Spjst Rest Home 1

Inspectors wroteBased on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plan in that: The facility failed to update Resident #1's care plan after an X-ray (a form of electromagnetic radiation used in medicine to create images of the inside of the body for diagnostic purposes) result dated 07/01/2026 reflected a nondisplaced (a fracture where the bone pieces stay properly aligned) acute appearing fracture noted of the right distal tibia (the lower end of the shinbone (tibia) that connects to the ankle joint) This deficient practice placed residents at risk for not getting right interventions, risk for harm and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly thaw raw chicken in the sink, not under running water, in its kitchen on 01/13/2026.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 01/13/2026 and 01/14/2026. 3. The facility failed to discard outdated food items located in the refrigerators on 01/13/2026 and 01/14/2026. 4. The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air on 01/13/2026 and 01/14/2026. 5. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 9 of 20 residents (Resident #3, Resident #19, Resident #27, Resident #34, Resident #38, Resident #43, Resident #63, Resident #64, and Resident #88) reviewed for misappropriation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (200-Hall Treatment Cart and 500-Hall Medication Cart). 1. The facility failed to ensure the 200-hall treatment cart was locked, medications and/or treatments secured, and not accessible to other staff, residents, and/or visitors.2. The facility failed to ensure Latanoprost (a medicated eye drop used to lower the pressure inside the eye) was stored at the proper temperature per manufacturer's recommendations. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications, missing medications, and access of others to residents' medications.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 kitchen reviewed for food and nutrition services. The facility failed to ensure DM B refrained from adding an unmeasured amount of liquid to Salisbury steak with gravy, seas white beans, and sauteed cabbage pureed meals during lunch service on 01/14/2026. This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss. Observation and interview of the pureed diet process, on 01/14/2025, at 11:09 AM, revealed DM B poured an unmeasured amount of chicken broth into the sea beans without measuring after mixing one time, she poured the beans into a serving pan, the beans were runny in appearance. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program, including hand hygiene and enhanced barrier precautions, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 8 (Resident #3, Resident #15, Resident #26, Resident #29, Resident #41, Resident #58, Resident #69 and Resident #87) of 23 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure LVN C practiced proper hand hygiene while serving and assisting Residents #15, # 29, #58, # 69, and #87 during the lunch meal on 01/13/2026.2. Ensure LVN C and CNA I practiced proper enhanced barrier precautions by wearing the appropriate personal protective equipment when performing wound care for Resident #3 on 1/14/2026.3. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and environment that promoted the maintenance or enhancement of their quality of life for 2 (Resident #26, Resident #41) of 12 residents reviewed for dignity. The facility failed to ensure that Resident #26 and Resident # 41 were provided dignified and individualized feeding assistance during the lunch meal on 01/15/2026. This failure could place residents at risk of diminished dignity and negatively affect their quality of life. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #7) of seven residents reviewed for quality of care. The facility failed to assess Resident #7 for emotional and physical distress after he was exposed to smoke inhalation after the air conditioning/heating unit began to smoke in his room and subsequently began not feeling well and had pain in his chest form smoke exposure. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. 1. The facility failed to ensure food in the freezer, refrigerator and dry storage room were properly stored, dated and labeled. 2. The facility failed to ensure kitchen staff performed hand hygiene while preparing food. 3. The facility failed to maintain kitchen equipment in clean operating condition. 4. The facility failed to ensure refrigerators in satellite kitchens maintained appropriate temperatures. 5. The facility failed to ensure clean dishes were stored away from food preparation area and cleaning cloths were stored away from food preparation areas. These failures could place residents who were served from the kitchen at risk of food-borne illness. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for all the residents reviewed for infection control, as indicated by: 1. LVN F, LVN I, and CMA N did not clean and disinfect the blood pressure monitor while using it on Resident #11, Resident #1, Resident #54, Resident #50, Resident #5, Resident #25, and Resident #46. 2. LVN F did not perform hand sanitizing before preparing medications and handling blood pressure monitor. 3. IP M handled clean items with soiled gloves while providing peri care to Resident #230 These failures could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 10 residents (Resident #38, Resident #48, Resident #58 , and Resident #73) reviewed for care plans. 1. The facility failed to ensure the comprehensive care plans for Resident #38 and Resident #58 included ADLs. 2. The facility failed to ensure the comprehensive care plans for Resident #48 and Resident #73 included diagnosis of mental illness. This failure could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 31, Resident #38, Resident #43, and Resident #58) reviewed quality of life. 1. The facility failed to ensure Resident #31's facial hair was removed. 2. The facility failed to ensure Resident # 38's, Resident #43's and Resident #58's nails were cleaned and smooth around the edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 12 of 12 residents on the secure unit. The facility failed to provide activities on the secured unit as scheduled on 10/05/24, 10/06/24, 10/12/24, and 10/13/24, These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life.

