sliding scale insulin immediately after he returned from a hospitalization. If the facility fails to obtain and verify appropriate medication orders for a resident with a history of consistently receiving sliding scale insulin, then residents are likely to experience poorly controlled blood glucose (sugar) levels, worsening symptoms, disease progression, and avoidable complications.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #4) of 2 (R #'s 3 and 4) resident, when the facility staff failed to:Use two staff members to safely transfer R #4 with a Hoyer lift (equipment used to move residents who have limited mobility) as required. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (NAIT #1 and NAIT #2) of 5 (NAITs #1, #2, #3, #4, and #5) Nurse Aides in Training completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 109 residents residing at the facility by allowing untrained staff to provide direct care to residents.

Inspectors wroteBased on observations, and interviews, the facility failed to properly store medications and medical supplies located in the facility medication carts and medication storage room when the staff failed to ensure:-Medication carts are free of any lose pills.-Medication carts are not left unlocked and unattended. -Expired medication and supplies are properly discarded.-Medications of discharged residents are taken out of the medication cart.-Medication fridge temperature is being monitored routinely. These deficient practices have the potential to affect all 109 residents as identified by the census provided by the Administrator on [DATE]. If the facility does not ensure safe storage practices, then residents are at risk for adverse effects due to improper storage and not receiving the full benefits of medications.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the nutritional needs and preferences were met for all 109 residents list on the resident census list provided on 01/04/26 by the facility Administrator by not following the menu. This deficient practice could prevent residents from eating well, not meeting their nutritional needs and lead to weight loss.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly label drink items while on carts in 400 hallway, 2. Properly store milk on ice on cart in 400 hallway,3. Properly label and store foods in the kitchen. These deficient practices are likely to affect all 109 residents listed on the resident census list provided by the Administrator on 1/04/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly.

Inspectors wroteBased on observation, record review and interview, the facility's Administrator (ADM), Infection Prevention Coordinator (IPC) and Interim Director of Nursing (IDON) failed to administer the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring staff were trained and/or competent before providing care to residents,2. Not ensuring appropriate infection control practices for residents with contact precautions,3. Failure to know specific orders are required for oxygen use. These deficient practices are likely to affect all 102 residents residing in the facility according to the daily census provided by the Admissions Coordinator (AC) on 12/07/25 and could lead to residents not maintaining their highest practicable physical, mental, and social well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement and follow an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by 1. Not ensuring transmission-based precautions (actions implemented based upon the means of transmission to prevent or control infection) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection).2. Not ensuring staff follow the appropriate precautions posted. These failed practices have the potential to affect all 109 residents living in the facility as identified by the census provided by the Administrator 01/04/26. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #11 and R #63) of 3 (R #11, R #63, R #109) residents reviewed for unnecessary medications, when staff failed to ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 4 (R #13, R #63, R #71 and R #94) of 5 (R #13, R #63, R #71, R #94 and R #109) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 3 (R #21, R #63 and R #71) of 4 (R #12, R #21, R #63, and R #71) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #21's diagnosis of Multidrug-Resistant Organism (MDRO; a germ that is resistant to many antibiotics),2. Develop a care plan to include interventions for R #21's need for Modified Protective Environment Precautions, (a facility policy with special instructions to protect residents in their environment).3. Develop a care plan for R #63's use of bed rails.4. Develop a care plan for R #71's use of Continuous Positive Airway Pressure Machine (CPAP; a medical device that delivers pressurized air through a mask to keep your airway open during sleep). [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 5 (R #20, R #35, R #41, R #71, and R #109) of 6 (R #20, R #35, R #41, R #63, R #71, and R #109) residents reviewed for respiratory care when the facility failed to:1. Ensure medical orders include the amount of oxygen (a specific flow rate; measurement of the volume of liquid or gas moving per unit of time) for R #20 and R #35.2. Ensure a medical order was in place for R #41's supplemental oxygen (extra oxygen required to support the body's vital functions) use. 3. Ensure medical orders, care plan and MDS (Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) were in place and accurate for R #71's use of a continuous positive airway pressure (CPAP; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain appropriate physician orders and complete assessments prior to installation of bed rails for 1 (R #118) of 2 (R #63 and R #118) residents reviewed for bed rails. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% as ordered to 3 (R #s 5, 20, and 100) of 6 (R #s 1, 5, 20, 33, 86, and 100) residents reviewed. During the survey period, the survey team observed 27 opportunities for error and identified 3 errors, resulting in a medication error rate of 11.11%. Failure to administer medications as ordered could result in residents not receiving the full benefit of the medication regime.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received dental services for 2 (R #34 and R #56) of 3 (R #3, R #34, and R #56) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing.

