Spring River Rehabilitation and Care Center

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident was free from abuse and neglect for 1 (R #1) of 1 (R #1) resident, when facility staff left R #1 outside in direct sunlight for an unknown period of time. This deficient practice could have resulted in R #1 being found unresponsive with severe sunburns.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) accurately reflected residents' clinical status for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for assessments. If staff do not accurately assess residents, then the resident may not receive the care needed to obtain optimal health.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide necessary care and services to prevent the worsening of a pressure ulcer (injury to skin and underlying tissue from prolonged pressure) for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for pressure ulcers/skin impairment. Specifically, the facility failed to accurately identify, assess, measure, stage, monitor, document, report, and adjust care for R #1's coccyx/sacral pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective, comprehensive Infection Prevention and Control Program for 3 (R #1, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5 and R #6) residents reviewed for infection control when the facility failed to:1. Post required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage for R #1, R #5 and R #6,2. Include R #1 in the facility's Antibiotic Stewardship monitoring program (tracking tool designed to ensure antibiotics are used only when necessary),3. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) within 14 days of a resident beginning hospice care for 1 (R #1) of 2 (R #1 and R #2) residents. Failure to complete a Significant Change MDS according within the required timelines may result in inaccurate or outdated care plans, missed identification of new or changing needs, or inadequate communication among interdisciplinary team members, which may lead to compromised resident safety and care.

Inspectors wroteBased on record review and interview, the facility failed to administer medication according to physician orders for 1 (R #3) of 5 (R #1, R #2, R #3, R #4, and R #5) residents when staff administered a blood pressure medication outside of the parameters defined by the physician. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 5 (R #3, R #9, R #10, R #12, and R #44) of 8 (R #2, R #3, R #5, R, #9, R #10, R #12, R #14, R and #44) residents reviewed for care plans when staff failed to:1. Develop and implement a care plan with interventions for R #3's oxygen therapy,2. Develop and implement a care plan with interventions for R #10's use of mobility bars and glasses,3. Develop and implement a care plan with interventions for placement in the secure/locked unit for R #9, R #12, and R #44. This deficient practice could likely result in proper care not being provided to residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (R #1, R #27, and R #42) of 3 (R #1, R #27, and R #42) residents when staff failed to:1. Remove gloves and sanitize hands before touching surroundings.2. Sanitize blood pressure cuff in between residents after use.3. Sanitize hands before and after medication administration.4. Use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were within reach of the residents while in the room for 5 (R #6, R #30, R #39, R #54, and R #100) of 6 (R #2, R #6, R #30, R #39, R #54, and R #100) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance.

Inspectors wroteBased on record review and interview, the facility failed to allow 1 (R #7) of 2 (R #7 and R #39) residents reviewed for hospice and pressure ulcers to choose the attending physician when they refused to accept medical orders for R #7's pressure ulcers from her hospice physician, instead sending R #7 to appointments at a wound clinic to obtain medical orders and care for pressure ulcers. If the facility does not allow residents to choose the physicians that are responsible for their care, then residents could experience feelings of frustration and depression.

Inspectors wroteBased on record review and interview, the facility failed to notify residents and their representatives in writing with explanation of why the move is required for 1 (R #7) of 1 (R #7) resident reviewed for room change notifications. If the facility fails to notify the resident and their representative(s) in writing, the resident and/or their representative(s) could experience confusion and frustration.

Inspectors wroteBased on record review, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis or need for secondary screening for 1 (R #72) of 1 (R #72) resident reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #7) of 2 (R #7 and R #106) residents reviewed for nutrition when staff failed to follow the diet order and nutritional recommendations allowing R #7 to have a 22 pound or 22.2% weight loss. This deficient practice is likely to lead to residents suffering from unplanned weight loss and malnutrition which could worsen medical conditions.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #8) of 4 (R #2, R #8, R #9, and R #72) residents reviewed for pain when the facility failed to administer medications as per physician's orders. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for 1 (R #106) of 1 (R #106) residents reviewed when:- Alternative meals were not offered,- Meal did not contain adequate protein,-Facility meal ticket did not match the menu. This deficient practice is likely to result in residents being unable to make informed meal choices and not receiving meals consistent with their preferences.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide assistive devices for 1 (R #106) of 5 (R #4, R #5, R #7, R #72, and R #106) residents reviewed during dining observation. If residents are not provided with special eating equipment as needed, then residents might be unable to consume their meals and beverages and is likely to result in weight loss, malnutrition, and dehydration.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following:1. Facility name.2. The current date.3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:1. Registered nurses.2. Licensed practical nurses.3. Certified nurse aides.4. Resident census. This deficient practice has the potential to affect all 110 residents as identified by the census provided by the Director of Nursing on 03/21/26 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the nutritional needs and preferences were met for all 110 residents listed on the facility census provided by the Director of Nursing (DON) on 03/21/26, when staff failed to updated and post the correct menu. These deficient practices are likely to lead to residents experiencing frustration, depression, and weight loss due to not knowing what food is being served or being able to choose what they eat.

Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient number of nursing personnel to meet the individualized care needs of its residents and failed to maintain accurate PPD (Person Per Day) to demonstrate compliance with federal staffing standards. This deficient practice has the potential to affect all 87 residents care residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. This deficient practice is likely to affect all 87 residents listed on the census provided by the Director of Operations (DOO) on 12/30/25 and could likely cause an increase in illnesses if safe food handling practices are not followed.

Inspectors wroteBased on record review and interview, the facility's Director of Operations (DOO) and Administrator (ADM) failed to manage the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring incidents of abuse and significant injuries were reported to the State Survey Agency by the required time.2. Not ensuring or knowing if the follow-up reports were submitted to the State Survey Agency.3. Not ensuring or knowing notification to State Licensing Office is needed for the ADM's leave of absence.4. Not ensuring an interim ADM is available to manage the facility.5. Not ensuring or knowing and attempting to stop the State Survey Agency from completing survey-related tasks required to identify noncompliance when onsite at the facility. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the governing body appointed an administrator who is responsible for the management of the facility. This deficiency can result in the facility not having an administrator to ensure the residents' day-to-day needs are met. A. On 12/30/25 at 10:31 am, a random observation of the facility revealed a license for the listed Administrator (ADM) hanging on the wall behind the reception area. B. On 12/30/25 at 10:37 am during an interview with the Director of Operations (DOO), she stated the administrator was on vacation and not available. C. On 01/28/26 at 12:02 pm during an interview with the DOO, she confirmed the administrator is not available and that she was the person handling things. She did not state why he was not available. D. [...]

Inspectors wroteBased on record review and interview, the facility failed to report incidents involving allegations of abuse and allegations that resulted in serious bodily injury to the State Agency, no later than two hours for 2 (R #13 and R #14) of 5 (R #12, R #13, R #14, R #15 and R #16) residents reviewed for abuse and neglect. If the facility fails to report allegations of abuse and neglect to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 5 (R #12, R #13, R #14, R #15 and R #16) of 5 (R #12, R #13, R #14, R #15 and R #16) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. R #12A. Record review of the facility's list of reportable incidents (list of events the facility reported to the State Survey Agency) revealed reportable incidents for R #12 on the following dates:1. 12/04/25,2. 12/22/25,3. 01/07/26,4. 01/11/26. B. Record review of the facility's five-day reports revealed the following:1. The investigations were completed.2. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality of care for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents reviewed when staff failed:1. To assist R #1 with fluid during mealtimes.2. To provide timely assistance for R #2's toileting needs. These deficient practices could likely cause residents to feel unimportant and frustrated.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were readily accessible for 1 (R #7) of 1 (R #7) resident reviewed for documentation accuracy when staff failed to provide timely access to the State Agency (SA) to the entire Electronic Health Record (EHR) for R #7. This deficient practice prevented a thorough investigation of R #7's history and has the potential to negatively impact the care staff provide to meet residents' needs due to state surveyors not being able to complete an unannounced investigation. A. Record Review of R #7's EHR, revealed that the complete EHR was unavailable and inaccessible. B. On 12/30/25 at 3:17 pm, during an interview with the Director of Operations (DOO), she indicated she was unable to produce R #7's record in its entirety. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were within reach of the residents while in the room for 4 (R #17, R #18, R #19, and R #20) of 6 (R #2, R #5, R #17, R #18, R #19, and R #20) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #15) of 1 (R #15) resident sampled for dignity, when staff failed to cover the resident's urine bag (medical device used to drain and collect urine when a person cannot urinate normally). This deficient practice could likely to result in residents feeling embarrassed and angry, and that their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1(R #3) of 5 (R #3, R #8, R #9, R #10, and R #11) residents reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #1) of 1 (R #1) resident reviewed for respiratory care when staff failed to follow the physician's order for oxygen use. This deficient practice is likely to result in residents experiencing worsening of their medical conditions.

