Squirrel Hill Wellness and Rehabilitation Center

Inspectors wroteBased on the review of facility policy, clinical records, observations, and resident and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers (PU/PI - injuries to the skin and underlying tissues resulting from prolonged pressure on the skin) for four of seven residents (Resident R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for food borne illness.

Inspectors wroteBased on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were documented accurately for four of six residents (Resident R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three nursing units (6th floor).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of four residents (Residents R5).

Inspectors wroteBased on review of facility policy, observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on three of three nursing units (4th floor, 5th floor, and 6th floor).

Inspectors wroteBased on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 1of 1 month (March 19, 2026 through April 2026).

Inspectors wroteBased on review facility documents, grievance logs, and individual resident interviews, it was determined that the facility failed to serve food that was palatable and attractive.

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen.

Inspectors wroteBased on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for three of seven residents (Resident R1, R2, and R3).

Inspectors wroteBased on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to report a misappropriation of resident property 12 of 14 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).

Inspectors wroteBased on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).

Inspectors wroteBased on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents (Resident R3, R4, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38).

Inspectors wroteBased on review of facility provided documents and and staff interviews, it was determined that the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents (Resident R3). During an interview on 12/30/25, at approximately 1:30 p.m. the (former) Nursing Home Administrator was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3. During an interview on 12/31/25, at approximately 11:30 a.m. the Director of Nursing was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3. During a telephone interview on 1/2/26, at 1:05 p.m. [...]

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide information regarding how to file a grievance and information on the grievance official on two of three nursing units (Fourth Floor and Fifth Floor) and failed provide and make accessible grievance forms to residents and visitors on three of three nursing units (Fourth Floor, Fifth Floor, and Sixth Floor). Review of the facility policy, Resident and Family Grievances dated 2/14/25, indicated, Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. During an observation of the Fourth Floor nursing unit on 12/5/25, at approximately 1:55 p.m. the grievance box was not easily observed. During an interview on 12/5/25, at approximately 2:00 p.m. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify a resident representative of a resident to resident abuse incident for one of four residents (Resident R1). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on a review of facility policy, nursing unit observations, and staff interviews, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units (Fourth Floor nursing unit).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to investigate a resident-to-resident abuse incident for one of four residents (Resident R1). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policies and documents, clinical record review and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in the actual harm of a facial laceration that required sutures for one of three residents (Resident R1) This was identified as past noncompliance.

Inspectors wroteBased on review of facility policy, observations, resident and staff interviews, and review of the pest control documentation it was determined that the facility failed to maintain effective pest control programs so that the facility was free of pests in the Main Kitchen.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the Department of Health most recent survey results were readily accessible to residents and visitors, for three of three locations (first floor lobby, nursing units fourth, and six floors). Findings Include: During an interview on 2/11/25, at 10:30 a.m., the Resident Group, four of four residents agreed that they were unaware of the location of the Department of Health survey results (Residents R5, R26 R28 and R52). During an observation on 2/12/25, at 9:20 a.m., signage in the lobby, fourth floor and sixth floor read survey results can be found on the 1st, 4th, and 6th floors (the public entry and resident care areas). During an observation on 2/12/25, at 9:20 a.m. in the lobby, no survey result book could be located. During an observation on 2/12/25, at 9:22 a.m. [...]

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employee E1, E3, E4, and E5).

Inspectors wroteBased on review of the facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for seven of the twenty-two residents reviewed (Resident R5, R11, R35, R41 R45, R52, and R55). Findings Include: A review of the facility policy Resident Rights Regarding Treatment and Advanced Directives last reviewed 10/20/24, indicated it's the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. [...]

Inspectors wroteBased on review of facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of two residents (Resident R217 and R218).

Inspectors wroteBased on policy review and observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms, dining rooms and hallways) for three of three nursing units. (4th, 5th, and 6th floor nursing units)

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS- periodic assessment of resident care needs) assessments were completed in the required time frame for seven of 25 residents (Resident R1, R23, R45, R49, R52, R57, and R58).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for ten of 51 residents (Resident R12, R14, R20, R30, R34, R35, R41, R43, R44, and R55).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of ten residents (Resident R8, R10, R13, R29, R36, R40, and R54).

