St. Anne's Salvatorian Campus

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents at risk of pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R34) of 1 resident reviewed. *R34 was admitted to the facility 2/23/26 without any pressure injuries, and the facility assessed R34 to be at high risk for the development of pressure injuries. R34 developed two avoidable facility acquired, unstageable pressure injuries to the right and left legs on 3/22/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not 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. This has the potential to affect all residents that reside at the facility. *Registered Nurse (RN)-F did not properly disinfect a glucometer that is shared between residents. This deficient practice has the potential to affect 5 residents that require blood sugar testing on the first floor. *The facility had a COVID-19 outbreak in February 2025 and did not provide evidence that the outbreak was reported to the local public health authority. This deficient practice had the potential to affect all residents residing in the facility during the February 2025 outbreak.

Inspectors wroteBased on record review and staff interview, the facility did not ensure the Infection Preventionist (IP) had specialized training in infection prevention and control. This has the potential to affect all 36 residents in the facility. *The Assistant Director of Nursing (ADON)-C began the IP role in August 2025 and did not provide evidence of completing specialized training in infection prevention and control prior to assuming the role of the IP.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 (R5, R6, R30, R37, and R1) of 8 resident's reviewed for hospitalization received the proper notice of transfer and bed-hold to include; date and reason for transfer, location of transfer, duration of bed hold, reserve bed hold payment, appeal rights, and name and address, and telephone number of the Office of the State Long-Term Care Ombudsman. *R5 transferred and admitted to the hospital on the following dates, 6/14/25, 7/2/25 and 12/4/25 while residing in the facility and evidence was not provided R5 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. [...]

Inspectors wroteBased on observation, interview, and record review ,the facility did not ensure the medical record reflected the advanced directive wishes for 1 (R40) of 3 residents reviewed.*R40 was readmitted on [DATE]. R40's Hospital Discharge summary dated [DATE] documents R40's code status was changed to DNR (do not resuscitate). On 4/29/26, R40 was observed wearing a purple DNI (do not intubate)/DNR bracelet on R40's right wrist. Despite this, R40's physician orders, code status by R40's picture in the electronic medical record and care plan continued to document full code until 4/29/26.

Inspectors wroteBased on interview and record review the facility did not ensure residents receiving psychotropic medications as needed (PRN) have an order limited to fourteen (14) days for 3 (R9, R6, and R34) of 7 residents reviewed for unnecessary medications: *R9 Clonazepam 0.5mg- 1 tablet every 12 hours as needed for increased agitation with no end date. *R6 has an order for Clonazepam 2mg- 1 tablet every 6 hours as needed for anxiety with no end date. *R34 Lorazepam 0.5 mg- 1 tablet every 3 hours as needed for anxiety with no end date.

Inspectors wroteBased on interview and record review, the facility failed to perform preadmission screening for individuals with a mental disorder for 1 (R17) of 1 resident reviewed for Pre-admission Screen and Resident Review (PASARR) Level II completion. *R17 had a positive Level I PASARR dated [DATE] and was identified to have a major mental disorder and, unspecified intellectual disabilities. The facility did not submit the positive Level 1 screen to the State mental health authority to complete a PASARR Level II evaluation after the initial 30-day hospital discharge exemption had expired. Findings Include:The facility policy titled admission Criteria/Requirements with an initial approval date [DATE] and reviewed date [DATE] documents: [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R9) of 12 resident's care plans reviewed were revised. R9's care plan was not revised after R9 was diagnosed with a right shoulder dislocation.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident was offered the COVID-19 vaccine when available to the facility for 1 (R21) of 5 residents reviewed for immunizations. *R21 did not have evidence of being offered the COVD-19 vaccine upon admission to the facility on 1/9/26.