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

Inspectors wroteBased on observation and interview, the facility failed to ensure staff administered and secured medications for 1 (R #17) of 1 (R #17) resident reviewed for medications when staff left a pre-poured (the practice of preparing and storing medications in advance of their scheduled administration) medication on the resident's dresser in his room. This deficient practice could likely result in residents not getting the medications they need.

Inspectors wroteBased on record review and interview, the facility failed to ensure the failed to ensure home health services were in place prior to discharge for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for discharge. If the facility does not ensure the home health agency receives and accepts the resident, a delay in health care can potentially lead to negative outcomes including:1. Worsening wounds if they are not cared for,2. Worsening in mobility due to lack of physical therapy or occupational therapy.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a functioning call light system for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents reviewed for call lights. If the facility fails to have call lights that are not functioning, residents cannot call staff in case of an emergency or get their needs met by the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and R #5) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed. This deficient practice could likely result in staff not being aware of the residents' daily care events, changes, and needs.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a change in condition in which a resident developed a fever for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice likely resulted in the resident receiving medication against physician orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure quality care that meets professional standards for 1 (R #1) of 1 (R #1) residents reviewed when the facility failed to follow a medical order and notify the provider about changes in a resident's onset of a fever. Failure to implement care orders and notify the provider about changes in resident's vital signs could likely lead to facility staff and the physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition.

Inspectors wroteBased on interviews, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and responded to by the physician. This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the resident's dietary needs not being met and longer waiting times for meal service for all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24.

Inspectors wroteBased on record review and interview, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) Plan. This can affect all 96 residents (per census list provided by the Administrator on 12/08/24). This deficient practice could likely result in the facility not making good faith attempts to identify and correct quality deficiencies that would lead to improvement in the lives of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections). This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the spread of infectious diseases. A. On 12/08/24 at 1:33 pm, during a random observation of the facility, signs indicated special contact and droplet precautions were on the doorways of room [ROOM NUMBER] and 135. B. On 12/10/24 at 11:11 am, during a random observation of the facility, Unit Secretary (US) walked past the personal protective equipment (PPE) carts (where the facility stores clean equipment such as gowns, masks, gloves, etc. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the inappropriate use of antibiotics.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a federally mandated assessment completed by facility staff) was accurate for 3 (R #4, R #22, and R #49) of 5 (R #4, R #22, R #49, R #81 and R #148) residents reviewed for accurate MDS assessments. If the MDS assessment is inaccurate, then residents are likely to not receive the services and support they need.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed the comprehensive care plans for 3 (R #34, R #42, and R #90) of 3 (R #34, R #42, and R #90) residents reviewed for comprehensive care plans. This failure has the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 4 (R #'s 34, 42, 67 and 90) of 4 (R #'s 34, 42, 67 and 90) residents reviewed when staff failed to: 1. Update the care plan to continue to monitor for pain medication effectiveness for R #34. 2. Update the care plan to continue with anti-depressant medications for behavior monitoring and side effects of the anti-depressant medication use for R #42. 3. Update the care plan to continue with care for R #67's left ankle fracture. 4. Update the care plan to continue with Foley Catheter for R #90. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Foley catheter (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) care for 1 (R #90) of 1 (R #90) residents reviewed for catheter care. This deficient practice is likely to result in a resident's catheters becoming unclean and unsanitary leading to urinary tract infections (UTI; an infection in any part of the urinary system) and other diseases.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when three medication errors occurred out of 31 opportunities, which resulted in an error rate of 6.45% for 1(R #4) of 8 (R #4, R #32, R #40, R #44, R #71, R #80, R #89, and R #92) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects.