Inspectors wroteBased on a review of the facility policy, clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for eight of ten residents (Residents R5, R11, R26, R35, R41, R45, R52, and R55).

Inspectors wroteBased on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required for two of 12 months (12/6/24 through 2/14/25).

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for three of four quarterly meetings (January 2024 through December 2024). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 10/20/24, indicated that the facility shall develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The QAA committee shall meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. [...]

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to implement and maintain an effective training program for four of four nurse aides (Employee E1, E3, E4, and E5).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for five of nine staff members (Employee E1, E3, E4, E7, and E8).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Abuse and Neglect Prevention for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Infection Prevention and Control program for six of nine staff members (Employee E1, E3, E4, E7, E8, and E9).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for seven of nine staff members (Employee E1, E3, E4, E6, E7, E8, and E9).

Inspectors wroteBased on observations, review of facility policies and documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to honor a resident's right to smoke, for 4 of 10 residents reviewed (Residents R11, R19, R28, and R53).

Inspectors wroteBased on review of facility policy, facility documentation, resident group and staff interviews, it was determined the facility failed to provide Resident Council the opportunity for meetings for three of twelve months (September 2024, October 2024, and November 2024).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide and make accessible grievance forms to residents and visitors on one of two nursing units (fourth floor) and failed to make the grievance box accessible on one of two nursing units (fourth floor).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated for one of two residents reviewed. (Resident R46).

Inspectors wroteBased on review of facility policy, manufacturer's information, clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R20).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that facility staff failed to maintain ongoing communication with the hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents reviewed (Resident R18).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for three of eight residents (Resident R58, R20, and R30).

Inspectors wroteBased on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for one out of four nurse aides (NA Employee E3).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy completed a Medication Regime Review (MRR) at least monthly for two of five residents (Resident R5 and R56).

Inspectors wroteBased on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of four residents (Residents R59 and R61) A review of the facility policy Documentation in the Clinical Record dated 10/20/24, indicated the resident's medical record shall be complete, accurate, and timely. During an interview on 2/13/25, at 1:00 p.m. the Director of Nursing revealed that clinical records shall be completed within 30 days of a resident discharge from the facility. A review of the clinical record on 2/13/25, indicated that Resident R59 was admitted to the facility on [DATE] and ceased to breathe on 12/2/24. A review of the Interdisciplinary Discharge Summary and Disposition of Medications forms dated 12/2/24, were not completed. [...]

Inspectors wroteBased on a review of facility documents, information from the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for two plus years ( 9/12/22 through 11/6/24) as required.

Inspectors wroteBased on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents (Resident R1).

Inspectors wroteBased on review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to protect residents from staff-initiated physicial abuse. This failure resulted in a staff member physically assaulting a resident and which resulted in serious injuries and transfer to hospital which created an Immediate Jeopardy situation for one of 104 residents (Resident R1).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse for one of 104 residents reviewed (Resident R1), which provided the opportunity of an additional eight days for abuse to possibly continue. This failure created an Immediate Jeopardy situation for one of 104 residents (Resident R1).

Inspectors wroteBased on review of facility documentation, review of cited deficiencies from the facility's annual survey of 4/16/21, and staff interview, it was determined that the facility's Quality assurance and performance improvement (QAPI) program failed to correct previous cited deficiencies. This has the potential to effect all 104 residents of the facility.

Inspectors wroteBased on review of facility policy, clinical records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity by not providing a privacy curtain for one of 25 residents reviewed (Resident 1), and one of two residents utilizing an indwelling urinary catheter (foley - a thin rubber tube inserted either through the urethra or suprapubic [abdomen] to allow for bladder drainage) (Resident R2) .

Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm of a skin tear, and neglect of notifying a physician and procuring order for the care of the skin tear, for one of nine residents (Resident R164).