Inspectors wroteBased on interviews and record review the facility did not ensure that residents' environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R2) residents reviewed for accidents. R2 sustained an avoidable fall from bed during cares. R2 was assessed as being dependent for bed mobility as assessed and documented on their significant change and most recent quarterly Minimum Data Set. An assessment code of 01 dependent indicates the need for two staff assistance. R2 was also assessed by therapy as being dependent on staff for bed mobility with the number of staff assistance needed not specified. R3's care plan dated 8/9/23 indicated R2 requires the assistance of 1 staff for bed mobility and was not reflective of current assessments or level of assist needed by R2. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 1 (R1) of 1 resident reviewed for adequate monitoring and indications for use with a medication was administered the medication in accordance with physician ordered parameters. R1 was transferred to the hospital on [DATE] following a fall and returned to the facility the same day. While in the emergency department R1 was diagnosed with atrial fibrillation (A Fib). On 11/27/25 Metoprolol Tartrate 25 mg (milligrams) once daily for heart failure and A Fib was ordered. This order was not implemented until 12/1/25. R1's Metoprolol Tartrate 25 mg orders included parameters to hold the medication for heart rate less than 60 or systolic blood pressure under 100. R1 received Metoprolol Tartrate 25 mg when this medication should have been held on 12/2/25, 12/9/25, 12/14/25, & 12/19/25.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to report an allegation of abuse to local law enforcement for one of one resident (Resident (R) 1) reviewed for abuse of six residents in the sample. This failure had the potential to increase a resident's risk of abuse throughout the facility.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure that staff discarded dispensed liquid medications that were not immediately administered to residents for one of two residents (Resident (R) 2) during medication administration for six residents in the sample. This failure had the potential to expose the resident to contamination in the medication.

Inspectors wroteBased on observations, record review, staff interviews, and facility policy review, the facility failed to follow appropriate infection control practices for hand hygiene for one of one residents (Resident (R) 2) observed during medication administration of six residents in the sample. The failure had the potential for the spread of pathogens in the facility.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R27) was free of significant medication errors. * R27 was not administered his AM medication on 1/27/25 because he told Registered Nurse (RN)-K he received it. The Medication Administration Record (MAR) was not signed out as to R27's medication being given that day and RN-K did no further investigation to find out if R27 received his medication however documented refused on all his AM medication. R27's AM medication included blood pressure medication and on 1/27/25 at 5:30 PM his blood pressure went up to 217/211 and R27 was transferred to the hospital and admitted . This resulted in actual harm to R27.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1of 2 residents (R5) reviewed for pressure injuries. R5, who was assessed to be at risk for pressure injuries, developed a stage 2 coccyx pressure injury on [DATE]. Facility staff did not complete a thorough assessment with measurements of the pressure injury until [DATE]. R5's care plan was not updated with new offloading interventions after the development of the coccyx pressure injury. On [DATE], R5 developed a Deep Tissue Injury (DTI) to R5's right heel. R5's care plan was not updated with new interventions after the development of the right heel deep tissue injury. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R28) out of 1 resident reviewed for accidents had adequate supervision, assistance, and interventions in place to prevent accidents. R28 was not provided one on one supervision while smoking leading to the potential for harm as R28 is physically and cognitively impaired.

Inspectors wroteBased on record review and interview, the facility did not conduct and document a facility-wide assessment. The assessment did not include the hours allocated for the (Infection Preventionist) IP, the Water Management Committee, infectious diseases, and staffing ratios. This had the potential to affect all 43 residents currently in the facility.

Inspectors wroteBased on observation, record review and interview, the facility did not implement infection control measures. This was observed with 2 (R41 and R38) of 2 residents with glucometer's. The facility did not conduct an infection control program to prevent, and track, potential infections. This had the potential to effect all 43 residents in the facility. * R41 and R38 received blood sugar through a unsanitized glucometer machine. * The facility did not transport linens under sanitary conditions. * The facility did not implement and document Legionella control measures. * The facility did not track staff who can utilize a N95 mask during an outbreak. * The facility did not calculate infections to determine trends for preventative interventions. * The facility did not document surveillance of infections to identify concerns.

Inspectors wrote3.) R22 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus Type 2 with Chronic Kidney Disease, Atrial Fibrillation, Venous Insufficiency, Depression, Hypothyroidism, Urine Retention, Congestive Heart Failure, Peripheral Vascular Disease, Anemia, Acquired absence of left leg below knee and Atherosclerotic Heart Disease. R22 was hospitalized on [DATE]. Facility progress notes document: 7/30/24 at 9:05 AM: Called to Res (residents) room by CNA (Certified Nursing Assistant) stating that Res. had a large amount of blood on his diaper and around his penis. Catheter bag was full of [NAME] blood,100 cc (cubic centimeters). Blood in catheter tubing. No movement of blood in tubing. Resident A&O (alert and oriented) X 3. Denies pain/discomfort. Abdomen soft & non-distended. Incontinent of a large amount of SF (soft formed) stool. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Surveyors made observations of residents waiting for assistance with delayed call light wait responses. Residents were interviewed and expressed concerns to surveyors that the facility does not have sufficient staff, resulting in delayed call light responses. Surveyor reviewed last 30 days of facility nursing schedules and nurse staff postings. Surveyor noted that the facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect a pattern of all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R16) of 1 resident reviewed for self-administration of medications was assessed prior to staff leaving medications at bedside for a resident. On 11/12/24, at 10:57 AM, R16 was observed to have multiple mediations sitting on her bedside table in a medication cup. R16 was not assessed to self-administer her medications and did not have an order from the facility provider for R16 to self- administer medications.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs of 1 (R7) resident) of 12 sampled residents reviewed for accommodations of needs. *R7's call light was observed to be out of reach of R7.

