St. Elizabeth Nursing Home

Inspectors wroteBased on interview and record review, the facility did not ensure that sufficient nursing staff were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R) for 4 of 4 Residents (R14, R16, R30, & R34) and 1 of 1 anonymous resident reviewed for staffing. Surveyors entered the facility on the weekend due to the facility being triggered for low weekend staffing. R14 voiced concerns regarding call lights not answered in a timely manner and the facility does not have enough staff to care for residents. R16 voiced concerns with call light times not being answered for 45 minutes. An anonymous resident voiced concern that she had to wait two and a half hours for someone to get her up in the morning. R30's call light was on for 1 hour and 16 minutes on 4/26/26 before staff answered it. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 5 residents (R13) reviewed for PASRR screening. R13 did not have a PASRR Level 2 completed. This is evidenced by: Facility policy SNF Admissions, admission Criteria/Requirements revised 2/11/26, states, in part: .Policy: Uniform guidelines will be in place to promote clear expectations around the admission of individuals to the skilled nursing facility (SNF). Procedure: F. Residents diagnosed with serious mental illness or developmental disabilities will be screened prior to admission utilizing Preadmission Screen and Resident Review (PASRR). a. PASRR will contribute to individual's plan of care. b. PASRR level 2 screen may be utilized to determine the facilities' ability to manage the individual need. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 14 sampled Residents (R32). R32 was not assisted with toileting between 8:15 AM and 1:53 PM.This is evidenced by:The facility's policy Standard ADL (Activities of Daily Living) Protocol, undated, includes: ADLS: .toileting. Problem: Individual requires assistance with Activities of Daily Living (ADLs). CNA: Toileting every 2 or 3 hours or per individual preference. Provide incontinence care as needed. R32 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset and vascular dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 2 of 2 residents (R5, R8) reviewed for catheters. Surveyors observed R5's indwelling urinary catheter to be resting in direct contact with the floor. Surveyors observed R8's indwelling urinary catheter to be resting in direct contact with the floor. This is evidenced by:Facility policy, titled Standard Indwelling Catheter Protocol, undated, states in part: Problem: Individual has indwelling catheter. Goal: Patency will be maintained and risk of infection will be minimized. CNA:.Keep drainage bag below level of bladder and off floor; tubing free of kinks, twists, or pressure. Example 1: R5 initially admitted to the facility on [DATE] with diagnoses that include, in part: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 3 residents (R3) reviewed for nutrition. R3 had a severe weight loss of 9.94% in 3 weeks. The facility did not notify the physician. The facility did not put interventions in place. Evidenced by:The facility policy entitled Nutrition at Risk, dated 11/30/06, states, in part: . Policy: Will provide services for nutritionally at-risk residents. Purpose: To ensure that these situations are addressed promptly and adequately. When a resident is determined to be at risk nutritionally, dining and nursing personnel will address the problem by assessment, diagnosis, care plan, implementation of action, and evaluation of the action in the respective discipline progress notes.1. Weight. C. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who need respiratory care are provided such care consistent with professional standards of practice for 2 of 3 residents (R34, R15) reviewed for oxygen. R34 did not have oxygen tubing dated or changed on a regular basis and did not have a sign on his door indicating oxygen was in use. R15 did not have oxygen tubing dated or changed on a regular basis. This is evidenced by:Facility policy, titled Safe Use of Oxygen, reviewed 2/11/26, states, in part: Policy: Entity will provide individuals who are in need of oxygen safe storage, use, and transportation in regulated health care settings. Procedure: A. Storage: .iv. Oxygen In Use signage will be posted in a prominent location. The facility did not provide any additional oxygen tubing/use policies. Example 1: [...]

Inspectors wroteBased on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R5) reviewed for hand hygiene while performing perineal (cleansing of the genital area) and catheter care (cleansing of the catheter tubing). CNA H (Certified Nursing Assistant) had a breach in infection control when performing perineal and catheter care. This is evidenced by:Facility policy, titled Hand Hygiene, reviewed on 5/8/25, states in part: Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. Procedure: A. Specific Indications for Hand Hygiene: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized, for 1 of 5 residents (R13) reviewed for immunizations. R13 was not offered the pneumococcal vaccination. This is evidenced by:Facility policy, titled Individual Immunizations, reviewed on 8/29/25, states in part: Policy: Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections. Procedure: 1. Immunization: a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. b. Individual will be offered immunizations based upon the Center for Disease Control (CDC). 3. Documentation: a. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 4 bathrooms affecting 7 residents (R4, R5, R6, R7, R8, R9, R10) reviewed for cleanly environment. R4 and R5's shared bathroom had a strong urine odor. There was dried urine and feces on the toilet chair (a device that sits over a toilet to provide extra support when using an existing toilet) and rim of the toilet. There was dried urine on the floor. R6's bathroom had feces on the toilet chair and rim of the toilet and the inside walls of the toilet. R7 and R8's shared bathroom had a strong urine odor. There was dried urine on the floor. There was feces on the back of the toilet chair. [...]