Inspectors wroteBased on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for two of nine residents (Residents R164 and R45) which resulted in actual harm of a skin tear to Resident R164 and a fractured bone spur and ligament injuries for Resident R45.

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility (Main Kitchen). During an observation of the Main Kitchen on 2/5/24, at 10:30 a.m. the following was observed: -Flour bin, soiled outside, small bowl used as a scoop, stored directly in flour. -Sugar bin, soiled outside. -Floor soiled. -Knives hanging on a magnetic wall holder were visibly dirty. -Flying insects present in food preparation area. -Water pooling in meal lids in a cart next to tray line. -#2 refrigerator, a partially consumed 20-ounce bottle of soda. -(2) dented large cans of peaches. -Dishwasher room: dishes stored under table on clean side, face up. [...]

Inspectors wroteBased on facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for two of two residents (Resident R18 and R9); failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 10 of 11 months (March 2023, April 2023, May 2023, June 2023, July, August 2023, September 2023, and October 2023, November 2023, and January 2024); and failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and implement measures to prevent growth.

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for nine of eleven months (May 2023, June 2023, August 2023, September 2023, and October 2023).

Inspectors wroteBased on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program so that the facility was free of pests in the Main Kitchen and on three of three nursing units (First Floor).

Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E11, E12, E13, E14, and E15).

Inspectors wroteBased on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of the 12 residents reviewed (Resident R76, R93, R104, R106, R111, R265, R266). Findings Include: A review of the facility policy Advanced Directives reviewed 10/1/22 and 10/1/22, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean, homelike environment for five of five nursing units (third, fourth, fifth, sixth, and seventh nursing units).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms assessable to resident ' s and visitor ' s from a wheelchair on two of three nursing units (fifth, and sixth floor nursing unit), failed to have a grievance box and forms accessible on one of three nursing units (fourth floor) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) on three of three nursing units (fourth, fifth, and sixth floor nursing units)

Inspectors wroteBased on review of clinical record reviews, resident interview and observations, and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for 11 of 32 residents (Resident R12, R13, R22, R33, R37, R42, R54, R57, R80, R98, and R108) Findings Include: Review of the facility policy Activities of Daily Living (ADLs) dated 10/2/23, indicated that the facility will provide care and services for the following activities of daily living: -Bathing, dressing, grooming, and oral care. -Transfer and Ambulation. -Toileting. -Eating to include meals and snacks. -Using speech, language, or other functional communication systems. Review of Resident R37's admission record indicated he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for five of eight residents reviewed (Residents R26, R59, R105, R111, and R265), and the facility failed to accurately assess one resident resulting in harm by hospitalization for hypoglycemia for one of five residents (Resident R59).

Inspectors wroteBased on review of national accepted guidelines for pressure ulcers, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents (Resident R6 and R50).

Inspectors wroteBased on review of facility policy, resident interviews, clinical record review, and confidential staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of four residents (Resident R15, R26, R105, and R109).

Inspectors wroteBased on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews were completed for three of five residents (Resident R82, R15, and R26).

Inspectors wroteBased on review of manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of three medication rooms (Fifth-floor medication room).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of nine staff members (Employees E12, E6, E16, and E17).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of nine staff members (Employees E12, E6, E16, and E17).

Inspectors wroteBased on review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of ten sampled residents (Resident R24).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one of ten residents (Resident R31).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for one of five residents (Resident R23).

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R47).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide services to a resident with a substance use disorder for one of two residents (Resident R23).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of four sampled residents (Resident R31).

Inspectors wroteBased on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of four residents (Resident R70).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain call bell equipment for one of five residents (Resident R81).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (Employees E11, E12, E13, E14, and E15).

Inspectors wroteBased on review of facility policy and staff interviews, it was determined that the facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles.

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of nine staff members (Employees E12, E6, E16, and E17).

