South Hampton Rehabilitation & Health Care Center

Inspectors wroteBased on observation, interview and record review, facility staff failed to perform hand hygiene to prevent the spread of infection during wound care, failed to place wound care supplies on a protective barrier, failed to wear appropriate personal protective equipment (PPE) during care for one resident (Resident #2) who required Enhanced Barrier Precautions (EBP) (an infection control intervention) for wounds. Facility staff failed to wear PPE during care for one resident (Resident #1) who required EBP for a feeding tube (medical device used to safely deliver liquid nutrition, hydration, and mediations directly into the stomach or small intestine) out of two sampled residents. The facility's census was 67. 1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide necessary treatment and services consistent with professional standards of practice, when staff failed to assess one resident (Resident #1's) skin upon readmission, failed to identify a left lower leg wound, and failed to obtain a physician's order for wound care treatment. The facility census was 67.1. Review of the facility's Skin Identification, Evaluation, and Monitoring policy, dated 02/26/26, showed staff are directed as follows:-A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified;-Licensed nurse upon admission with complete a physical skin evaluation and document findings. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings and failed to complete a Resident Inventory Listing for two residents (Resident #1 and #2) out of three residents. The census was 69.1. Review of the facility's, Cash and Valuables Policy Update, undated, showed the facility will not be responsible for any money or personal items exceeding $40.00 limit. Review of the facility's admission agreement, dated 02/2018, showed the facility shall not be liable for any of the residents' items that are lost or stolen, except for those items noted for replacement under state guidelines that the facility might reside. [...]

Inspectors wroteBased on interview and record review the facility failed to provide training for abuse, neglect, exploitation, and misappropriation of resident property and the reporting and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property for two employees (Certified Nurse Assistant (CNA) B and Nurse Aide (NA) C ) out of three employee. The facility census was 69.1. Review of the facility's policy, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed facility staff shall be trained on the Abuse Prohibition Program during orientation, annually and ongoing during education sessions, and per state regulations. The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to prevent the misappropriation of money from one resident's (Resident #1's) credit card when Nurse Aide (NA) A used the resident's credit card without permission for his/her personal use. The facility census was 82.1. Review of the facility's, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed the owner, licensee, administrator, employee, or agent of the facility prohibit the misappropriation of resident property. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/26, showed staff assessed the resident as cognitively intact with an admission date of 09/15/22. Review of the resident's online bank statement, dated 02/21/26, showed an unauthorized transaction of $145.76 at a Computer Repair store. [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of misappropriation of one resident (Resident #1's) credit card to the State Survey Agency (SSA) within the 24-hour time frame. The facility census was 82.1. Review of the facility's, Abuse, Prevention and Prohibition Policy, dated 03/2025, showed staff are directed that all alleged violations involving misappropriation of resident property will be reported immediately to the administrator or his/her designee. The person made aware of allegations will report the allegations to the mandated state agency and law enforcement. Review of the facility's investigation, dated 02/23/26, showed the resident reported his/her debit card was missing to an agency nurse sometime between 02/20/26 through 02/21/26. The resident reported there were fraudulent charges on the account. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide necessary treatment and services consistent with professional standards of practice, to promote the healing of existing pressure ulcers for two residents (Resident #2 and #3) out of two sampled residents who admitted to the facility with pressure ulcers, when staff failed to document a full wound assessment, complete weekly skin assessments, and follow up on the Registered Dietician's recommendations for Resident #2, and failed to document the administration of wound treatments as ordered by the physician for Resident #2 and #3. The facility census was 74.1. Review of the facility's Wound Care policy, dated 01/2025, showed the following documentation should be recorded in the resident's medical record: -Type of wound and location: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to prevent a fall with major injury by not ensuring staff provided protective oversight for one resident (Resident #1) out of one sampled resident during a shower and failed to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers) during a transfer for one resident (Resident #4) out of one sampled resident. The facility census was 69. The administrator was notified on 09/22/25 of past Non-Compliance which occurred on 09/20/25 when the administrator implemented a new intervention to monitor the resident while showering. Staff were in-serviced on 09/20/25 and 09/21/25 regarding the new intervention.1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure two Nurse Aides (NA)'s (NA B and NA C) out of three sampled NAs completed the required nurse aide training program within four months of employment in the facility. The facility census was 69.1. Review showed the facility did not provide a policy in regard to requirements for NA's training program completion within four months of employment. 2. Review of NA B's personnel file showed a hire date of 04/08/25. The file did not contain documentation the NA completed the required nurse aide training program. 3. Review of NA B's personnel file showed a hire date of 04/14/25. The file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/22/25 at 10:56 A.M., Registered Nurse A said he/she was responsible to conduct the nurse aide training courses. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received regular and pureed diets. The facility census was 57. 1. Review of the facility's Standardized Recipes policy, undated, showed standardized recipes will be used for all menu items, including pureed and therapeutic diets. Review showed each standardized recipe will include measurement and/or weight of ingredients and serving sizes. Review of the facility menu for Week 4, Day 17 showed the menu directed staff to serve: -Two, three ounce tuna patties, four ounces of yellow rice, four ounces of spinach and one slice of bread to residents who received regular diets; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain an air gap in two ice machine drains. These failures have the potential to affect all residents. The facility census was 57. 1. Review of the facility's Food Storage policy, undated showed: -All food items will be labeled and the label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date; -Wrap food properly. Never leave any food item uncovered and not labeled; -Set refrigerators to the proper temperature to ensure the internal temperature of the food is 41 degrees Fahrenheit (F) or lower. Place hanging thermometer in the warmest part of the refrigerator. [...]