Inspectors wroteF695 Based on observation, interviews, and record reviews, the facility failed to ensure professional standards of practice for respiratory care were followed. For all residents reviewed for respiratory care as indicated by: 1. The nasal cannula of Resident #34 and the CPAP of Resident #32 were not in a bag when unused. 2. The oxygen concentrator filters of Resident #32 and Resident #24 were covered in dust. These failures could place the residents at risk of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 2 of 2 medication storage rooms and 1 of 3 medication carts. A) The facility failed to ensure expired supplies were removed from the medication storage room for Halls 100 and 200 including 1 box of Colostomy (a surgical opening for the colon in the abdomen) supplies that expired 2/5/2018, 3 bisacodyl suppositories that expired 8/2024, and chlorhexidine wipes that expired 7/2/2023. B) The facility failed to ensure expired supplies were removed from the medication storage room for halls 300 and 400 including a foley catheter insertion tray with expiration date of 5/31/2023 and Normal Saline IV flush with expiration date 4/30/2023. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity by contracted staff for 1 (Resident # 69) of 1 resident reviewed for resident rights. The facility failed to ensure contracted staff did not check vital signs (blood pressure, heart rate, and temperature) while at the dining room table during meal service. This deficient practice placed the resident at risk of a decline in their sense of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #230) reviewed for privacy. The facility failed to ensure IP M provided privacy during peri care for Resident #230, by closing the door and fully drawing the privacy curtain. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that proper care practices related to catheterization were maintained for one of one resident(s) reviewed for catheter care, as indicated by: 1. The foley catheter bag of Resident #70 was laying on the floor. These failures can place the resident at risk for infection, urethral (the tube that carries urine from the bladder exit the body) tears or dislodging the catheter. Record review of Resident #70's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but were not limited to retention of urine (inability to urinate), hypertension (high blood pressure), and muscle weakness. Record review of Resident #70's annual MDS dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was prepared in a form designed to meet individual needs for 6 of 6 residents (Resident #14, Resident #18, Resident #24, Resident #63, Resident #70, and Resident #75) reviewed for pureed diets. Cook K failed to ensure food prepared for residents receiving a pureed diet was in the proper consistency for this diet. This failure could place residents who received pureed diets at risk of not having nutritional needs met by consuming foods that could cause poor intake, choking and decreased meal intakes.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption in personal refrigerators for 1 of 1 residents. 1. The facility failed to conduct and/or document the temperature and contents of Resident #22's personal refrigerator. This deficient practice could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. The facility failed to conduct and/or document the servicing of residents in room air-conditioning/heating units which resulted in the smoking of Resident #7's unit. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for three (Resident #1, and Resident #2) of five residents reviewed for accidents and hazards. Hospitality Aide A and CNA C observed the sling prior to entering Resident #1 room and determined at this time the sling was not safe to use. Hospitality Aide A and CNA C did not report this to anyone and used the unsafe sling on the Mechanical lift during transfer of Resident #1. Hospitality Aide A and CNA C observed the loops on the sling to be frayed. There were four green loops on the sling and three of the four green loops broke during the transfer. The bottom four blue loops were already torn and unable to use prior to hooking the sling to Mechanical lift. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1 and Resident #2 .reviewed for Mechanical lift transfers. The facility failed to ensure Resident #1 was transferred with qualified staff. Hospitality Aide A knew the sling was not safe to use by observing the bottom loops were broken and three of the four top purple loops was frayed and beginning to tear. Hospitality Aide A did not report the unsafe sling to nurse prior to using the sling. Hospitality Aides were allowed to assist with resident transfers outside of the scope of their job description. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 6 residents (Resident #1) reviewed for safe requirements. The facility failed to provide a safe sling to be used for Resident #1 on [DATE]. On [DATE], Resident #1 was being transferred by Mechanical lift and the sling broke while Resident #1 was in the air, and she fell and hit her face on the legs of the Mechanical lift. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury, serious impairment, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff did not use physical abuse or corporal punishment on a resident for one of three residents (Resident #1) reviewed for abuse. CNA C pulled Resident #1's hands and refused to stop when Resident #1 repeatedly stated to stop and there was a bruise on Resident #1's right hand after CNA C pulled on her hand. Resident #1 stated CNA C was hurting her while attempted to transfer her from lying position in bed to sitting position on the side of bed. Resident #1 was afraid of CNA C and isolated self in room after the incident. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. The facility did not implement the Abuse and Neglect Policy when CNA C abused Resident #1 and CNA C was not immediately relieved of duty. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. The facility failed to ensure the safe transfer of residents when hospitality aides were allowed to assist with resident transfers outside of the scope of their job description. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death.

Inspectors wroteTag: F 689 S/S= Surveyor Name(s): [NAME] Investigator VI Immediate Supervisor: [NAME] Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents and hazards. The facility failed to ensure staff properly transferred Resident #1 from her wheelchair to the shower chair. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 1 residents (Resident #1) whose care was reviewed in that: CNA A told Resident #1 she was going to go to bed even though Resident #1 did not want to go to bed. This failure could place residents at risk of psychosocial harm and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, when the events that cause the allegation involved abuse or resulted in serious bodily injury for one of eight residents (Resident #1) reviewed for injury of unknown origin. The facility did not report a fracture of unknown origin to Resident #1's tibia until the fourth day after it was identified. This failure placed residents at risk of not having abuse or neglect identified swiftly and thus being subjected to further abuse or neglect.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of three residents (Resident #49) reviewed for pain management. The facility failed to ensure Resident #49 was assessed, monitored, and received pain medication prior to wound care provided for a cancerous open lesion on the left side of her face. This failure could place all residents at risk for unnecessary pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage rooms and 1 of 1 nurse treatment carts. A) The facility failed to ensure 4 boxes containing 2 bottles each of expired glucose control solutions were removed from the medication storage room for Halls 5 and 6. B) The facility failed to ensure the wound treatment cart was locked while unattended by LVN A. C) The facility failed to ensure a container of disinfectant wipes was not left unattended on top of the nurse wound treatment cart in the memory care unit. These failures could place residents at risk of inaccurate blood glucose readings resulting in adverse health consequences, risk of injury from access to disinfectant wipes and medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 3 of 3 residents (Resident's #45, #138 and #49) reviewed for infection control measures. The facility failed to ensure LVN A followed standard precautions during wound care. This failure could place residents who receive wound care at risk for the development of infections.

Inspectors wroteBased on interview and record review, the facility failed to 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 6 residents reviewed for pharmaceutical services. (Resident #49) The facility failed to provide Resident #49 pain medication, Morphine Concentrate Schedule Solution II; 100mg/5ml (20 mg/mL); amt 1ml oral, 15 minutes prior to wound care as ordered. This failure placed the resident at risk of increased pain, poor sleep patterns, increased anxiety and depression, and decreased sense of wellbeing.