Inspectors wroteBased on review of Centers for Medicare & Medicaid Services documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive, person-centered care plan with all requirements, when a comprehensive care plan is being utilized in place of a baseline care plan for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental and psychological needs for one of six residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis center (an outpatient treatment center for those with chronic kidney failure) for four of six residents. (Residents R1, R2, R3 and R4).

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that the Activities department had a qualified director to oversee the activities program.

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food temperatures,and food expiration dates in the Main Kitchen and cleanliness of two of four nursing unit food pantries (4th floor and 7th floor pantries) creating the potential for food-borne illness.

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to make certain all residents had accessible access to a telephone to make a call with privacy on four of four nursing units (Fourth Floor, Fifth Floor, Sixth Floor, and Seventh floor).

Inspectors wroteBased on review of facility policy, and resident and staff interviews, and observations, it was determined that the facility failed to maintain sanitary conditions and a homelike environment on three of four resident floors (Fourth, Fifth and Sixth floors).

Inspectors wroteBased on review of the grievance policy, facility documents and staff interview it was determined that the facility failed to document, assign, resolve, and provide response to residents and/or their responsible parties regarding concerns for seven of seven grievances reviewed.

Inspectors wroteBased on review of facility policy and clinical record review and resident, and staff interviews, it was determined that the facility failed to make certain that bathing, nail care, and assistance for activities of daily living were consistently provided for four of seven residents (Residents R61, R132, R357, R368).

Inspectors wroteBased on resident group interview and staff interview, it was determined that the facility failed to provide an ongoing program of activites based on the identified preferences/interests for eleven of eleven resident's to enhance the resident's quality of life.

Inspectors wroteBased on review of facility policy and clinical records, observations and staff interview it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of three residents (Resident's R99 and R147).

Inspectors wroteBased on review of facility policy, manufacturer recommendations, observations, and staff interviews, it was determined that the facility failed to properly store biologicals and medications in two of three medication rooms (4th and 5th floors) and two of four medication carts (4th Floor South and 6th Floor North medication cart.)

Inspectors wroteBased on observations, staff interviews and manufacturer guidelines, the facility failed to perform glucometer control testing on four of six nursing units (4th floor South and North Units and 5th floor South and North units.) Manufacturer guidelines for the Assure Platinum Blood Glucose meter (a machine used to check the blood sugar levels of residents) indicate that the meter should be tested when using a new bottle of test strips. During an observation on 2/27/23, at 2:05 p.m. of the glucometer control testing logs for the 4th floor, the South Hall was noted to have no tests performed for the month of January 2023 and only two tests performed during the 26-day review period in February 2023. The North Hall logs was noted to have no tests performed for the month of January 2023, and three tests performed during the 26-day review period in February 2023. [...]

Inspectors wroteBased on a Resident Group meeting and individual resident and staff interviews, it was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance for receiving telephone calls for three of three residents (Resident R17, R73 and R145) and provide prompt assistance to meet residents care needs for two of five residents who require incontinence care (Residents R10 and R73)

Inspectors wroteBased on review of facility policy and clinical records, and resident and staff interviews it was determined that the facility failed to prevent the misappropriation of resident property for four of six resident (Residents R108, R130, R106 and R99)

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to report an incident of alleged verbal abuse as required to the State Agency for one of three residents (Resident R72).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to communication needs for one of two residents (Resident R 98).

Inspectors wroteBased on clinical record review, resident interviews, and staff interviews it was determined that the facility failed to follow physician orders as required for one of three residents (Resident R365) and failed to ensure qualified and appropriately trained staff were providing direct care to residents for one of one Resident (Resident R132). The Nursing Home Reform Act, adopted by Congress as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), mandated training and evaluation standards for nurse aides who work in nursing facilities. Each state is responsible for following the terms of this federal law. The facility Job description for Certified Nursing Assistant dated 10/1/22 in accordance with current federal, state, and local standards governing the facility and lists job duties including Personal Care Functions: [...]

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to provide necessary treatment and services to promote healing of pressure injuries for two of five residents (Residents R361 and R369).

Inspectors wroteBased on review of facility policy and clinical record and staff and resident interviews, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R72)