Inspectors wroteBased on interview and record review, facility staff failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information to the Payroll-Based Journal (PBJ) from October 1, 2024, through December 31, 2024. The facility census was 57. 1. The facility did not provide a policy for Payroll-Based Journal submission. 2. Review of the CMS Electronic Staffing Data Submission PBJ Policy Manual for submission guidelines showed submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. Timeframes for each reporting period are as follows: Fiscal Quarter 1 - Date Range October 1-December 31 - submission deadline February 14; Fiscal Quarter 2 - Date Range January 1-March 31 - submission deadline May 15; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to follow infection control practices when staff did not disinfect the blood glucose monitor between uses for three residents (Resident #37, #33, and #48) out of four sampled residents. The facility failed to provide current infection prevention policies that were updated and reviewed annually. The facility census was 57. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the commingling of 17 resident's (Resident #13, #19, #21, #46, #63, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #77) personal funds with the facility operating funds out of 55 sampled residents. The facility census was 55. 1. Review of the facility's policy titled Facility Resident Trust Fund Policy, revised 05/12, showed the facility will maintain a full and complete separate accounting ledger for each resident. The facility will maintain current written individual ledgers of all financial transactions. If a check is received for the resident's Accounts Receivable balance along with money for their resident trust account, the entire check should be deposited to the resident trust fund. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails for five residents (Resident #3, #6, #7, #19 and #26) out of six sampled residents, failed to assess residents for the use of bed rails and perform an entrapment assessment for two residents (Resident #7 and #26) of six sampled residents. The facility census was 57. 1. Review of the facility's policy titled Bed Rails, dated December 2024, showed prior to the installation of bed rails, attempts to provide the resident with alternative measures to meet their need for positioning, mobility, or transfer ability while in bed will be made. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure three Nurse Aides (NA)s (NA B, NA C, and NA D) of five sampled NA's completed the required nurse aide training program within four months of employment in the facility. The facility census was 57. 1. Review of the policies provided by the facility did not contain a policy for NA qualifications. 2. Review of the Facility Assessment Tool, dated August 18, 2017, showed the Facility Assessment did not address Nurse Aide Qualifications and Training Requirements. 3. Review of NA B's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 4. Review of NA C's personnel file showed a hire date of 11/05/24. The file did not contain documentation the NA completed the required nurse aide training program. 5. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 57. 1. Review of the facility's policy titled Antibiotic Stewardship & MDROs (Multiresistant Organisms), dated 2019, showed the Infection Preventionist (IP) will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON (Director of Nursing), Medical and Consultant Pharmacist and ongoing system review. Ongoing review and updates will be completed based on standards of practice, and collaboration with Medical Director and Pharmacy Consultant. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document neurological assessments for one resident (Resident #1) out of one sampled resident who had a fall with head injury. The facility census was 57. 1. Review of the facility's Fall Prevention policy, undated, showed it did not address a neurological post fall assessment for residents who incurred a head injury. Review of the facility's paper Neurological Evaluation flowsheet, revised November 2023, showed staff are directed to document neurological assessments for unwitnessed falls and head injuries every 15 minutes for one hour; every 30 minutes for two hours; every hour for four hours; and every shift for 72 hours. Review showed the neurological assessment should include: -Level of consciousness (Awake and Alert); -Orientation (Time/Place/Person); [...]