Inspectors wroteBased on interview and record review, the facility did not ensure residents the right to formulate an advance directive for 1 of 1 (R22) residents reviewed for advanced directives. R22's code status was not clearly indicated in the medical record.

Inspectors wroteBased on observation and interview the facility did not ensure residents' right to personal privacy and confidentiality of his or her personal and medical records for 2 of 2 (R38 and R41) residents reviewed. R38's medication cards and MAR (Medication Administration Record) were left on the medication cart unattended and in open view of residents or visitors. R41's MAR was left on the medication cart unattended and in open view of residents or visitors. The facility Policy and Procedure titled Medication Administration General Guidelines dated May 2018 documents (in part) . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration 2) Medications are administered in accordance with written orders of the prescriber. [...]

Inspectors wroteBased on interview and record review, the facility did not submit for a completion of a Level 2 Pre-admission Screening and Resident Review (PASARR) assessment for 2 (R9 and R38) of 2 residents reviewed for Level 2 PASARR Screens. R9 and R38 did not have a completed Level 2 PASARR screen for residents with mental illness or developmental disability.

Inspectors wroteBased on observation, interview and record review, the facility did not complete neurological checks in accordance with policy and procedure for 2 (R25 & R 28) of 2 residents reviewed for unwitnessed falls. *R25 did not receive neurological checks in accordance facility's policy and procedure for 5 unwitnessed falls. *R28 did not receive neurological checks in accordance facility's policy and procedure for an unwitnessed fall.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who are continent of bladder and bowel received services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 2 (R22) residents reviewed for bowel and bladder. R22 had a decline in bowel continence following admission to the facility. The facility did not comprehensively assess R22's decline and no new interventions were implemented. The facility was not documenting or monitoring R22's bowel movements.

Inspectors wroteBased on observation, interview, and records review the facility did not ensure 1 (R16) of 1 resident who receive dialysis had physician orders, monitoring, and communication with dialysis facility. R16 was admitted to the facility needing dialysis and did not have physician orders regarding the care and treatment of dialysis. The facility did not monitor R16's dialysis access site daily. There wasn't consistent communication between the facility and the dialysis facility. R16 did not have a comprehensive care plan that addressed dialysis.

Inspectors wroteBased on observation, interviews and record review, the Facility did not regularly assess the risk of entrapment and review the risk & benefits for 1 (R5) of 1 Residents observed having bed rails. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. R5, who is dependent on staff for mobility, was observed to have a half side rail/grab bar on the right side of the bed and did not have a completed side rail risk assessment since 9/18/2023. R5 was not included in the monthly safety audits of side rails completed by the maintenance department.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R10) of 3 residents reviewed, received medically related social services to attain their highest practicable mental and psychosocial well-being resulting in R10's increased level of depression, anxiety and uncertainty regarding transfer/discharge.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure it's medication error rates are not 5 percent or greater. The facility had a medication error rate of 8%.

Inspectors wroteBased on observations and interview, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the and the expiration date when applicable for 3 of 3 (R9, R41 and R44) residents reviewed. Insulin pens and vials in the medication cart and medication room refrigerator were open and used, but not dated when opened.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 2 residents (R5) reviewed for hospice care. R5 was being treated for an unstageable coccyx pressure injury and a Deep Tissue Injury (DTI) to R5's right heel. R5 was hospitalized from [DATE] through [DATE] with sepsis related to bilateral parotitis (inflammation and infection of both parotid glands [salivary glands located in front of the ears]). While hospitalized , R5's pressure injuries were both staged as unstageable. R5 was readmitted to the facility on [DATE] on hospice. Facility staff determined that hospice staff would be responsible for assessing and treating R5's pressure injuries. Communication between the facility and hospice staff was not clear. [...]