Inspectors wroteBased on 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 33 of 33 residents residing in the facility. The facility's Water Management Plan team members were not aware of their role nor were control measures being executed and documented. The facility had no infection control rates calculated for the past year. The facilities COVID-19 and Pneumococcal vaccine protocol does not contain the newest Centers for Disease Control and Prevention (CDC) guidance. The facility has two policies and procedures that were not reviewed annually. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 1 of 3 (R18) reviewed for advanced directives. The code status preference form for R18 was not completed when she went from Do Not Resuscitate (DNR) to wanting Cardiopulmonary Resuscitation (CPR).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep monitoring/tracking to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 6 residents (R8, R15, and R30) reviewed for unnecessary medications. R8 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R15 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R30 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. This is evidenced by: Example 1 R8 was admitted to the facility on [DATE] with diagnoses that include, in part: depression, unspecified (medical condition characterized by low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning); [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident environment remains as free of accident and hazards as possible for 1 of 1 sampled residents (R8). Surveyor observed R8's motorized wheelchair (Motorized Assistive Devices) being charged in her room. Staff state the wheelchair should be charged in the Beauty Shop. Evidenced by The facility policy, Motorized Assistive Device, reviewed 11/8/23, documents, in part, as follows: Policy: Individuals identified to use motorized assistive devices to reach the highest level of independent mobility will demonstrate safe and proper use of the equipment. Battery Storage: Batteries must be charged in a non-resident approved area. On 2/11/25 at 12:00 PM, Surveyor observed R8's motorized wheelchair battery plugged in and charging in her room next to R8's bed where R8 was sleeping. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents (R6) reviewed for pain management. The facility failed to provide R6 with his scheduled pain patch and effectively manage his pain causing him to miss two physical therapy sessions. The facility also failed to assess the resident's pain goal and complete a comprehensive care plan to include his pain goal and non-pharmacological interventions. This is evidenced by: The facility policy entitled, Pain, dated 8/10/23, states, in part: Policy: Nursing staff will identify appropriate treatment and services for each individual's pain management .2. Care Planning a. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident (R) for 1 of 1 residents (R6). R6 did not receive his ordered Lidocaine (Numbing medication used for pain control) on 1/21/25, 1/22/25, 1/23/25, 1/24/25, 2/6/25, 2/7/25, and 2/10/25 due to the medication not being available. This is evidenced by: The facility policy entitled, Medication Administration-General Guidelines, dated 12/2019, states, in part, . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . D. Documentation (including electronic) . 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents (R) receiving psychotropic medication were free from unnecessary medications for 2 of 5 residents (R16 and R22) reviewed for unnecessary medications. R16 receives psychotropic medications. R16 does not have a care plan with targeted behaviors or behavior tracking for the anti-anxiety or antidepressant medications. R16 was receiving an as needed (PRN) anti-anxiety medication beyond 14 days without physician follow up. R22 receives psychotropic medication. R22 did not have an Abnormal Involuntary Movement Scale (AIMS; screening to identify abnormal movements which can develop as a side effect of antipsychotic medication use).

Inspectors wroteBased on interview and record review, the facility did not ensure the COVID-19 Vaccine policy and procedure was up-to-date and implemented for 2 of 5 (R22 and R11) residents reviewed. R22 and R11 did not have, nor were they offered the 2024-2025 COVID-19 Vaccine. This is evidenced by: The facility's Policy and Procedure titled Individual Immunizations dated 12/5/24 documents in part: .1. Immunization a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered, b. Individual will be offered immunization based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP . The facility provided the following: The CDC's Recommendation Adult Immunization Schedule United States 2024 dated 11/16/23 documents, in part: [...]

