Soundview Rehabilitation and Health Care Inc

Inspectors wroteBased on interview and record review the facility failed to prevent the loss of controlled (narcotic) medications for 1 of 1 sampled resident (Resident 3) reviewed. This failure resulted in Resident 3's narcotic pain medication being diverted within the facility, and Resident 3's controlled medication for use other than their pain management program.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 2) was adequately monitored and supervised while walking to the emergency room (ER). This failure placed residents at risk for fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services which assured the accurate acquiring, dispensing, and administration of all drugs to meet the needs of each resident for 2 of 3 sampled residents (Residents 7 and 8) reviewed for medications. Failure to accurately transcribe physician's orders placed residents at risk for medication errors, medical complications, and unmet needs.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise care plans for 5 of 10 sampled residents (Resident's 4, 7, 8, 33 and 35) reviewed for care planning. These failures placed residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 7 of 12 sampled residents (Residents 7,8,18,24,33,44 and 52), that had concerns related to staffing on 2 of 2 halls (Portage and Ship Harbor). The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily living including nail care, restorative care, and meal assistance and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager, (Staff P), had proper qualifications. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure preplanned menus were followed. Failure to follow the preplanned menus altered the nutritional content of the diet and placed residents at risk for malnutrition and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appetizing, palatable, and warm food for 7 of 7 residents (2, 7, 9, 18, 24, 26, and 27) reviewed for dining. This failure placed the residents at risk of a diminished dining experience and less than adequate nutritional intake, potentially leading to weight loss, dissatisfaction with meals and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to consistently serve meals within the posted timeframe's and had longer than a 14 hour wait between when dinner and breakfast were served for 2 of 2 hallways. Failure to serve nourishing snacks to 5 of 7 residents (2, 12, 18, 24 and 26) and meals in a timely manner placed residents at risk of nutritional concerns, food temperatures served outside the desired temperature range, and a decreased quality of life.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety 1 of 1nourishment refrigerators. The failure to ensure the nourishment refrigerator were free from potential contaminants, maintenance to ensure the nourishment refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included .In an observation on 03/23/2026 at 12:19 PM the nourishment refrigerator and freezer had multiple items in it opened, undated and expired food items. Observed a sign on the refrigerator that read the refrigerator/freezer were used for patient snacks and supplements and any non-labeled items would be discarded, signed by the dietary manager. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and and Control Guidelines and standards of practice for 2 of 2 hallways (Portage Hall and Ship Harbor Hall) reviewed for Contact Precautions (infection control measures used to prevent the spread of germs through direct or indirect contact by wearing a gown and gloves before entering the resident room) for residents (Resident 20, 33, and 49) and ensure appropriate disinfection of blood glucose meters (device used to measure blood glucose levels) between each resident use. The facility failed to ensure staff were compliant with appropriate hand hygiene practices during wound care for 1 of 1 residents (Resident 28). These failures placed all residents and staff at risk of potential infection.