Inspectors wroteBased upon interview and record review, the facility did not ensure it maintained an antibiotic stewardship program for 1 (R7) of 1 residents reviewed receiving an antibiotic prophylactically for clostridium difficile (c-diff). R7 started receiving vancomycin prophylactically for c-diff in April of 2023. The facility infection preventionist (IP)/Director of Nursing (DON)-B was not aware R7 received an antibiotic prophylactically. R7's antibiotic use was not monitored or reviewed during infection prevention and control surveillance and reporting to the facility quality improvement team (QAPI).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report to the State Survey Agency (SA) an allegation of physical abuse for one of two residents (Resident (R) 6) reviewed for abuse out of a total sample of 16. This had the potential to compromise or impede the protection of residents when allegations of abuse were made.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a thorough investigation of an allegation of physical abuse for one of two residents (Resident (R) 6) reviewed for abuse out of a total sample of 16. The failure to conduct a thorough investigation had the potential to compromise and/or impede the protection of residents against abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 residents (R20) was free from abuse. The facility did not ensure R20 was free from an alleged sexual abuse by a visitor. On 7/21/23, Certified Nursing Assistant (CNA-D), observed visitor (I) inappropriately touching R20 with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of abuse. Visitor (I) remained in the facility and was later observed in R20's room with the lights off and with his hand under the covers while R20 was in bed. CNA-D did not report the observations of alleged sexual abuse until 7/24/23, allowing visitor (I) to visit R20 one more time (on 7/23/23) before being reported. The facility did not protect R20 from further potential sexual abuse. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (R20) of 1 residents reviewed where an allegation of abuse was not reported as a suspicion of a crime to law enforcement, and where 2 (R20 and R30) of 3 residents reviewed for allegations of abuse was not reported immediately, but not later than 2 hours to the state agency, and steps were not immediately taken to prevent further potential abuse. On 7/21/23, Certified Nursing Assistant (CNA-D), observed a visitor (Visitor I) inappropriately touching R20, with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of sexual abuse as a suspicion of a crime to the Nursing Home Administrator (NHA-A) or designee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R137, R31, R88, R21, & R87) of 5 Residents reviewed for pressure injuries. * On 1/24/2023, R137 developed a Stage 3 pressure injury to the coccyx and a Stage 3 pressure injury to the right ear A treatment was not started until 3 days later on 1/27/23. The pressure injury resolved on 2/7/23. On 1/31/2023 the Stage 3 pressure injury to the coccyx became Unstageable and no treatment was implemented at that time. The coccyx pressure injury became infected and was treated with antibiotics. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of Residents with the potential to affect all 37 Residents currently residing in the facility. Findings Include: 1. Surveyor requested a policy and procedure for linen distribution within the facility, but no policy was able to be provided by the facility. On 8/7/23 at 8:15 AM, Surveyor observed and approximately counted clean linen located on each of the 4 units located in the facility which included the following: [NAME]- 11 Residents Clean Linen Room-no towels, no washcloths, 2 bath blankets, 3 bed blankets, 1 fitted sheet, 1 flat sheet. 1st basket cart in hallway-1 gown, 2 fitted sheets 2nd basket cart in hallway-5 towels, 2 fitted sheets, 2 washcloths St. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review the facility did not did not ensure sufficient nursing staff to answer residents' call lights and provide care in accordance with the plans of care. This had the potential to affect all 37 residents residing in the facility at the time of the Survey. *There were multiple observations during Survey of a lack of nursing staff supervision in the dining room while residents were eating. *Observations of R1 not being assisted with meals. Per Certified Nursing Assistant (CNA)-FF, she assists a resident with meals in their room and also R1 who eats in the dining room. CNA-FF stated it is impossible to be in two places at once. * R1 was observed bringing R1's breakfast tray into R1's room. The CNA stated she would get R1 out of bed before lunch because they were extremely short staffed that morning. [...]

Inspectors wroteBased on interview and record review, the facility did not use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day 7 days a week. This deficient practice had the potential to affect all 37 residents residing in the facility. * On the following weekends there was no RN in the building for 8 consecutive hours: [DATE], [DATE], [DATE], [DATE] & [DATE]; [DATE] & [DATE]; [DATE] & [DATE]; [DATE] & [DATE]; [DATE], [DATE] & [DATE]; [DATE] & [DATE]; [DATE], [DATE], [DATE] & [DATE]; [DATE], [DATE] & [DATE].