Inspectors wroteBased on interview and record review the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This affected 1 of 4 sampled residents (R2). On 10/15/24, R2 was seen in the Emergency Department (ED) where he was diagnosed with a Urinary Tract Infection (UTI) that grew greater than 100,000 colonies of Enterobacter cloacae complex and greater than 100,000 colonies of Methicillin Resistant Staphylococcus aureus (MRSA), a multi-drug resistant organism. The facility failed to obtain R2's Urinalysis Culture and Sensitivity (UA C/S) from the hospital to ensure R2 was receiving the appropriate antibiotic. R2 was not receiving the correct antibiotic to effectively treat MRSA. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 3 (R3) residents reviewed for physician notification. R3 had four instances of hypotension (low blood pressure) from November 2024 to January 2025. The facility did not call the on-call physician to report R3's hypotension to allow for an alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled Change of Condition and Provider Notification with a review date of 8/10/23 states in part; [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for 1 of 3 Residents (R3) reviewed for weights. R3 has a history of Congestive Heart Failure (Failure of the heart to adequately pump blood, causing fluid to back up into the lungs) and had no physician order for weights, and was not weighed for months at a time. This is evidenced by: The facility policy, entitled, Weighing Individuals, dated 6/13/23, states, in part: Policy: Individuals are weighed according to orders. Procedure: A. Weights are obtained per order and reviewed: 1. On admission/readmission, 2. Weekly for the first four weeks, 3. Monthly. B. Weights are documented and reviewed with previous weights for any changes. C. The Provider is updated with weights as ordered or indicated . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles for 1 of 1 residents (R2) reviewed for insulin administration. Surveyor observed Medication Technician Med Tech E (Medication Technician) administer Humalog (Lispro) to R2 from a vial with no resident name indicated. This is evidenced by: The facility policy, Medication Administration, effective May 2018, documents, in part, as follows: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to he facility's medication distribution system (procurement, storage, handling, and administration.) Five Rights: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R7 and R8). R7 had a change in condition on 6/22/24. R7 has diabetes mellitus type 2. The facility has not completed daily diabetic foot checks, assessed, nor measured R7's diabetic wound, described the wound bed or continuously monitored R7's wound. In addition, R7's provider was not updated. R7 was sent to the hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. R7 developed a new diabetic wound that worsened and became infected with MRSA (Methicillin-Resistant Staphylococcus Aureus), Corynebacterium Striatum, Pseudomonas aeruginosa, and Enterococcus Faecalis; [...]