Inspectors wroteBased on observation, and interviews, the facility failed to protect residents' personal health information (PHI) by leaving a document containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) in a hallway. This deficient practice has the potential to affect residents residing on the 300 and 200 hall and can lead to unauthorized access to sensitive information, putting residents' privacy at risk.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance.

Inspectors wroteBased on observation and interview, the facility failed to promote care with dignity and respect for 1(R #22) of 9(R #1, R #6, R #11, R #22, R #28, R #35, R #41, R #64 and R #71) residents reviewed for dignity and respect by not knocking on R#22's door before entering room. This deficient practice is likely to impact residents' dignity and respect for their personal space.

Inspectors wroteBased on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis for 1 (R #12) of 2 (R #11 and R #12) residents reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.

Inspectors wroteBased on record review, observation and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #21) of 2 (R #12 and R #21) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #100) of 1 (R #100) resident reviewed when the staff failed to follow physician orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #5) of 1 (R #5) resident is receiving restorative services (services necessary to ensure the resident's abilities are not diminished). If the facility is not ensuring residents receive restorative services at the commencement of therapy services when indicated, residents are likely to experience a decrease in their activities of daily living.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide restorative physical therapy service devices as recommended by the therapy department for 1 (R #5) of 1 (R #5) residents. This deficient practice is likely to result in residents having pain and a decrease in mobility, causing psychosocial harm and despair.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with a foley catheter (a flexible, tube-like medical device inserted into the bladder to drain urine) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #63) of 1 (R #63) resident reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 109 residents as identified by the census provided by the Administrator on 01/04/2026 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off the residents' current diagnosis for 1 (R #63) of 2 (R #21 and #63) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure transportation was provided for a scheduled oncology (the study and treatment of tumors) appointment for 1 (R #94) of 1 (R #94) resident reviewed. This failure resulted in the resident missing a prescribed chemotherapy treatment, potentially impacting the resident's health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received rehab therapy (intended to restore the body to their highest degree of performance) services within a reasonable timeframe after the doctor ordered it for 1 (R #5) of 1 (R #5) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in residents' functional mobility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) and Nurse Aides in Trainings (NAIT) received the required in-service training of 12 hours per year for 2 (CNA #4 and NAIT #1) of 5 (CNA #2, CNA #4, NAIT #1, NAIT #2, NAIT #3) CNA's reviewed for training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to administer medication as prescribed for 3 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3) reviewed for medication administration when staff failed to: 1. Ensure medications were administered to R #1 and R #2 as ordered and documented.2. Ensure R #1 and R #2 were given the correct medications. 3. Ensure R #3 's Fentanyl patch (medication used to treat pain) was properly paced on resident. If the facility does not administer medications as prescribed, the resident is likely to not get the therapeutic results of medication needed and may result in unmanaged symptoms or adverse outcomes.

Inspectors wrotePAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure a resident was free of accident hazards when staff failed to assist a resident who required two persons assistance and a mechanical lift (a device such as Hoyer Lift that is used to lift and move a person from on location to another) when changing positions for 1 (R #1) of 1 (R #1) resident. This failure could likely result in resident to fall and inquire injuries.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications for 2 (R #2 and 3) of 3 (R #2, 3 and 9) residents were: - available in the facility to be administered to R #3, - administered at the right time 6:30 AM for R #2. These deficient practices could likely result in unresolved infections, worsening of infection or uncontrolled pain.