Inspectors wroteBased on observation, interview and record review the facility did not maintain an infection prevention and control program in accordance with professional standards of practice having the potential to affect all 37 residents residing in the facility. *The facility did not have documentation from December 2022 regarding an influenza outbreak and control measures/interventions during the outbreak. *The facility's water management program was not comprehensive and lacked a thorough assessment of risk areas and measures taken to reduce contamination. *Observations of glucometers not being disinfected between uses. *Observations throughout Survey of linen carts not being covered.

Inspectors wroteBased on interview and record review the facility did not have a qualified Infection Preventionist who worked at least part time which had the potential to affect all 39 residents residing in the facility. *The Director of Nursing (DON)-B was serving as the facility's Infection Preventionist and did not have proper credentials.

Inspectors wroteBased on staff interview and record review, the Facility did not ensure a baseline care plan was developed and implemented within 48 hours of a Resident's admission for 10 (R9, R21, R33, R31, R34, R10, R137, R20, R13, & R1) of 13 Residents. * R9 was originally admitted to the facility on [DATE]. The Facility did not complete the baseline care plan and has a status of in progress. * R21 was admitted to the facility on [DATE]. The Facility did not complete the baseline care plan and has a status of in progress. * R33 was admitted to the facility on [DATE]. The Facility did not have any interventions on the baseline care plan to incorporate R33's needs. * R31 was admitted to the facility on [DATE]. The Facility did not have any interventions on the baseline care plan to incorporate R31's needs. * R34 was admitted to the facility on [DATE]. [...]

Inspectors wrote2. R21 was admitted to the facility on [DATE]. The physician orders with an order date of 2/23/23 documents Eliquis Oral Tablet 5 MG (Apixaban). Give 1 tablet by mouth two times a day for clot in the lung for 6 Months. Surveyor reviewed R21's comprehensive care plans and noted the following care plans: * Code status initiated 7/4/23. * Alteration in nutrition Initiated 2/7/23 & revised 6/23/23. * Activities 3/24/23 & revised 6/29/23. * ADL (activities daily living) self care performance deficit initiated & revised 12/29/22. * Peripheral Vascular Disease initiated 12/29/22 & revised 3/9/23. * Wishes to rehab, work on getting a prosthesis & eventually go back to SSR ([Name of] Residence) initiated 12/5/22 & revised 7/4/23. * Diabetes Mellitus Initiated 12/29/22 * Actual fall Initiated 12/8/22. * At risk for falls Initiated & revised 12/29/22. * Uses antidepressant medication. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 4 (R21, R137, R31, & R1) of 4 Residents reviewed received required assistance with their ADL's (activities daily living). * R21, R137, and R31 did not receive their weekly showers/baths consistently per their plan of care. * R1 did not receive supervision and assistance by staff to eat despite assessments indicating R1 needed assistance.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for neurological checks after a potential head injury for 3 (R89, R20 and R9) out of 7 residents reviewed for neurological checks and clarification of orders for an orthopedic device for 1 (R288-A) out of 14 residents reviewed for quality of care. *R288-A was observed wearing a CAM boot to the Left Lower Extremity (LLE). There were no orders clarifying when to don or doff the boot and the boot was not care planned. *R89 sustained a fall and did not have neurological checks completed. *R20 sustained a fall and did not have neurological checks completed. *R9 sustained a fall and did not have neurological checks completed.

Inspectors wroteBased on observation, interview and record review the facility did not ensure adequate supervision to prevent accidents for 7 (R18, R288-A, R228-B, R20, R9, R89, R137) 7 residents reviewed for accidents. *R18 had multiple falls without thorough investigations and root cause analyses *R288-A had two falls without thorough investigations *R288-B had a fall and there were no new interventions put in place. *R20 had multiple falls, one with a fracture, without thorough investigations and root cause analyses. *R9 had two falls without thorough investigations and root cause analyses *R89 had multiple falls without thorough investigations. *R137 had a fall that was not thoroughly investigated, and care plan not revised.