Inspectors wroteBased on interview and record review, facility staff failed to have a system in place to ensure Certified Nurse Aides (CNA)s received the required 12 hours in-service education based on performance reviews annually for three CNAs (CNA E, F, & G) out of three sampled CNAs. The facility census was 57. 1. Review of the policies provided by the facility did not show a policy for staff training, CNA training, or staff/CNA evaluations. Review of the Facility Assessment, dated August 18, 2017, showed the required in-services for nurse aides must: -Be sufficient to ensure the continuing competency of nurse aides (NA)s, but must be no less than 12 hours per year; -Address areas of weakness as determined in the NAs' performance training; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide documentation for two residents (Resident #28 and #37) out of five sampled residents were provided education and offered the current COVID-19 immunization. The facility census was 57. 1. Review of the facility's policy titled Resident Immunizations and Vaccinations, dated 09/2/22, showed it did not address the vaccination policy for Coronavirus 2019 (COVID-19). 2. Review of the facility policy titled Severe acute respiratory syndrome coronavirus (SARS-CoV-2) Infection, dated 08/22/24, showed the community/facility should follow county, state and federal recommendations applicable for SARS-CoV-2 infection prevention and treatment. The community/facility and its employers are reminded that general population guidance is different from long term care/Senior Living guidance. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written documentation of responses related to grievances, and the policy failed to address the residents' right to file a grievance anonymously. The facility failed to ensure the results of grievances were maintained for a period of no less than three years and failed to educate and review guidelines on how to file a grievance with the residents. The facility census was 57. 1. Review of the facility's Resident Rights statement, undated, showed residents will always be provided with the highest level of care and service, and if for any reason a resident, and/or Responsible Party feel such needs are not being met by the facility staff, they are entitled to a variety of avenues in which to resolve their concern(s). [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 57. 1. Review of the facility's Activity Director (AD) Job Description, undated, showed the job description did not include the necessity for completion of an approved training course. 2. Review of the AD employee file showed the file did not contain documentation the AD had completed a state approved training course. During an interview on 04/16/25 at 3:06 P.M., the AD said he/she did not know the position required education. The AD said he/she had not been directed by facility staff to take any courses and had been in the position for about a year. During an interview on 04/18/25 at 11:31 A.M., the administrator said he/she did not know the AD should be certified.

Inspectors wroteBased on interview and record review, facility staff failed to update their Facility-Wide Assessment, an assessment completed by facility staff to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies annually and as necessary. The facility census was 57. 1. Review of the policies provided by the facility did not contain a policy for the Facility-Wide Assessment. Review of the facility's Facility Assessment Tool, dated 08/18/17, showed nursing facilities will conduct, document, and annually review a Facility-Wide Assessment, which includes both their resident population and the resources the facility needs to care for their residents. The facility must review and update this assessment annually or whenever there are facility plans for any change that would require a modification of any part of this assessment. [...]