Inspectors wroteBased on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 114 residents who resided in the facility when staff failed to: 1. Offer baths or showers to the residents as scheduled and per residents' preference. 2. To answer call lights within a reasonable timeframe (under 10 minutes) for residents that require activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance. These deficient practices are likely to negatively impact resident comfort.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 5, and 6) of 2 (R #'s 5, and 6) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the PEG (Percutaneous (through the skin) Endoscopic (a medical procedure that uses a scope to look into the digestive system) Gastrostomy (a surgical procedure that creates an opening through the abdominal wall) tube (a device utilized to provide liquid nutrition and medications, via a tube into the stomach or intestine) for 1 (R #1) of 1 (R #1) resident, was managed according to current acceptable standards of practice to ensure safety of the resident. This deficient practice could cause significant health problems such as infection or displacement of the tube

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 1 (R # 2) of 1 (R # 2) resident reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 1 (R #9) of 1 (R #9) resident reviewed for choices when staff failed to offer R #9 showers per her preference. This deficient practice is likely to result in the residents' personal choices not being honored.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated with the post fall neurological evaluations/assessments (a thorough assessment of your nervous system, including your brain, spinal cord, and peripheral nerves) for 1 (R #4) of 1 (R #4) resident reviewed for falls. This deficient practice could likely result in staff not knowing residents' daily care events, changes, and their needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents are able to receive mail on Saturdays for all 114 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation.

Inspectors wroteBased on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 114 residents who resided in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled. 2. Provide meals and snacks to residents timely. 3. Meet the needs of the residents. These deficient practices are likely to negatively impact resident comfort.

Inspectors wroteBased on observation and interview, the facility failed to ensure food holding temperatures were at 135° (degrees). Failure to ensure the food is at appropriate temperature is likely to cause residents not to eat meals which could lead to weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: 1. Deliver meals consistently and timely 2. Deliver snacks consistently and timely These deficient practices affected all 114 residents residing in the facility and are likely to cause anger and frustration with the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to : -Store open food in a manner that prevents cross contamination and label and date food. -Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen. - Document the correct sanitizing solution as required. -Maintain the kitchen environment in a clean and sanitary manner. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. This failure had the potential to affect all residents who ate food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 (R #56) of 1 (R #56) resident was provided privacy in his own room and with visitors. Facility staff invaded R #56's privacy by assigning a staff member to to provide 1:1 sitter (a staff member assigned to monitor and accompany a resident) care. The sitter consistently sat at a table in his room during all hours of the day and night. This deficient practice is likely to cause residents to feel invaded and overwhelmed by staff.

Inspectors wroteBased on record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 96 and 105) of 2 (R #'s 96 and 105) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review, interview and observation, the facility failed to provide an ongoing program of activities designed to meet the interests for 1 (R # 72) of 1 (R # 72) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests as identified on his individual care plan. If resident is not provided or encouraged to attend/participate in activities that meets his interests, then he is likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 2 (R #'s 29 and 115) of 2 (R #'s 29 and 115) residents reviewed for dialysis. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on observation, record review and interview, the facility administered medications with an error rate greater that 5%. Medications were observed being administered to 2 (R #33 and 54) residents past the ordered medication administration time. Of 25 opportunities, 12 medication were administered late, an error of administration. This likely resulted in a medication error rate of 48%. If medications are not administered at the scheduled ordered times, the treatment will be less effective and residents will receive less than optimal care.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication storage room were not expired. These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications and medical supplies due to inappropriate storage.

Inspectors wroteBased on observation, record review and interview, the facility failed to promote care with dignity and respect for 1 (R #418) of 1 (R #418) resident reviewed for residents rights by administering an insulin injection in the dining room while having lunch. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a Comprehensive MDS (Minimum Data Set) Assessment was accurate for 1 (R # 72) of 1 (R #72) residents reviewed for accurate MDS Assessments. If resident assessments are not accurate, the facility could misidentify clinical complications resulting in failure to provide adequate care to treat the resident's medical condition.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #56) of 3 (R #56, 58, and 104) residents. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 2 (R #25 and #56) of 2 (R #25 and #56) residents reviewed. If the facility is not updating the care plan to reflect the coordination of care with outside entities then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care for 1 (R #68) of 1 (R #68) resident reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #51) of 1 (R #51) residents reviewed for food preferences. If the facility is not incorporating resident preferences into resident diets the residents are likely to experience weight loss, frustration and depression.

Inspectors wroteBased on record review and interview, the facility failed to ensure for 1 (R #1) of 3 (R #1, 2 and 3) residents reviewed for bowel monitoring and interventions when the facility failed to monitor R #1 for constipation (problem with passing stool). This deficient practice likely resulted in R #1 having ongoing constipation, fecal impaction (hardened stool stuck in rectum or lower colon due to chronic constipation) and abdominal pain.