Inspectors wroteBased on observation, record review, and interview, the facility did not label medications with open dates, store medications in sanitary conditions, or removed expired medications in accordance with currently accepted professional principles affecting 4 (R9, R91, R7, R3) residents with medications not labeled when open and potentially affecting all residents that take stock medications in the facility. *The first floor medication cart had an expired stock medication. The second floor medication room had expired stock medications. The second floor medication room refrigerator was dirty, damp, and had food commingled with medications. *R9 had hydrocortisone 25 mg suppositories in the medication refrigerator that had expired. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 2 of 5 direct staff chosen at random received effective communication training. CNA (Certified Nursing Assistant)-U & LPN (Licensed Practical Nurse)-W did not receive effective communication training. This has the potential to affect 24 Residents who reside on the 2nd floor where CNA-U & LPN-W typically are assigned.

Inspectors wroteBased on record review and interview, the facility did not ensure 5 of 5 Certified Nurse Aides (CNAs)(CNA-R, CNA-S, CNA-T, CNA-U, CNA-V), Licensed Practical Nurse(LPN-W), Housekeeper(HK-X), and Assistant [NAME] (AC-Y) reviewed received behavioral health training to care for Residents diagnosed with mental health illnesses as indicated on the facility assessment. *CNA-R with a date of hire 12/18/13 did not receive Behavioral Health Training. *CNA-S with a date of hire 1/10/23 did not receive Behavioral Health Training. *CNA-T with a date of hire 4/4/23 did not receive Behavioral Health Training. *CNA-U with a date of hire 6/7/23 did not receive Behavioral Health Training. *CNA-V with a date of hire 2/20/18 did not receive Behavioral Health Training. *LPN-W with a date of hire 7/25/22 did not receive Behavioral Health Training. [...]

Inspectors wroteBased on interview and record review the Facility did not notify a Resident's attending physician when there was an allegation of sexual abuse and of a significant weight loss involving 1 (R20) of 12 Residents reviewed for notification of changes. Findings Include: Surveyor reviewed the facility's policy and procedure for Change of Condition and Provider Notification last reviewed 8/10/23 and notes the following: .l. Policy: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. ll. Procedure: 1. Change of Condition a. Change of condition(COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. 3. Notification a. [...]

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate an allegation of abuse to prevent further potential abuse for 1 (R30) of 3 residents with allegations of abuse. *R30 reported an allegation of abuse by a Certified Nursing Assistant and that allegation was not thoroughly investigated by the facility to determine if the allegation was substantiated. No staff statements were obtained, and no determination was made of which staff member was rough with R30 to further the investigation and prevent potential further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide proper foot care for 2 of 2 (R20 and R33) Residents. *On admission it is documented that R20 would benefit from seeing the podiatrist, but no referral was made. *R33, who is diabetic had a very long toe nail on the right foot and no timely referral to the podiatrist was completed.

Inspectors wroteBased on observation, interview and record review, the Facility did not provide services and treatment to restore or improve as much bladder function to the extent possible for 1 (R33) of 1 Residents reviewed for bladder function. R33 was admitted to the facility on [DATE] with an indwelling Foley catheter. The indwelling catheter was removed during an urology appointment on 8/2/23. After the Foley catheter was removed, the Facility did not complete a comprehensive bladder assessment to assist R33 to improve or restore as much bladder function as possible, did not implement a urinary care plan, did not discontinue the catheter care plan and monitoring R33's catheter was not discontinued.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R13 and R21) of 2 Residents reviewed for side rails had assessments for the need to use side rails, that consent was obtained for their use prior to installation, risks and benefits were discussed, and that alternatives were attempted prior to installation. *R13 had no current side rail assessment. *R21 had no side rail assessment completed. Findings Include: 1.) R13 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus, Paraplegia, Rheumatoid Arthritis, Agoraphobia with Panic Disorder, and Depression. R13 is currently R13's own person. Surveyor reviewed R13's Quarterly Minimum Data Set (MDS) dated [DATE] which documents that R13 has Brief Interview for Mental Status (BIMS) of 15, indicating R13 is cognitively intact for daily decision making. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not identify and seek ways to support Resident's individual needs through the assessment and care planning process, make referrals and obtain needed services from outside entities, and provide and arrange for needed mental and psychosocial services related to difficulty coping with change in condition and loss of meaningful life, and need for emotional support for 1 of 1 Resident's (R20) reviewed for medically related social services. R20 was not provided medical related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility did not ensure the monthly pharmacist recommendations were reported to the attending physician, medical director, and the director of nursing and the reported recommendations were acted upon for 2 (R30 and R21) of 5 residents reviewed for unnecessary medications. *R30 had a recommendation from the pharmacist on 8/3/2023 for the physician to provide an appropriate diagnosis for the use of Quetiapine. The facility was unaware of the recommendation until Surveyor brought forth the concern. *R21 had a recommendation from the pharmacist on 1/25/2023 for lab work to be completed. There was no documentation showing the physician was notified of this recommendation and the labs were not drawn.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 2 (R9 & R21) of 5 Residents reviewed. The Facility did not monitor R9 & R21 for potential negative side effects associated with anticoagulant use.