Inspectors wroteBased on observation and interview the facility failed to maintain a resident call light system that was functionable and audible, as required in 2 of 2 halls (Portage Hall and Ships Harbor Hall). This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for three of three residents (27, 31, and 28) reviewed for dignity. This failure had the potential to result in embarrassment and psychological harm to Resident's when staff members failed to provide privacy during care.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a clean, safe, comfortable and homelike environment for 2 of 2 halls (Portage Hall and Ship Harbor Hall), 1 of 1 shower rooms and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for restraints and securement of a cable box device, and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for floorboards. Failure to maintain carpets, floorboards, shower rooms and bed rails and floorboards in good repair and safely functioning, and carpets and shower room in sanitary condition placed residents at risk for diminished quality of life and compromised dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the identification of verbal and mental abuse, and the protection of residents from their Alleged Perpetrator/Alleged Perpetrators (AP/APs), after allegations of abuse were reported to the facility for 1 of 1 residents (Resident 14) reviewed for abuse/neglect. This failure placed all residents at risk for further abuse, fear, and unmet care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was not administered an antipsychotic (medication that affected the brain, emotions, or behaviors) unless the medication was necessary to treat a specific condition documented in the clinical record for 1 of 5 sampled residents (Resident 35), reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure reporting of alleged verbal and mental abuse, resident to resident altercations, to the State Agency for 2 of 2 residents (Resident 14 and unidentified resident), reviewed for abuse/neglect reporting. This failure placed residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five (Resident 31) residents reviewed for care planning. The failure to ensure the comprehensive care plan was implemented to maintain or attain the residents highest practicable well-being placed the residents at risk of not receiving services that would meet their needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with grooming, including nail care for 3 of 4 residents (9, 31 and 37) reviewed who were unable to carry out their ADL's (activities of daily living) independently. Facility failure to provide the resident, who was dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 14 and 27) reviewed received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The failure to secure a wound vacuum (wound vac-medical device that uses controlled suction to speed healing of chronic or deep wounds) when ordered, provide pressure relieving devices and supplements as ordered for Resident 27 placed them at risk for delay in healing and poor quality of life. The failure to coordinate timely a timely orthopedic appointment per resident's orders and preferences placed them at risk for delay in healing for Resident 14. These failures placed all residents at risk for delay in care and treatment, confusion, and potentially poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess, and revise interventions as needed to prevent or address significant weight loss for two of five residents (3 and 11) reviewed for nutritional status and weight loss. These failures placed residents at risk for significant decline in nutritional status and related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 2 residents (Resident 11 and 44) reviewed for respiratory care. The facility failed to ensure a Trilogy device (portable ventilator-a medical device that mechanically moves breathable air into and out of the lungs to assist or replace spontaneous breathing) orders were complete and in place, to include the prescribed pressure settings, checking, refilling and cleaning of the device. The facility failed to ensure oxygen (O2) was administered with appropriate physician orders to titrate O2 and change O2 tubing. These failures placed residents at risk for ineffective assisted ventilation, shortness of breath, decreased oxygen saturation and other respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 residents (Resident 6), reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing), had consistent, completed and accurate assessments on the facility's dialysis communication form (a form containing vital information about the resident which is sent to the dialysis center for coordination of care and services). This failure placed the resident at risk for medical complications and unmet care needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%, unit of measure). During observation of 26 opportunities for error, 3 of the 26 medications were administered late, resulting in an error rate of 11.54 %. Further, Resident 2 received medications when they should have been held. These failures placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered per physician orders for 1 of 5 residents (Resident 35) and medications not documented when administered for 1 of 1 residents (Resident 7) reviewed for medication management. These failures placed residents at risk for medical complications, unintended health consequences, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper labeling of insulin (injectable medication that regulates blood sugar) in 1 of 2 medication carts (Portage Hall Medication Cart), failed to correctly monitor temperatures of vaccines in medication fridge, and secure medication carts according to current standards of practice in 2 of 2 medication carts (Portage Hall and Ship Harbor Hall Medication Carts), and 1 of 1 medication rooms reviewed for medication storage and handling. These failures placed residents at risk of receiving compromised or ineffective medications, unauthorized access to medications and biologicals, and potential drug misuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident choices/preferences regarding their bathing schedule were obtained and honored for 4 of 6 sampled residents (Residents 1, 2, 3, 4, and 7) reviewed for preferences. This failure placed residents at risk of being unable to exercise their rights, not having their choices/preferences honored, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a policy, comprehensively assessed residents, documented risk and benefits, ensured ongoing monitoring and maintenance for 3 of 3 sampled residents (Residents 4, 5, and 6) reviewed for bed rails/side rails. These failures placed residents at risk for injury, entrapment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, what information was conveyed to the receiving provider, or a bed hold offered upon transfer, of discharges and/or transfers, as required for 2 of 4 sampled residents (Residents 2, and 3), reviewed for hospitalization and bed hold. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation and interviews, the facility failed to properly store, distribute and serve food in accordance with professional standard for food service safety. The facility failed to store perishable foods properly and failed to dispose of outdated foods timely in 2 of 2 storage areas. These failures placed residents at risk of food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage properly for 2 of 2 dumpsters. Failure to ensure garage was disposed of properly and the area was clean and free of litter, placed residents at risk for contamination of their environment by attracting bugs, rodents, birds and other germ carrying vectors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were met for 1of 1 sampled residents (Resident 134) reviewed for intravenous (IV - into the vein) medication administration, 3 of 5 residents (Residents 18, 19, and 29) reviewed for unnecessary medication review, and for 1 of 2 residents (Resident 19) reviewed for pressure ulcers. These failures placed the residents at risk of complications, worsening infections, delay in healing, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were com-pliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 2 units (Ship Harbor and Portage) reviewed for transmission-based precautions (TBP) for residents (Residents 4, 12, and 28) who had tested positive for Coronavirus Disease 2019 (COVID-19 -an infectious disease-causing respiratory illness with symptoms) The facility failed to ensure licensed staff implemented the use of Enhanced Barrier Precautions (EBP) for 2 of 2 residents (Residents 19, and 134) while they provided direct care to residents on EBP, failed to ensure staff were compliant with appropriate hand hygiene practices during perineal care (process of cleaning genitals and anal area) for 1 of 1 resident (Resident 12), and failed to ensure they had a system in place for the transport of clean [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed for safe administration of medications for 2 of 3 residents (Residents 26, and 134), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment placed the residents at risk for medication errors, adverse medication interactions, and complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 2 of 3 residents (Residents 4, and 6), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, anxiety, and a diminished quality of life. <Resident 4> Resident 4 was a long-term resident at the facility. According to the quarterly MDS (an assessment tool), dated 02/18/2025, Resident 4 was severely cognitively impaired. During an observation on 05/09/2025 at 10:44 AM, Resident 4 was in bed with no call light within reach. During an observation on 05/09/2025 11:21 AM, Resident 4 was in bed with no call light within reach. During an observation on 05/09/2025 at 11:43 AM, Resident 4 was in bed with no call light within reach. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to complete annual staff performance reviews as required for 3 of 5 sampled staff (Staff N, S, and T). The facility also did not ensure that the required 12 hours of education based on these evaluations were completed for 2 of 5 staff members (Staff S and T). This failure placed residents at risk of receiving care from inadequately trained and/or underqualified staff, which diminished the quality of life. Findings Included . Review of the document titled 'CNA_hours_HCA_12mos', documented that from April 2024 to May 2025, Staff M was missing 5 of 12 hours of annual education, and Staff T was missing 2 of 12 hours of yearly education. A review of employee files on 05/12/2025, provided by the Facility Administrator, revealed that there were no annual evaluations for staff members N, S, and T. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%, unit of measure). During observation of 25 opportunities for error, 2 of the 25 medications were administered late, resulting in an error rate of 8 %. These failures placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and/or discard undated, opened vials of aplisol (solution used to test for persons with possible Tuberculosis- an infectious respiratory disease) and ensure refrigerated drugs were stored at proper temperatures in 1 of 1 medication rooms. This failure placed the residents at risk of receiving compromised or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible for 1 of 5 residents (Resident 11) reviewed for unnecessary medications and 1 of 3 residents (Resident 383) reviewed for pain. The facility failed to ensure the residents' medical records had active orders and complete and accurate Medical Administration Records (MAR) which placed the residents at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to designate one individual as the Infection Preventionist (IP) who worked at least part-time at the facility. This failure placed the residents at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 6 residents (Residents 1, and 2) who had physician orders to obtain daily and weekly weights were obtained accordingly. This failed practice placed residents at risk of poor health outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to conduct thorough investigations for 3 of 3 residents (Resident 1, 2 and 3) reviewed for abuse/neglect. Failure to conduct thorough investigations to identify root cause(s) and all contributing factors placed residents at risk for unidentified abuse or neglect, inappropriate corrective actions, and ineffective care planning.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from abuse and neglect by staff for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failed practice placed residents at risk for further abuse and/or neglect and potential injuries.