Inspectors wroteBased on interview and record review, facility staff failed to annually review resident rights and responsibilities with the residents as directed by facility policy. The facility census was 57. 1. Review of the facility policy for Resident Council, reviewed 02/2016, showed a designated staff member, other than the administrator, is to coordinate and render assistance to the Council. The Council is to review procedures for implementing resident rights and facility responsibilities and the Council can make recommendations for changes and additions which will strengthen the facility's policies and procedures as they effect resident rights and facility responsibilities. The designated staff member is to assist with Resident Council Meetings and to prepare and disseminate the report/minutes to all residents, the administrator, and the facility staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. The facility staff failed to maintain freezer temperatures in a manner to prevent possible food spoilage. The facility staff failed to maintain the kitchen ceiling in good repair to prevent the growth and harborage of bacteria. The facility census was 58. 1. Review of the facility's Basics for Handling Food Safely policy, undated, showed the policy did not contain guidance for labeling and dating food or drinks. Review of the Registered Dietician kitchen inspection, dated 1/22/24, showed all food was not properly covered, labeled and dated. Observation on 02/20/24 from 10:20 A.M. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls and floors in good repair, and to maintain resident bed linens. The facility census was 58. 1. Review of the facility's policies showed the facility did not provide a policy for homelike environmental conditions. 2. Observation on 02/23/24 at 10:31 A.M., showed resident occupied room [ROOM NUMBER] bathroom with black residue on the toilet caulk, stained and chipped areas on the floor, and towel rack bolts exposed on the wall without a towel rack. 3. Observation on 02/20/24 at 10:35 A.M. and 02/21/24 at 08:56 A.M., showed Resident #51 in his/her bed. Observation showed the bed sheets and pillowcase with brown stains. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #1, #11, #27,#36, #41, and #51). The facility census was 58. 1. Review of the facility's policies showed staff did not provide a policy for care plans or care planning. 2. Review of Resident #1's Annual Minimum Data Set, (MDS), a federally mandated assessment tool, dated 01/04/24, showed staff assessed the resident as: -Cognitively impaired; -Received an anticoagulant (a blood thinner); -Diagnoses of a stroke, hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and aphasia (the loss of ability to understand or express speech). [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to keep treatment carts locked when left unsupervised, failed to ensure one resident (Resident #11) did not have a lighter near oxygen while in use and failed to document a smoking assessment was completed. Staff failed to document an unwitnessed fall, notifiy of the family, and notify the physician of the fall for one resident (Resident #39). The facility census was 58. 1. Review of the facility's Medication, Storage of policy undated showed: -All medications for residents must be stored at or near the nurse station in a locked mobile medication cart; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile; -An unattended medication cart must remain locked at all times. [...]