Inspectors wroteBased on record review and interview, the facility failed to maintain a process to ensure residents were bathing on a regular basis, for 3 ( R #10, R #9, and, R #8) of 6 ( R #10, R #9, R #12, R #13 , R #8, and R #11 ) residents reviewed for showers. This deficient practice could likely result in residents feeling frustrated and uncomfortable. Findings for R #10: A. Record review of R# 10's face sheet revealed that R #10 was admitted to the facility on [DATE]. B. Record review of R #10's shower sheets and bathing documentation for February 1st through February 21st 2024, revealed she had four showers. C. On 02/21/24 at 9:21 am, during an interview with R #10, she stated during her care plan conference, she preferred to shower three times a week. She said many times the nursing aides told her they were short handed on the hall; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to serve food according to the presented menu and meal ticket for 1 (R #8) of 2 (R #8, R #1) reviewed for food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a manner that prevented foods in dry storage from becoming contaminated from rodent activity. This deficient practice could lead to foodborne illnesses that could affect all 115 residents identified on the alphabetical census list provided by the Administrator on 10/23/23 who eat food prepared in the kitchen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program by not ensuring the facility was free of rodents. This deficient practice is likely to affect all 115 residents listed on the resident census list provided by the Administrator on 10/23/23 and could likely lead to contamination of food prepared in the kitchen causing illness in the residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide training and maintain a sufficient amount of dietary staff to meet the needs of all residents listed on the census that was provided on by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents not receiving food on time or food that was stored and prepared safely to the industry standard. A. Record review of the dining services policy titled Department Staffing. last revised 09/2017, revealed: The Dining Services department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. Further review revealed the following: 3. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to: 1. Serve food according to the presented menu 2. Communicate menu changes with residents; and 3. Maintain a process that would allow residents to communicate their preferences regarding menu options one (1), two (2) or the always available menu options. 4. Offered enough fresh fruits and vegetables to all residents and enough healthy choices for dialysis and diabetic residents. This deficient practice has the potential to affect all residents listed on the census presented by the Center Executive Director on 07/31/23. These deficient practices could likely result in resident frustration and/or unsatisfaction with meal options.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain a snack program that would include all residents for snack preferences and diet textures; and failed to maintain consistent meal service times. This deficient practice has the potential to affect all residents listed on the census presented by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents not receiving a snack and/or receiving a snack that does not meet their diet and/or diet texture; and residents may not receive meals if they have scheduled appointments and meals are not served at posted meal times.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Proper handling techniques were used when handling cups and glasses when soup and drinks were distributed to residents served in the dining room. 2. Food was not stored properly, not discarded at their expiration date. These deficient practices are likely to affect all 116 residents listed on the resident census list provided by Center Executive Director (CED) on 07/31/23; and could likely lead to foodborne illness in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: 1. Foods being held for meals maintain a temperature of at least 135 degrees Fahrenheit; and 2. Equipment is serviced to maintain it's regular functional capacity These deficient practices have the potential to affect all residents listed on the censes provided by the Center Executive Director on 07/31/23. This deficient practice could likely result in residents feeling frustrated if they receive cold food and safe food handling measures not being met due to malfunctioning equipment.

Inspectors wroteBased on observation and interview, the facility failed to maintain the cleanliness of the ceiling vents and the condition of the ceiling in the kitchen area. This deficient practice has the potential to affect all residents listed on the census provided by the Center Executive Director on 07/31/23. This deficient practice could likely result in the contamination of resident food.

Inspectors wroteBased on observation, record review and interview, the facility failed to promote care with dignity and respect for 2 (R #36 and #162) of 2 ( R #36 and #162) residents interviewed and during random observation by entering R #36 and R #162 rooms without first knocking on the door. This deficient practice likely resulted in residents feeling embarrassed, ashamed, and as if their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) unattended. This has the potential to affect all 28 residents on hallway 100 and all 30 residents on hallway 300 (residents were identified by the Resident census list provided by the Administrator on 07/31/23). If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on interview, the facility has failed to maintain a process of returning laundered clothing articles. This has the possibility to affect all residents listed on the census that was provided by the ADON (Assistant Director of Nursing) on 07/31/23. This deficient practice could likely result in residents feeling frustrated due to their belongings not being returned.