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

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had completed and signed consent/refusal forms to show they consented to or declined the pneumococcal (for pneumonia, an infection and inflammation of the lung) vaccine for 2 (R #38 and R #74) of 5 (R #27, R #36, R #38, R #74, and R #85) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia, then they have a higher likelihood of contracting the illness and spreading it to other residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations to 3 (R #36, R #38, and R #74) of 5 (R #27, R #36, R #38, R #74, and R #85) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 1 (R #22) of 2 (R #22, and R #103) residents evaluated for bed rail use, when staff used the bed rails without orders, written consent or comprehensive assessment. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity.

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep residents free from accidents for 1 (R #64) of 1 (R #64) residents reviewed for smoking when staff failed to hold smoking supplies. This deficient practice led to R #64 smoking in his room at the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure adequate monitoring of medications for 1 (R #34) of 4 (R #34, R #49, R #67, and R #77) residents reviewed for unnecessary medications. This deficient practice is likely to result in failure to address adverse effects resulting in unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. This deficient practice could likely result residents and visitors not knowing the staff working.

Inspectors wroteBased on interview and record review, the facility failed to monitor residents' weights, assess the cause of unintentional weight loss and implement interventions to prevent further weight loss for 4 (R #1, R #2, R #3, and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for nutrition. This deficient practice could likely result in the residents losing weight causing physical and mental health issues.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #1 and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for care plans. If the facility fails to develop and implement comprehensive person-centered care plans, then staff are likely to not understand the care and needs of the residents which may result in worsening of medical conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 2 (R #1 and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in boney areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to 1. Conduct consistent pressure ulcer wound assessments with measurements. 2. Obtain and implement wound care treatment orders timely. 3. Initiate and implement wound care treatment interventions in care plans. This deficient practice is likely to lead to residents developing new pressure ulcers or the worsening of current pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #3) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need.

Inspectors wroteBased on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 103 people residing in the facility by allowing unauthorized persons access to their medical supplies and personal health information.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were treated in a respectful manner that preserved the residents' dignity for 3 (R #1, R #3, and R #8) of 3 (R #1, R #3, and R #8) residents reviewed for residents' rights when they failed to: 1. Allow R #1 to refuse care. 2. Assist R #3 with incontinence care as needed. 3. Allow R #8 to exercise his right to visit other residents in the facility. 4. Speak to R #8 in a dignified manner. These deficient practices likely resulted in residents feeling unimportant, embarrassed, and undervalued.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure care plans were accurate and complete for 2 (R #3 and R #4) out of 2 (R #3 and R #4) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to meet professional standards of quality for 3 (R #3, R #4, R #6) of 5 (R #3, R #4, R #5, R #6, and R #9) residents when staff: 1. Failed to properly transfer R #3 causing his indwelling urinary catheter (a medical device that drains urine from the bladder) to be pulled out. 2. Failed to obtain physician orders for the use and care of resident's catheters. 3. Failed to handle and assist a resident with medications in a safe manner. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience pain, discomfort and not get the care they need.

