Smoky Hill Rehabilitation Center

Inspectors wroteThe facility identified a census of 65 residents, with three residents reviewed for lack of assessment and change of condition. Based on record review and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to assess a resident, (R)1 after she had a change in condition on 01/13/26 and 01/14/26, which included lethargy, weakness, inability to ambulate, inability to feed herself, and frequent urination. The facility failed to consider hyperglycemia or dehydration as a potential cause of R1's symptoms. On 01/14/26, R1 required transfer to the emergency room, and R1 had a blood glucose level of 1020 milligrams per deciliter (mg/dL) (an extremely high blood glucose level, which constitutes a severe life-threatening emergency) upon admission to the hospital emergency room. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility identified a census of 65 residents, with three residents sampled. Based on record review, observation, and interview, the facility failed to provide required respiratory care and equipment for Resident (R) 2 when the facility failed to provide a working Bi-Level Positive Airway Pressure (Bi-Pap-medical device which helps with breathing) for R2 upon release from the hospital, which contributed to R2 developing mucous plugs overnight and R2 becoming hypercapnic (a condition defined by abnormally high levels of carbon dioxide (CO2) with retention of CO2. Due to the failure, R2 was readmitted to the hospital the next day with a high CO2 level of 87 milliequivalents per liter (mEq/L), normal ranges of CO2 is 23 to 30 mEq/L.

Inspectors wroteThe facility identified a census of 67 residents. The sample included five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided bathing care per each resident's care plan/preference for Resident (R)1, R2, R3, and R4.

Inspectors wroteThe facility identified a census of 67 residents. The sample included five residents reviewed for activities of daily living (ADL) and dignity. Based on observation, record review, and interview, the facility failed to promote R1's dignity by the failure to recognize R1's colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) bag leaked through his shirt for approximately 45 minutes as he sat in the hallway unassisted.

Inspectors wroteThe facility identified a census of 61 residents. Based on observation, interview, and record review, the facility failed to prepare, store, and serve meals under sanitary conditions for the 61 residents who received meals from the facility kitchen. This deficient practice placed all of the residents in the facility at risk for food-borne illnesses.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents who ate in the dining room. This placed the residents who ate in the main dining room at risk for unhomelike, unsanitary conditions.

Inspectors wrote- R3's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure, obesity (excessive body fat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), chronic pain, tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). [...]

Inspectors wroteThe facility had a census of 65 residents. Based on observation, interview, and record review, the facility failed to store medications securely and dispose of expired medications timely. This deficient practice placed residents of the facility at risk for ineffective medication and unsafe access to medications.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide assistance in privacy for Residents (R) 44 and R48 who wore incontinent briefs, which were visible from the hallway to visitors, staff, and other residents. This deficient practice placed R48 and 4 for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents, with three reviewed for Medicare Liability Notices. Based on the record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) Centers for Medicare and Medicaid Services (CMS) Form 10055) for skilled services for Resident (R) 12 and R216, which included the estimated cost of services. This placed the residents at risk for uninformed care decisions.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents, with four reviewed for hospitalization. Based on the record review and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of R43's discharge. This placed the residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R) 48's care plan to include the physician-ordered fluid restriction. This placed the resident at risk of fluid overload and unmet care needs.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide activities of daily living support for Resident (R) 44 and R48, who required assistance from staff. This placed the residents at risk for ongoing unmet needs and care.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents, with four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine into a collection bag) or urinary tract infection (UTI - an infection in any part of the urinary system). Based on observation, interview, and record review, the facility failed to provide urinary catheter care in a manner to prevent urinary tract infections for Resident (R) 12. This deficient practice placed R12 at risk for infections and catheter-related complications.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to monitor Resident (R) 48's physician order for fluid restriction. This placed R48 at risk of complications related to hydration status due to the resident's cardiac status.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to obtain an appropriate indication or the required physician documentation for the continued use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication for R42. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and potential adverse effects.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 18, who admitted to hospice on 02/25/25, which included a plan of care and a description of the services provided, such as contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to ensure R43's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) tubing and uncovered bag off the floor.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on the interview and record review, the facility failed to offer pneumococcal (type of bacterial infection) PCV20 immunizations for Residents (R)3, R18, and R39, per the guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection.