Inspectors wroteBased on interview and record review, the facility failed to immediately report to the state agency potential abuse and/or neglect for 1 of 3 residents (Resident 1) reviewed for allegations of abuse and/or neglect. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) license completed a Nursing Assistant Certified (NAC) class and passed the state license exam within four months of hire for 1 of 1 NAR's (Staff E) reviewed for staff licenses. This failure placed residents at risk to receive care from unlicensed staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff J) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and national standards of practice for 2 of 2 hallways (Portage and Ship Harbor) throughout the facility. The facility failed to ensure the implementation of Enhanced Barrier Precautions (EBP) for 14 of 14 residents (Resident 30, 6, 9, 19, 17, 12, 2, 13, 16, 4, 235, 188, 189, and 190) reviewed for transmission-based precautions. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for 4 of 4 sampled residents (Residents 12, 19, 27 and 23) reviewed for dignity. This failure had the potential to result in psychological harm to residents when staff members failed to treat residents in a dignified manner and honor their rights.

Inspectors wroteBased on observations, interviews, record review, the facility failed to develop and/or implement policies and procedures for ensuring a communicable disease outbreak for Coronavirus Disease 2019 COVID-19) was reported to the state reporting agency (Complaint Resolution Unit - CRU) 1 of 1 disease outbreaks reviewed and failed to report 1 or 1 residents (Resident 32) reviewed for death. The facility failed to report a communicable disease outbreak in the facility, failed to report an unexpected death in the facility, and failed to log either on the state reporting log. This failure to report to the required state agency and log the outbreaks and unexpected deaths on the state reporting log placed all residents at risk for unidentified and uninvestigated concerns.

Inspectors wroteBased on interview, and record review the facility failed to provide written notice to 4 of 4 residents (Resident 18, 240, 241 and 242) and their family member in a manner, which they understood, of the facility's intention and justification for discharging the resident. The facility also failed to provide the resident and their family member information on their right to appeal the discharge decision, including contact data for advocacy groups.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met for 2 of 2 (18 and 235) residents reviewed for bowel management, 2 of 2 (9 and 30) residents reviewed for percutaneous endoscopic gastrostomy (PEG) tube (tube inserted into the stomach to aid in supplemental nutrition), 1 of 1 (Resident 8) residents reviewed for a toileting plan, and 1 of 1 (Resident 6) residents reviewed for positioning and comfort. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for 1 of 1 resident (Resident 7) reviewed for falls. The facility failed to adequately supervise Resident 7 who had 9 falls in 90 days, and placed residents who were assessed to be fall risk and placed residents at risk for injury and negative outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 5 of 23 sampled residents (Residents 9, 185, 85, 27 and 18), 1 of 2 family complaints and 2 of 2 anonymous complaints that had concerns related to staffing on 2 of 2 halls (Portage and Ship Harbor). The facility had insufficient staff to ensure residents received prompt call light response, assistance with activities of daily living including toileting, oral care, repositioning, and meal assistance and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk to experience feelings of frustration, vulnerability, diminished quality of life, and unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Nurses (LN) and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 6 of 6 sampled staff (Staff C, D, H, P, S, and BB ) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws 1 of 1 medication storage rooms. The facility failed ensure vaccines were dated when opened and failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in a separate locked permanently affixed compartment, and access to the locked box was not accessible to others. These failures placed residents at risk for having unintended access to drugs that should have been securely stored.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the provided liability notice was completed accurately for 3 of 3 sampled residents (Residents 135, 136, and 137) reviewed for liability notices. This failure placed residents at risk of not being fully informed of the potential cost of continued services.