Inspectors wroteBased on 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. This has the potential to affect all 38 residents residing at the facility. Residents (R6 and R11) expressed long call light wait times due to not having enough staff. Staff voiced concerns with not being able to get tasks done due to not having enough staff per shift. Facility Scheduler indicated previous Administration directed Scheduler K to follow a grid that shows staff per resident ratio per shift. The grid does not take into consideration the acuity of the facility's resident population. The grid is currently being used to determine how to staff the facility. Evidenced by: The facility assessment titled Facility Wide Resource Assessment dated 12/22, states, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not conduct and document an up-to-date facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not review and update that assessment, as necessary, and at least annually. The lack of assessment has the potential to affect all 38 residents. The facility's Facility Assessment has not been updated annually and/or as necessary. Facility assessment dated 12/22, does not address current resident population at facility and resources/education needed for facility to appropriately care for resident population. Evidenced by: The facility document, Facility Wide Resource Assessment, dated 12/22, states in part; [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 4 of 4 sampled residents (R7, R8, R1, and R15) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to ensure daily diabetic foot checks were completed for R7, R8, R1, and R15. As evidenced by: The facility policy Standard Diabetes Mellitus Protocol, undated, indicates in part as follows: Problem: Patient has potential for fluctuating blood sugar and/or complications of diabetes mellitus. Complete daily foot checks. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 15 residents (R2) reviewed for abuse. On 8/2/24, the facility became aware of an allegation of abuse by a Certified Nursing Assistant to a resident and did not conduct a thorough investigation.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 3 of 3 residents reviewed for indwelling catheters (R1, R11, and R14.) R1 has an indwelling urinary catheter, and his urine output is not being monitored. Additionally, R1 has a physician order for monthly catheter changes, which is not current standard of practice. R11 has an indwelling urinary catheter, and her urine output is not being monitored. Additionally, R11 has a physician order for monthly catheter changes, which is not current standard of practice. R14 has an indwelling urinary catheter and has active orders for two different sizes of foley catheter. This is evidenced by: Facility policy titled Bowel and Bladder - Catheter Care, dated 6/24/22, states in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R11, R10, and R12) of 5 residents reviewed for receiving a psychotropic medication were free from unnecessary drugs. R11 receives Quetiapine, an antipsychotic medication, for agitation/anxiety. R10 receives Citalopram (antidepressant) and was receiving Haldol (antipsychotic) and the physician orders do not indicate which diagnoses are associated with these medications. R12 receives Quetiapine, an antipsychotic medication, for dementing illness with behaviors. This is evidenced by: The facility policy titled, Medication Monitoring and Management, with an effective date of May 2018, indicates, in part: .Procedures: A.5) When a resident receives a new medication, the medication order is evaluated for the following: .b. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of significant medication errors for 3 of 7 total sampled residents (R1, R9, and R13). R9 did not receive a dose of her Apixaban (blood thinner) on 9/7/24 at 8:00 PM. R13 did not receive 2 doses of her Insulin Glargine (Long-Acting Insulin) on 9/20/24 and 9/22/24 at 8:00 PM. R1 did not receive scheduled doses of insulin and had an anticoagulant held and not given without a valid signed physician's order, nor was the doctor notified of these medication errors. Example 1 R9 admitted to the facility on [DATE] with diagnoses that include, in part: Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, Acute embolism and thrombosis of inferior vena cava, dysphagia (difficulty swallowing) . R9's September 2024 Medication Administration Record (MAR) indicates, in part: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a Registered Nurse (RN) worked for 8 consecutive hours in a day, 7 days a week. This has the potential to affect all 32 residents (R) residing within the facility. On Saturday July 6, 2024, and Sunday July 7, 2024, the facility did not have an RN in the building 8 consecutive hours. On 6/17/24 at approximately 4:00 PM, after reviewing the facility provided schedules, surveyor interviewed ADON C (Assistant Director of Nursing) regarding RN (Registered Nurse) coverage. Surveyor requested ADON C review the schedules and indicate which nursing staff listed were RNs. Nursing staff listed for Saturday July 6, 2024 and Sunday July 7, 2024 schedules were not noted to be RNs. ADON C indicated there is not always a Registered Nurse in the facility on weekends for 8 consecutive hours.

Inspectors wroteBased on interview and record review, the facility failed to provide social service assistance for 4 (R2, R5, R3, and R4) of 4 residents reviewed for social services. R2, R5, R3, and R4 were not assisted with their care conference meetings. The facility indicated they went several months without a social worker. The facility failed to support all residents in having care conference meetings at least quarterly to ensure person centered care and goals were priority while residing at facility. Evidenced by: The facility policy titled, Individual Advance Care Planning, dated 2/21/24, states, in part; .Individual, guardian and/or their individual representative will be provided the opportunity to discuss advance care planning with appropriate interdisciplinary team members and providers .B. Upon admission/re-admission, change in condition, and at Care Conferences: 1. [...]

Inspectors wroteExample 2 On 7/17/24 at 9:41 AM, Surveyor interviewed R4. Surveyor asked R4 if medications are given to her or if they are left at her bedside. R4 stated staff generally bring her medications into her room and leave them on her bedside table. R4 stated, I am usually somewhere between sleep and awake when they come in. I don't like when they hover over me, so they leave the medications on the bedside table, and I take them within the hour. Surveyor asked R4 if the facility had performed an assessment for safe medication administration. R4 stated she did not recall an assessment. Surveyor reviewed R4's care plan, orders, and MAR/TAR (Medication Administration Record/Treatment Administration Record). R4's documentation does not have any notation indicating that R4 can safely self-administer medications. On 7/17/24 at 2:28 PM, Surveyor interviewed DON B (Director of Nursing). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 2 of 3 residents (R4 and R6) reviewed for abuse. On 6/23/24, the facility became aware of an alleged violation of abuse between R4 and R6 and did not conduct an investigation. Evidenced by: The Facility policy entitled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 11/8/2023, states in part; Procedure: *Individuals will be protected from abuse, neglect, and harm while they are residing at the facility *No abuse or harm of any type will be tolerated. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a discharge planning process that included preparation for discharge, ensuring discharge needs are identified and incorporated into a discharge planning care plan for 1 (R2) of 3 reviewed out of a total sample of 5 residents. Facility staff knew R2 had a plan to discharge home however, the facility was not discussing R2's discharge plan with R2. On 6/15/24 R2 decided to discharge home without a safe discharge plan in place. The facility was aware of R2's desire to return home but was not working on a safe discharge plan. Evidenced by The facility policy titled, Individual Transfer and Discharge, dated 2/21/24, states, in part; .The interdisciplinary Team will facilitate successful individual transfer and/or discharge, while complying with applicable regulations . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene. R4 did not receive a shower between 7/5/24 and 7/17/24. Evidenced by: Surveyors requested a policy related to ADL (Activities of Daily Living)/Showers and no further information was provided by the facility. R4 was admitted to facility on 9/7/23, with diagnoses that include, in part: need for assistance with personal care, morbid obesity due to excess calories, anemia (not enough oxygen in the blood which can cause tiredness, weakness, and shortness of breath), depression, urinary incontinence (inability to control bladder function), muscle weakness, and difficulty in walking. [...]