Inspectors wroteThe facility identified a census of 63 residents, with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to obtain the as needed (PRN) pain medicine prescribed to Resident (R) 1 after a total hip replacement. The facility further failed to follow R1's discharge orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's Electronic Medical Record as needed, requiring R1 to ask for the pain medication. On 02/11/25, R1 admitted to the facility for skilled care for rehabilitation after a total hip replacement. The orders from the surgical center documented R1 was to receive 5 milligrams (mg) of oxycodone (pain medication) as needed every six hours, acetaminophen 1000 mg every six hours scheduled, and an order to discontinue the Norco (pain medication) 5/325 mg. [...]

Inspectors wroteThe facility identified a census of 63 residents, with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to obtain the as-needed (PRN) pain medicine prescribed to Resident (R) 1 after a total hip replacement. The facility further failed to follow R1's discharge orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's Electronic Medical Record (EMR) as needed, requiring R1 to ask for the pain medication. These significant medication errors placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment.

Inspectors wroteThe facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect. On 08/16/24 at 07:00 AM Certified Nurse Aide (CNA) M entered R1's room, asked if he wanted to get up and when R1 did not answer, CNA M lifted the covers, patted the front of R1's brief, and left the room without ensuring R1 had his call light in reach. At 08:32 AM, CNA M entered R1's room and placed his food tray on the bedside table but did not raise the head of the bed or unwrap R1's silverware. R1 proceeded to eat breakfast lying flat, using his left hand, and dropping food all over the front of his shirt. At 09:18 AM R1 reached into his brief and pulled out feces. R1 still did not have a call light in reach to call for staff assistance. [...]

Inspectors wroteThe facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received adequate post-fall treatment consistent with the standards of practice. On 08/16/24 at 09:45 AM R1 fell from a seated position out of bed, onto the floor. R1 fell to the right, hitting his head on the floor. R1 remained on the floor, yelling until staff entered the room at 09:48 AM. Licensed Nurse (LN) G entered the room, assessed his blood pressure with a wrist cuff then all staff left the room to get linens, leaving R1 on the floor yelling. Staff returned and began cleaning the area and preparing R1's bed. During this time, R1 remained on the floor, moaning and yelling. Certified Nurse's Aide M and Licensed Nurse (LN) G started to assist R1 off the floor. [...]

Inspectors wroteThe facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed the facility failed to implement safety interventions to ensure Resident (R) 1 remained free from falls. On 08/16/24, R1, laid flat in his bed around 07:00 AM. The bed was not in the lowest position and R1 did not have his call light within reach. Certified Nurse Aide (CNA) M entered R1's room, asked if R1 wanted to get up and when R1 did not answer, CNA M lifted the covers, patted the front of R1's brief and left the room without ensuring R1 had his flat call light in reach. At 08:32 AM, another staff entered R1's room, placed a food tray on the bedside table but did not ensure R1 had his call light. At 09:39 AM, R1 pulled himself to a seated position on the side of the bed. [...]

Inspectors wroteThe facility identified a census of 75 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to provide adequate supervision and intervene during Resident (R) 1's unsafe behaviors to prevent injury. On 06/15/24, R1 repeatedly leaned forward in his wheelchair and then leaned forward too far, fell headfirst to the floor, and sustained a broken nose and a head laceration (cut). This deficient practice also placed R1 at risk for falls, injuries, and pain.

Inspectors wroteThe facility identified a census of 77 residents with three residents reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 for his activities of daily living, personal health, hygiene, nourishment, and hydration, as well as a sanitary and homelike environment. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for ongoing neglect.