Inspectors wroteBased on interview and record review, the Facility did not ensure that 3 (R21, R30, & R13) of 5 Residents were free from unnecessary drugs. * R21 receives Duloxetine HCI delayed release sprinkle 80 mg (milligram) in the morning and Bupropion HCI extended release 150 mg in the morning for depression without consistent side effect monitoring of the antidepressant medications and behavior monitoring. * R30 receives Seroquel without behavior monitoring or negative side effect monitoring and there is no diagnosis for use of the Seroquel. * R13 receives Sertraline HCl Tablet 100 MG without any behavior monitoring.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 7 medication errors in 29 opportunities which resulted in a medication error rate of 24.14%. Medication errors were identified for R33, R7 & R17. * R33 received Eliquis 5 mg and Metoprolol Tartrate 25 mg late. * R7's Brimodine Tartrate Solution 0.15%, Atropine Sulfate Solution 1%, Dorzolamide HCI-Timolol Mal Solution 22.3-6.8 mg/ml & Prednisolone Acetate Suspension 1% eye drops were not dated when opened. LPN-P did not wait 5 minutes after administering Atropine Sulfate Solution 1% eye drops before administering Dorzolamide HCI-Timolol Mal Solution 22.3-68 mg/ml eye drops. * R17 received the incorrect dose of Lisinopril. R17 received 5 mg (milligrams). R17 should have received 2.5 mg.

Inspectors wroteBased on record review and interview, the facility did not obtain laboratory services when ordered by a nurse practitioner for 1 (R137) of 1 residents reviewed for laboratory services. *R137 had a CBC (complete blood count) and CMP (comprehensive metabolic panel) ordered by a nurse practitioner on 1/26/2023. The lab tests were not drawn or reported to the ordering nurse practitioner that the order was not carried out.

Inspectors wroteBased on observation and interview, the Facility does not conduct regular inspection of all bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 (R13 and R21), of 2 Residents observed with side rails/enabler bars up during the survey process. *R13 did not have regular inspection of R13's half side rails for possible entrapment. *R21 did not have regular inspection of R21's enabler bars for possible entrapment. Findings Include: On 8/13/23 at 3:18 PM, Director of Nursing (DON-B) stated there is no policy for side rails or required regular inspection of side rails. 1.) R13 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus, Paraplegia, Rheumatoid Arthritis, Agoraphobia with Panic Disorder, and Depression. R13 is currently R13's own person. [...]

Inspectors wroteBased on record review and interview, the facility did not notify and resident representatives of a transfer and the reasons for the transfer in writing to include the date, the location to which the resident is being transferred, a statement of the resident's appeal rights including the name, mailing and email address, and telephone number of the entity to which the appeal would be submitted, and information on how to obtain an appeal form, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 3 (R34, R10, and R9) of 3 residents reviewed for hospitalization. *R34 was hospitalized on [DATE] and no transfer notice was provided to R34 and R34's representative. *R10 was hospitalized on [DATE] and no transfer notice was provided to R10 and R10's representative. [...]

Inspectors wroteBased on record review and interview, the facility did not notify residents and resident representatives of the duration of the bed-hold policy during which the resident was permitted to return to the facility and the reserve bed payment policy for 3 (R34, R10, and R9) of 3 residents reviewed for hospitalization. *R34 was hospitalized on [DATE] and no bed hold notice was provided to R34 and R34's representative. *R10 was hospitalized on [DATE] and no bed hold notice was provided to R10 and R10's representative. *R9 was hospitalized on [DATE], 1/16/2023, 1/22/2023, 2/4/2023, and 5/30/2023 and no bed hold notice was provided to R9 and R9's representative.