Inspectors wroteBased on interview and record review, facility staff failed to have a system in place to ensure a Certified Nursing Assistant (CNA) received the required 12 hours in-service education based on performance reviews annually for six CNA (CNA C, D, E, F, G, and H) out of six sampled CNAs. The facility census was 58 residents. 1. Review of the facility's policies showed facility staff did not provide a policy for staff training, CNA training, or staff/CNA evaluations. Review of the Facility Assessment, reviewed December 2023, showed the required in-service for nurse aides must: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Address areas of weakness as determined in nurse aides' performance training; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired; [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow physician's orders in a timely manner for rehabilitation services for one resident (Resident #50) of eight sampled residents. The facility census was 58. 1. Review of the facility's policies showed staff did not provide a policy for therapy provision. Review of Resident #50's Significant Change Assessment Minimum Data Sets (MDS), a ferdally mandated assessment, dated 11/20/23, showed staff assessed the resident as: -Upper body dressing declined from required supervision to requiring partial/moderate assistance; -Lower body dressing declined from required supervision to requiring partial/moderate assistance; -Toilet transfers declined from required supervision to requiring partial/moderate assistance; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to maintain proper infection control practices for two residents (Resident #17 and #57) during perineal care and during ostomy catheter care for one resident (Resident #210). The facility census was 58. 1. Review of the facility's Gloves policy, undated, showed staff are instructed to the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with the mucous membranes, non-intact skin, any moist body substances (blood, urine, feces wound drainage, oral secretions, sputum, vomitus or items/surfaces soiled with these substances) and/or persons with a rash; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff made inappropriate comments to residents during care, failed to knock when they entered resident's room, provide privacy during care, and maintain a dignified dining room experience and protect their medical information for ten (Resident #7, #21, #22, #27, #38, #46, # 48, #49, #58, #322) residents. The facility had a census of 64. 1. Review of the facility policies showed staff did not provide a policy for dignity. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/17/22, showed staff assessed the resident as follows: -Required extensive assistance of one staff member for bed mobility; [...]

Inspectors wroteBased on interview and record review the facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for four residents (Resident #24, #38, #47, and #61). The facility census was 64. 1. Review of the facility's Advance Directive Policy, undated, showed staff are directed to obtain information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 2. Review of Resident #24's Face Sheet in their Electronic Medical Record (EMR) showed staff documented the resident as DNR status. Review of the resident's paper chart showed it contained a Physician's Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], documented as a DNR status. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to maintain professional standards of care when staff failed to follow physician's orders for two residents (Resident #48, and #63), and failed to ensure one resident (Resident #24) had a physician order for dialysis and and one resident (Resident #47) had an order for hospice in their medical record. The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for following physician orders. 2. Review of Resident #48's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/3/22, showed facility staff assessed the resident as follows: -Severely cognitively impaired; -Required extensive assistance from staff for dressing, personal hygiene and bathing; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to ensure safe propulsion for three residents (Resident #22, #46, and #51) in wheelchairs in a manner to prevent accidents, failed to position one resident in the wheelchair with the wheelchair brakes on (Resident #46), and failed to use the mechanical lift (an assistive device used to help transfer residents between a bed and chair) in a manner to prevent accidents for one resident (Resident #38). The facility census was 64. 1. Review of the facility's Wheelchair, Use of policy, undated, showed: Purpose: To provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living. Guidelines: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Residents #64 and #318) and failed to obtain an appropriate diagnosis for the use of antipsychotic medications for two residents (Residents # 61 and #318). The facility census was 64. 1. Review of the facility's policies showed staff did not provide a policy for PRN Psychotropic medications. 2. Review of Resident #64's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 01/31/23, showed staff assessed the resident as follows: -Received antianxiety medication and antidepressant 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene and glove changes during incontinent care for two (Resident #1 and #38) residents, failed to clean away from a urostomy catheter and perinal area for one resident (Resident #19), and staff wiped multiple times with the same area of the wipe for one resident (Resident #21) during perineal care. The facility census was 64. 1. Review of Centers for Disease Control and Prevention CDC Hand Hygiene in Healthcare Settings guidelines, last reviewed 1/10/20, showed the guidance directs healthcare personnel to follow the following recommendations: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they assessed residents using the quarterly Minimum Date Sets (MDS), a federally mandated assessment completed by staff, no less frequently than once every three months, for three residents (Resident #46, #58, and #322). The facility census was 64. 1. Review of the facility provided policies, showed the facility did not provide a policy for MDS completion. Review of the October 2019 RAI Manual, page 2-33, showed: The Quarterly assessment is an non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. 2. [...]

Inspectors wroteBased on interview and record review facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #61 and #64). The facility census was 64. 1. Review of the facility's Comprehensive Care Plan Policy, undated showed: Purpose: An individualized care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment. -A well-developed care plan will be oriented to assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs. 2. [...]