Inspectors wroteThe facility identified a census of 76 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review and interview, the facility failed to prevent Resident (R) 1 from acquiring two Stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcers on R1's bilateral posterior (back) upper thighs. R1 sustained shearing (the separation of skin layers caused by friction or trauma) and friction (the mechanical force exerted on skin that is dragged across any surface) injuries to the back of his bilateral thighs. [...]

Inspectors wroteThe facility identified a census of 77 residents with three residents reviewed for neglect. Based on record review and interview, the facility failed to develop and implement written policies and procedures that included what constitutes and how to recognize abuse, neglect, and exploitation of residents, and misappropriation of resident property. This failure placed all cognitively imapired residents who lived at the facility at risk for ongoing abuse or neglect. (Refer to F600)

Inspectors wroteThe facility identified a census of 76 residents with three residents reviewed for infection control. Based on record review, observation, and interview, the facility failed to provide Resident (R) 2 a safe, clean, comfortable, and homelike environment when staff stripped R2's urine-soaked bedding and left them on the end of his bed creating an unpleasant smell in R2's room. This deficient practice placed R2 at risk for an unclean and uncomfortable environment.

Inspectors wroteThe facility identified a census of 76 residents with three residents reviewed for infection control. Based on record review, observation, and interview, the facility failed to utilize accepted infection control practices when Certified Nurse's Aide, (CNA) M performed peri care on Resident (R) 2 without using gloves. This deficient practice placed R2 at risk for infections and an unclean environment.

Inspectors wroteThe facility had a census of 78 residents. The sample included six residents. Based on observation, record review, and interview, the facility failed to provide a baseline care plan within 48 hours of admission for Resident (R) 1, which placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 78 residents. The sample included six residents. Based on observation, record review, and interview, the facility failed to provide interventions to prevent skin breakdown for Resident (R) 6 who had shearing (the separation of skin layers caused by friction or trauma). This placed R6 at increased risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and delayed healing.

Inspectors wroteThe facility had a census of 78 residents. The sample included six residents. Based on observation, interview, and record review, the facility failed to provide a dysphagia (swallowing difficulty) diet for Resident (R) 6 as ordered by the physician. This placed the resident at risk of choking and decreased nourishment.

Inspectors wroteThe facility had a census of 78 residents. The sample included six residents. Based on observation and interview, the facility failed to display accurate and up to date nursing personnel hours for staff responsible for providing direct care accessible to residents and their visitors.

Inspectors wroteThe facility had a census of 69 residents. The sample included 18 residents with six reviewed for falls. Based on observation, record review, and interview the facility failed to provide adequate supervision and appropriate assessment for the safe use of reclining chairs to prevent falls and hospitalizations for Resident (R)123 who had multiple recliner related falls, one of which resulted in a hip fracture, for R123. Findings Included: [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed.

Inspectors wroteThe facility identified a census of 69 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed all the residents who received food from the facility kitchen at risk related to food borne illnesses and food safety concerns.

Inspectors wroteThe facility identified a census of 69 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and boredom. Findings Included: - A review of the facility's Activity Calendar for August, June, and July of 2023 indicated on Saturdays the residents would socialize, read, and get fresh air outside the facility (weather permitted). The calendars indicated a movie would be played on some Saturdays. The calendar revealed either a church service or television service would be provided to the residents. The calendar indicated a Sunday Newspaper was provided for the residents. [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to storage of respiratory equipment, hand hygiene during wound care, foam wheelchair cushion cleanliness, and monitoring of washing machine water temperature. These deficient practices had the risk to spread illness and infections to all residents.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to provide care in a respectful, dignified manner for Resident (R) 28 and R48. This placed the residents at risk for impaired dignity and quality of life.