Inspectors wroteThis is a repeat deficiency Based on record review and interview, the facility failed to ensure that residents or their representatives were invited and able to participate in care plan meetings for 2 (R #'s 29 and 35) of 5 (R #'s 10, 14, 29, 35 and 65) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents are likely not get the care and treatment that they need or want.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that dialysis residents received a meal, snack or sack lunch prior to leaving to their appointment for 2 (R #60 and #162) of 2 (R #60 and #162) residents reviewed for nutrition. This deficient practice is likely to result in weight loss and deterioration of overall health and wellbeing for dialysis residents.

Inspectors wroteThis is a repeat deficiency Based on record review, observation and interview, the facility failed to ensure that 2 (R #35 and #160) of 2 (R #35 and 160) residents reviewed for behavioral health concerns were receiving necessary behavioral health care to meet the resident's need. This deficient practice could likely cause the residents to not receive the mental health care and assistance that they need exacerbating (increasing in severity) anger, depression and other negative feelings .

Inspectors wroteThis is a repeat deficiency. Based on interview and record review, the facility failed to ensure for 4 (R #s 9, 108, 161 and 162 ) of 4 (R #s 9, 108, 161 and 162) residents reviewed for medication administration; had their medications administered correctly by: 1. Giving the resident the wrong antibiotic R #162; 2. Giving two doses of oxycodone causing an overdose R #108; 3. Two residents not receiving their medications consistently and as the physician ordered for R #9 and R #161. These deficient practices caused an overdose for one resident, and could likely have caused any of the following: allergic reaction, infections to worsen, and a potential for the resident to develop a blood clot causing significant and unnecessary harm.

Inspectors wroteThis is a repeat deficiency Based on observation and interviews the facility failed to: 1. Properly store medications in a medication cart. 2. Properly label alcoholic beverages in the medication refrigerator. 3. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures. 4. Provide a separately locked, permanently affixed compartments for storage of controlled drugs in the medication refrigerator. 5. Properly label two open multidose vials (vials used for multiple patient) with the open date. 6. Personal items should not be stored in the medication cart. [...]

Inspectors wroteBased on interview, the facility failed to coordinate dental services for 2 (R #10 and R #43) of 3 (R #'s 10, 14, and 43) residents reviewed for dental care. This deficient practice could likely result in residents experiencing oral pain or discomfort.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure that meals were served at an appetizing temperature and were attractive and palatable (pleasant to taste) for 9 (R #'s 4, 7, 28, 33, 34, 41, 49, 52 and 70) of 10 (R's #'s 4, 7, 28, 33, 34, 41, 49, 50, 52 and 70) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight.

Inspectors wroteThis is a repeat deficiency Based on interview, observation, and record review, the facility failed to provide proper infection control practices by not performing hand hygiene between resident care and getting ice from the ice cooler for 2 (R #36 and resident unknown) 2 (R#36 and resident unknown) residents. This deficient practice could likely result in the spread of infectious agents (Viruses and bacteria) between the residents and/or staff.

Inspectors wroteBased on record review and interview, the facility failed to update a resident's end-of-life treatment for 1 (R #65) of 2 (R #65 and R #53) residents reviewed for advanced directives (a written document stating how you want medical decisions to be made if you lose the ability to make them for yourself). This deficient practice could likely result in residents not having their preferences honored during an end of life event.

Inspectors wroteBased on observation and interview, the facility failed to keep residents free from physical restraints for 1 (R #163) of 1 (R #163) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity.

Inspectors wroteBased on interview and record review, the facility failed to coordinate vision and hearing service for 3 (R#'s 10, 14, and 43) of 3 (R #'s 10, 14, and 43) residents reviewed for outside services. This deficient practice could likely result in residents not being able to see or hear to their fullest extent.

Inspectors wroteBased on interview, observation , and record review, the facility failed to provide podiatry services for 1 (R #14) of 2 ( R #14 and R #65) residents reviewed for toenail care. This deficient practice could likely result in toenail infections going untreated.

Inspectors wroteThis is a repeat deficiency Based on observation, record review, and interview, that facility failed to maintain oxygen according to professional standards for 1 (R #33) of 1 (R #33) residents reviewed for respiratory care by not ensuring the resident always had access to portable oxygen. This deficient practice could likely result in the resident not having oxygen when he needs it.