Inspectors wroteBased on interview, and record review, the facility has not established 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 for 1 of 1 residents (R1). R1 was admitted to the facility with a diagnoses of C. diff (Clostridium difficile) infection and isolation precautions were not implemented per current standards of practice. This is Evidenced by: The facility policy, Outbreak and Isolation Procedures, with a review date of 9/20/23, indicates, in part: .3. Isolation precautions are encouraged for individuals and/or staff for any contagious element according to the CDC (Centers for Disease Control) guidelines . According to the CDC website (https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html) C. Diff: [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician when 1 of 3 sampled residents reviewed discharge (R1), left the facility against medical advice (AMA).

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of misappropriation for 1 of 7 (R1) sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to arrange home health services for 1 of 5 sampled residents reviewed for discharge (R55).

Inspectors wroteBased on observation, interview, and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 31 residents. The facility does not have a staff call-in process to ensure appropriate signs and symptoms (S/Sx) of illness are known, length of time off is adequate, and that staff are testing for COVID when they have S/Sx that may be indicative of COVID. Resident surveillance does not include S/Sx and symptom onset dates. The facility only tracks residents that are being treated with antibiotics. Facility was unable to provide McGeers documentation to show criteria was met for antibiotic use. Facility does not have infection control rates for the past year. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 18 sampled residents (R20, R13, R29, and R22) and 1 of 3 supplemental residents (R35). R20, R13, R35, R29, and R22 voiced concerns related to facility cleanliness. Surveyor observed dust to be gathered in corners, under heat registers, under beds, along baseboards, and along floor transition strips in the facility hallways, resident rooms, and the dining area. Surveyors observed dried spills and stains on the floor and overflowing waste baskets. Facility staff voiced concerns related to not having enough housekeeping staff to complete daily cleaning and deep cleaning. Evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not have a system in place to ensure there was at least one licensed staff member available 24 hours a day, seven days a week who could immediately initiate cardiopulmonary resuscitation (CPR) to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 13 of 31 (R) residents residing in the facility. The facility failed to provide licensed staff on two partial shifts who could immediately initiate CPR to any resident whose advanced directive indicated they desired to be a full code. The facility failed to have a process in place or a tracking system to ensure employees are current and up to date on their CPR certifications. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the facility crash cart was checked by facility staff to ensure appropriate basic life support (BLS) could be provided to any resident requiring such care prior to arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 13 of 31 (R) residents residing in the facility. Facility did not ensure to follow standards of practice for wound care for 1 of 2 Residents reviewed for wounds out of a total sample of 18 Residents (R4). The facility did not ensure the necessary supplies and equipment were readily available for residents of the facility who have chosen to receive basic life support if needed. The facility did not complete R4's wound care treatments per physician orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service for 1 Resident (R17) reviewed of a total sample of 18 Residents. R17 voiced concerns of his Amazon packages being opened prior to being delivered to his room. This is evidenced by: The facility policy titled, Exhibit E Resident Rights, undated, states in part, 1. Dignified Existence; Communication and Access. Resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside Facility. [...]

Inspectors wroteBased on record review, observation, and interview, the facility did not ensure prompt resolution of all grievances for 1 of 18 sampled residents (R4) and 1 of 1 supplemental residents (R35) reviewed for grievances. Resident Representative L indicated she has brought forth concerns regarding R35's care and treatment and has not received any follow up. Facility staff voiced being aware of Resident Representative L's concerns regarding R35 and did not follow the facility's grievance process. R4 voiced concern of calling the police due to the call light not being answered and having to be incontinent in her bed. R4 voiced concern of being left on the bed pan and forgotten about to staff. Evidenced by: Facility policy, entitled Grievance, last reviewed 3/8/23, includes: . [...]