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

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of staff to resident abuse was reported within two hours to the State Survey Agency for 1 (R #3) of 1 (R #3) residents reviewed for reporting of alleged violations. If the facility is not immediately reporting allegations of abuse, then residents are likely to be at risk of further abuse.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a thorough investigation for 1 (R #3) of 1 (R #3) residents when staff failed to: 1. Complete a thorough investigation regarding an allegation of abuse. 2. Provide a follow-up report to the State Agency within five working days from the date of the incident. If the facility fails to complete a thorough investigation and five day follow-up report then residents are likely to feel frustrated and unsafe.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure baseline care plans were completed for 1 (R #2) out of 1 (R #2) residents reviewed for care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #3) of 1 (R #3) residents reviewed. This deficient practice could likely result in staff not being aware of the residents' daily care events, changes, and needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure medications are properly stored in the medication carts; 2. Ensure the expired supplies were not kept in the medication cart; 3. Ensure wound care treatment supplies were kept in a separate cart than medication; 4. Ensure medication which needed to be kept in the refrigerators was refrigerated; 5. Ensure opened and accessed flex pen [a device pre-filled with insulin; should be dated with the last date staff should use the product (expiration date) and discarded in within 28 days of the date, unless the manufacturer specified a different date] were dated as to when nursing staff initially opened and assessed the pen; 6. Ensure expired medications or supplies were not stored in the supply room; 7. Ensure the refrigerator contains a permanently affixed compartment for controlled substances. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practice could likely affect all 94 residents who reside at the facility, if the staff is not ensuring RC grievances are responded to and resolutions are communicated back to the RC group, then residents are likely to feel that their concerns don't matter and they have no influence over changing issues identified by residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an activities program desinged to meet the interest of each resdient for 11 (R #4, R #7, R #17, R #21, R #43, R #46, R #51, R #58, R #142, R #143 and R #293) of 11 (R #4, R #7, R #17, R #21, R #43, R #46, R #51, R #58, R #142, R #143 and R #293) residents reviewed for activities. This deficient practice could result in residents feeling less connected to their peers, having lower self-esteem, and experiencing a decline in psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #28) of 1 (R #28) resident reviewed for vision, had proper assistive devices to maintain her vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see, read, and participate in activities.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate monitoring of behaviors for 3 (R #45, R #24, and R #70 ) of 4 ( R # 45, R #24, and R #70) residents reviewed for behaviors and psychotropic medication administration disclosure (referred to the types of medications that affects the mind, emotions and behaviors consent form). If the facility is not providing adequate monitoring of resident's behaviors that warrant the use of psychotropic medications (drugs that treat mental health disorders) then residents are likely to be receiving psychotropic medication unnecessarily.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when 4 medication errors occurred out of 35 medications given, which resulted in an error rate of 11.43% for 2 (R #24 and R #78) of 6 (R #9, R #24, R #42, R #47, R #56, and R #78) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when: 1. Staff reused foley catheter (indwelling flexible tube inserted into the bladder) tubing and bag for R #24. 2. The nurse did not wash hands prior to donning (put on) gloves. If the facility is not adhering to infection control practices then residents are likely to be at risk of infection or disease.

Inspectors wroteBased on observation and interview, the facility failed to treat residents with respect and dignity for 1 (R #59) of 1 (R #59) residents observed during random observation when they failed to ensure staff knocked on the resident's bedroom door before entering their room. This deficient practice could likely result in residents feeling unimportant and lacking privacy.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #24) of 1 (R #24) resident reviewed for MDS accuracy. This deficient practice could likely result in the facility not having an accurate assessment of residents care needs.

Inspectors wroteBased interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans which included information about a resident's preferences, discharge goals, and wound care for 2 (R #293 & R #42) of 4 (R #42, R #293, R #31, and R #78) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and treatment needed to reach their highest practicable level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan within seven days of completion of the comprehensive assessment and revise the care plan for 2 (R #28 and R #293) of 2 (R #28 and R #293) residents reviewed for care plan timing and revisions. This deficient practice could likely result in staff being unaware of changes in the care provided, and residents not receiving the care related to changes in their health status.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident received treatment and care per physician's orders and in accordance with professional standards of practice for 1 (R #3) of 1 (R #3) residents reviewed for receiving antibiotics. This deficient practice is likely to result in residents not being appropriately treated for infections.

Inspectors wrotePast Non-Compliance Based on record review and interview, the facility failed to ensure residents were free from accident and hazards for 1 (R #92) of 1 (R #92) residents reviewed for falls when R #92 fell and hit her head on the hoyer lift (portable whole body lift) that was left unattended in the hallway. If the facility is not ensuring that the environment is free from accidents hazards then residents are likely at risk of falling and getting injured.

Inspectors wroteBased on observation, record review, and interview, the facility failed to properly date oxygen tubing or chart it in the Electronic Administration Treatment Record (ETAR) for 1 (R#7) of 1 ( R #7) resident reviewed for respiratory care. These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to reduced flow of oxygen.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' money will be safeguarded from loss for 4 (R #1, 2, 3, and 4) residents reviewed for personal property when they failed to act as a fiduciary (involving trust, especially with regard to the relationship between a trustee and a beneficiary) of the residents' funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the residents' financial affairs includes money an individual gives to the facility for the sake of providing a resident with a non-covered service. In these instances, the facility will provide a receipt to the gift giver and retain a copy. This deficient practice resulted in unaccounted property (loss of money) for the residents and made them feel as if their money was not safely handled.