Inspectors wroteThe facilty idenitfied a census of 69. The sample inlcuded 18 residents. based on observation, interview, and record review, the facility failed to ensure Resident (R)48 received a pressure reducing device for her wheelchair, in order to reduce the risk for pressure injury development. This placed R48 at increased risk for avoidable pressure injuries.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide a sanitary and clean homelike environment for Resident (R) 58, who had food crumbs left in the wheelchair. This deficient practice placed R58 at risk of pests and impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 28. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with one resident reviewed for hospitalization. Based on observation, interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)28 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's two transfers to the hospital. This placed the resident at risk for impaired rights.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with five residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for Resident (R) 55 who required extensive assistance from staff to complete the care. This deficient practice placed R55 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with five residents reviewed for prevention and treatment of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 17, who had a history of a wound infection. The facility also failed to ensure pressure reducing measures were in place for R46. This deficient practice placed these residents at risk of development of pressure ulcers, of wound worsening and complications related to infections.

Inspectors wroteThe facility had a census of 69 residents. The sample included 18 residents with one reviewed for incontinence cares. Based on observation, record review and interview the facility failed to implement an individualized toileting plan for Resident (R)123. This deficient practice placed R123 at risk for complications related to incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with two residents reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review, the facility failed to assess and document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day, and failed to obtain communication from the dialysis center and assess post dialysis for Resident (R) 55. This deficient practice placed the resident at risk for complications related to dialysis.

Inspectors wroteThe facility had a census of 69 residents. The sample included 18 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)58, who had an ordered one-quarter side rail on the right side of his bed but actually had a larger rail, attached to the left side. This placed the resident at risk for injury related to incorrect or unsafe use of side rails.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19's therapeutic diet as ordered by her physician. This deficient practice placed R19 at risk for choking and malnutrition.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was in place to communicate necessary information regarding Resident (R) 17's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial care for R17.

Inspectors wroteThe facility identified a census of 69 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide mail services on Saturdays. Findings Included: - On 08/16/23 at 02:01 PM, Resident Council members reported the Activity Coordinator (AC) Z worked Monday through Friday. The council reported no mail has been passed out on weekends. The council stated weekend mail may be held until the following Monday and passed out. On 08/17/23 at 09:00AM Activities Coordinator (AC) X indicated he passed out mail on some weekends but often mail was collected and given out the following Monday if no one is available to pass it out. He stated he would try to come in as much as he could or have another staff member try to pass it out. [...]

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for R7, placing the resident at risk for undignified care and services.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to complete a medication self-administration assessment for Resident (R) 20. This placed the resident at risk to not receive his medications or receive the wrong dose of the medications.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to accommodate the needs of Resident (R) 7, when staff did not provide a chair pad in a recliner the resident wanted to sit in which prevented R7 from sitting in her preferred chair. This placed the resident at risk for discomfort and impaired dignity

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide one of three sampled residents, Resident (R) 52 (or their representative) the completed Notice of Medicare Non-Coverage Form (NOMNC) 10123 Centers for Medicare and Medicare Services (CMS). This placed the resident at risk to make uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 11, who had multiple behaviors. This placed the resident at risk for inappropriate interventions to prevent or lessen behaviors.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents, with one reviewed for skin conditions. Based on observation, record review, and interview, the facility failed to update Resident (R) 10's care plan with an appropriate intervention to protect his toes, after he received an injury to his left big toe. This placed R10 at risk for further injuries to his toes.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents with seven residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for three of the seven reviewed for ADLs. Resident (R) 38, R252 and R23. This placed the residents at risk for poor personal hygiene.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions for accidents for two sampled residents. R102 who had three falls from a recliner and R10 who sustained an injury on his toe. This placed the residents at risk for further injury.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents, with one resident reviewed for pain. Based on observation, record review, and interview. The facility failed to assess and administer pain medication in a timely manner to one sampled resident, Resident (R) 7, who had pain. This placed R7 at risk for further pain and discomfort.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16, with two reviewed for dementia care. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services for one sampled resident (R) 11, who had dementia related behaviors. This placed the resident at risk for injury and unmet needs.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to provide timely dental care for one sampled resident, Resident R (46). This placed R46 at risk for weight loss and dental issues.

Inspectors wroteThe facility had a census of 55 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for one resident, Resident (R) 27. This placed the resident at risk for inadequate nutrition.