Inspectors wroteBased on record review and interview, the facility did not ensure their abuse policy was implemented for 1 of 8 (CNA I) (Certified Nursing Assistant) employees reviewed for caregiver background checks.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents (R) receive care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 4 Residents reviewed for Pressure Injuries out of a total sample of 18 Residents (R4, and R9). The facility did not follow R4's physician orders for wound care treatment. The facility did not follow R9's physician orders for wound care treatment. This is evidenced by: The facility policy entitled Pressure Injury Prevention and Managing Skin Integrity, Review date of 8/10/23, states in part: . I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries . II . 2. Identify Interventions and Care Plan a. Identify Interventions i. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment remained free of hazards for 2 of 2 Residents (R35 and R29) who smoke, out of a total sample of 4 Residents. NHA A (Nursing Home Administrator) indicated there were no residents who smoke during Entrance Conference while Surveyors observed two residents smoking near the front door entrance. The facility failed to assess R35 and R29 for safety, failed to have a plan in place for storing smoking materials, and failed to have a designated area for smoking that includes a safe way to dispose of cigarette butts. Evidenced by: On 1/24/24 at 9:20 AM, during Entrance Conference, NHA A indicated there are no residents who smoke residing in the home. NHA A provided a Survey Ready Binder with the following: Facility's Survey Ready Binder included a form, undated, stating: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services 1 of 1 sampled resident (R2) reviewed for G/T (gastrostomy tube) care. Facility staff checked R2's G/T placement by auscultation prior to a bolus feeding. The facility did not follow the current standard of care of checking G/T placement. This is evidenced by: The facility provided book entitled Nursing Procedures, eight edition, author [NAME], pages 796-797, states in part, . Tube Feedings .verify tube placement before administration using at least two of the following methods: . Aspirate contents from the tube with an enteral syringe . and evaluate the color of the aspirate; . If performed in your facility, measure the pH (potential of hydrogen) is usually 5 or less . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs for 1 of 5 Residents (R30) reviewed for unnecessary medicaitons. R30 is taking Trazadone and Melatonin for sleep. R30 does not have a sleep assessment to show the need or effectiveness of the medication. This is evidenced by: Facility Policy entitled 'Medication Monitoring and Management,' dated May 2018, states in part: .IIIB2:Medication Management. Policy .when selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. Procedures. A. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure each residents medication regimen was free of unnecessary psychotropic medications for 3 of 5 Residents (R24, R3, and R2) reviewed for unnecessary medications. R24's care plan is not personalized and does not include non-pharmacological interventions related to receiving psychotropic medications. R24 does not have consents signed for her psychotropic medications. R24's behavior tracking is incomplete for multiple shifts. R3 had a physician order for as needed lorazepam (a psychotropic medication used for anxiety) that extends greater than 14 days without a provider documented rationale. R2 has a dementia diagnosis and is receiving an antipsychotic medicaiton for behaviors that are not persistent or harmful to himself or others. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 1 of 18 sampled residents (R2) and 2 supplemental residents (R23 and R6). R23 was treated with antibiotics for a urinalysis culture and sensitivity (UA C/S) dated 11/13/23. Facility did not provide sensitivity to show antibiotic ordered was effective. Facility did not provide Standards of Practice (SOP) McGeers documentation to show criteria was met. R23 was treated with antibiotics for urinary tract infection (UTI) dated 11/16/23. Facility could not provide the UA C/S or McGeers. R2 was treated with antibiotics for a UA C/S dated 12/29/23 that indicated a recollection recommended due to mixed multiple morphologies present including potential uropathogens. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 3 of 5 residents (R2, R30, and R24) reviewed for immunizations. R2 was not offered pneumococcal vaccines. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Quality Assessment and Assurance (QAA) committee with the required members met at least quarterly. This practice has the potential to affect 31 of 31 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive care and treatment in accordance to professional standards for 2 of 7 sampled residents (R1 and R6). R1 did not attend a scheduled appointment that was part of her admission orders to the facility. The facility failed to follow R6's hospital discharge instructions. R6's orders indicated R6 should utilize Bipap machine every HS (at night/bedtime), and this was not done. R6 went from 10/9/23 to 11/9/23 (time of survey) without utilizing Bipap machine. This is evidenced by: Example 1 The Facilities Policy and Procedure entitled Resident Appointments and Transportation, undated, documents in part: [...]