Inspectors wroteBased on interview, and record review, the facility failed to provide a written bed-hold notice, at the time of transfer or within 24 hours of transfer to the hospital, for 1 of 1 resident (Resident 18) reviewed for hospitalization. This failure placed the resident at risk for a 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 Level II Preadmission Screening and Resident Review (PASRR) screening for residents for a serious mental illness (SMI), intellectual disability (ID) or a related condition was completed if the scheduled discharge did not occur for 1 of 5 sampled residents (Resident 19) reviewed. Additionally, the facility failed to ensure a resident with a Level 1 PASRR screening form was complete prior to admission to the nursing facility for 1 of 8 sample residents (Resident 240) reviewed. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or intellectual disability care needs.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise care plans for 2 of 4 sampled residents (Resident 18 and 19) reviewed for care planning. These failures placed residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop, implement, and document a person-centered discharge planning process for 3 of 3 discharged residents (Resident 240, 241 and 242) when reviewed for discharge planning. Failure to initiate and update a discharge plan consistent with the resident's or their representatives' expressed desires and goals led to the residents leaving the facility against medical advice (AMA) and placed the residents at risk for medical complications, a decreased sense of self-worth and poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident 4) was provided physician ordered pressure relief interventions. Failure to implement use of off-loading boots, in accordance with the wound care team's recommendation, placed residents at risk for pressure ulcer (PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear [a combination of downward pressure and friction]) development, worsening of their PU, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Resident 13 and 235) reviewed for use and care of a catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services, to minimize the risk of associated urinary tract infections. This failure placed residents at risk for discomfort, loss of dignity, continued urinary tract infections and other health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 237) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure there was an order with parameters in place and failed to ensure oxygen (O2) tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 sampled residents (Resident 19) reviewed for dialysis services received consistent, ongoing communication and collaboration with the dialysis facility regarding care and services for dialysis residents, including the failure to consistently and accurately complete Resident 19's pre and post dialysis assessments and to obtain and review the dialysis run sheets, prevented staff from identifying how many liters of fluid were removed, what complications, if any, occurred (low blood pressure etc.) and what medications were administered, what labs were drawn, the lab results, and whether there were order changes and/or any follow up required. The nursing home failed to communicate, and to coordinate medication administration arrangements on dialysis days. [...]

Inspectors wroteBased on interview, and record review, the facility failed to consistently provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 sampled residents (Resident 19). Failure to ensure timely processing and administration of ordered medications placed residents at risk for discomfort and pain, anxiety, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 5 sampled residents (Resident 7 and 27) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications were present for psychotropic medications and that residents received gradual dose reductions. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on record review, and interview the facility failed to develop, implement and maintain an in-service training program ensure 2 of 2 Nursing Assistant's (Staff H and BB) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse for 1 of 3 sample residents (Resident 2) reviewed for abuse. Resident 2 experienced harm when they had increased discomfort when a caregiver was physically forceful in providing care, and psychological harm when the resident expressed there was a delay in seeking continence care and remained in soiled briefs until the next shift due to fear and humiliation. This failure placed all other residents at potential risk for abuse, discomfort, risk of injury, psychosocial harm, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for 3 of 8 sampled residents (Resident 3, 4, and 5) reviewed for dignity. Additionally, the facility failed to follow up with the residents for additional information, monitor residents for psychosocial harm, and document or make care plan revisions. This failed practice placed residents at risk for diminished self-worth, humiliation, embarrassment, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy regarding identifying and investigating potential allegations of abuse and neglect for 3 of4 residents (Resident 3, 4, and 5) reviewed for abuse and neglect. The failure to identify potential abuse, timely report allegations of potential abuse, complete timely and thorough investigations of the potential abuse, assess and monitor the residents for physical and psychosocial harm, notify responsible parties and providers, and to document the allegations and revise resident care plans placed residents at risk for injury, fearfulness, frustration, humiliation, and further potential abuse.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate for an allegation of possible abuse and/or neglect for 1 of 3 sampled residents (Resident 2) reviewed for allegations of abuse and/or neglect. The failure to obtain witness statements from the alleged staff member Staff B, Certified Nursing Assistant (CNA), other key staff who regularly worked with Staff B, and/or received reports from residents about Staff B's treatment of them, and to investigate allegations made by additional residents, compromised the facility from making an informed decision if abuse was substantiated, identifying the extent and impact of the potential abuse, and placed residents at risk for unidentified abuse and/or neglect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. Failure to monitor and document Resident 1's condition when they were diagnosed with a urinary tract infection and pneumonia and failure to accurately and timely document when clots/bleeding were observed in the resident's brief, resulted in inaccurate and missing information in Resident 1's clinical record and placed the resident at risk for unidentified complications. This failure placed residents at risk for medical complications, unidentified change in condition, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly assess and stage a newly identified pressure injury (PI - a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device), inform the resident's physician, obtain treatment orders, and develop an individualized care plan for a new PI for 1 of 3 sampled residents (Resident 1) reviewed for PI's. This failure placed residents at risk for deterioration of their wounds and for diminished quality of life.