St. Joseph Manor Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when a facility staff member physically forced the resident into his/her room. Upon assessment, the resident was had burst blood vessel on his/her left thumb. The facility census was 65. On 6/25/26, the Administrator was notified of the past noncompliance incident which occurred on 6/18/26. On 6/18/26, facility administration was notified of an allegation of staff to resident abuse, an investigation immediately began and corrective actions were implemented to include: Assessment of the Resident, suspension of the accused staff member, interviews with other residents for indications of abuse, and mandatory in-service training for all staff on abuse, dignity and safe resident handling. The noncompliance was corrected on 6/19/26. [...]

Inspectors wroteBased on record review and interviews, the facility failed to obtain written authorization from one resident (Resident #2) to deposit pension personal funds into the facility operating account. The facility census was 65. Review of facility policy, Deposit of Residents' Personal Funds, revised March 2021, showed:- Residents are not required to deposit personal funds with the facility;- If a resident chooses for the facility to hold, safeguard, and manage his or her personal funds, the facility will deposit the funds in an interest-bearing account that is separate from facility operating accounts;- A copy of the resident's or representative's authorization designating the facility as the agency to manage the resident's funds I filed in the resident's financial record;1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the Resident Smoking Policy when one sampled resident (Resident #3) out of 5 sampled residents was observed smoking cannabis, a federally illegal substance, 10 feet from the building in a non-designated smoking area. The facility census was 65. Record review of the facility's policy, Smoking Policy, dated 10/2/24, showed:- Smoking will only be allowed in designated area(s) at designated times in the facility that are not near flammable substances or where oxygen is in use. - The Smoking Policy outlines the designated areas, notices, education and requirements for smoking on the facility property to ensure precautions are taken for the resident's individual safety as well as the safety of others in the facility. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to keep four residents (Residents #1, #2, #3, and #4) free from resident-to-resident physical abuse, resulting in injury when Resident #1 scratched Resident #2 on the neck and Resident #2 hit Resident #1 on the cheek causing redness. On a separate occasion Resident #3 scratched Resident #4's fingers. Facility census was 68. Review of the facility's Abuse Prevention Program policy, dated 2001, showed:-Our residents have the right to be free from abuse;-This includes but is not limited to freedom from verbal, mental, or physical abuse;-As part of the resident abuse preventions, the administration will protect residents from abuse by anyone, including, but not necessarily limited to other residents; -Develop and implement policies and procedures to aid our facility in preventing abuse or mistreatment of the residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to honor the resident's right to self determination for one resident (Resident #1) when the facility did not honor the request for a bedside urinary catheter bag to be placed at night while sleeping, and left the resident in a leg bag causing urinary leakage, a saturated bed, loss of dignity and mental anguish. This affected one resident out of five sampled residents. The facility census was 58. Review of the facility's undated Resident Rights Policy showed every resident has the right to a dignified existence, self-determination, and to right to be a part of their care and treatment plan decision making.1. [...]

Inspectors wroteBased on interviews and facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service since August 2024. This failure had the potential to affect 55 residents who received food from the kitchen. The facility census was 56. Review of the facility's undated job description titled Dietary Manager, revised 04/16/12, provided by the facility, revealed, . Employment Standards: Education: Must possess, as a minimum, a high school diploma, completion of approved dietary manager's course is preferred. Experience: Must have, as a minimum, two (2) years experience in a supervisory capacity in a hospital, skilled nursing care facility, or other related medical facility. Training in cost control, food management, diet therapy, etc. is preferred. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to maintain an effective infection prevention and control program (IPCP) as follows: 1. The facility staff failed to clean and disinfect the multi-use glucometer with the correct disinfectant per the manufacturer's instructions when performing fingerstick blood glucose testing between residents (Resident (R) 10 and R19). 2. The facility staff failed to wear the proper personal protective equipment (PPE) when sorting dirty linens and personal clothes in the soiled linen room of the laundry room. 3. The facility staff failed to wear the proper PPE when entering a resident's room that was on airborne precautions due to a COVID positive status (R22). 4. The facility staff failed to wear the proper PPE for enhanced barrier precautions while administering medications through a gastrostomy tube for R54. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to restraints for seven of 16 sampled residents (Resident (R) 26, R32, R34, R10, R9, R19, and R20), fall assessments for three of 16 residents (R35, R4 and R55) and a urinary tract infection (UTI) for one (R22) of 16 residents. This deficient practice increased the potential for missed opportunities of care or services. The facility census was 56. Review of the facility's policy titled, Proper Use of Side Rails, dated December 2016, revealed, . Definition: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that psychotropic medications ordered on an as needed (PRN) basis for three of 16 sampled residents (Resident (R) 19, R35 and R16), included a stop date no later than 14 days after receipt of the order, resulting in the potential for adverse side effects from unnecessary medications. The facility census was 56. Review of the facility policy titled, Antipsychotic Medication revised December 2016 revealed, Policy Statement . Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. [...]

Inspectors wroteBased on record review, interview, review of the Social Services Director (SSD) job description, and facility policy review, the facility failed to ensure one of one (Resident (R) 21) reviewed for a serious mental health illness out of a sample of 16 residents was offered medically related services to include a support plan based on the Preadmission Screening and Resident Review (PASRR) Level II evaluation. This had the potential for the resident to have unmet mental health needs. The facility census was 56. Review of the Position Description, revised 01/11/12 and provided by the facility, revealed, Job Title: Social Services Director, Summary Description: The Social Services Director is responsible . to ensure that the medically-related emotional and social needs of the patient/resident are met/maintained on an individual basis. Essential Functions and Responsibilities . 2. [...]

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) in order to reduce the development of antibiotic-resistance organisms for one of three residents (Resident (R) 22) reviewed for UTIs out of a total sample of 16. This failure had the potential to affect all residents' safety related to antibiotic usage and increased the risk of antibiotic-resistance. The facility census was 56. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, revealed, . Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. [...]

Inspectors wroteBased on interviews and record review, the facility failed to keep one resident (Resident #1) free from verbal and physical abuse. Certified Nurse Aide (CNA) A engaged in a verbal altercation with Resident #1 which escalated to CNA A pushing the resident from his/her wheelchair. The facility census was 67. Review of the facility's policy on Abuse Prevention, dated December 2016, showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. -As part of the resident abuse prevention, the administration will: -Protect residents from abuse by anyone including, but not necessarily limited to: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow physician's order for wound treatment for one resident's (Resident #322) Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon and muscle caused by prolonged pressure to a bony area) on the left Ischium (the bottom of the pelvic bone), when facility staff used a bordered gauze dressing to cover Resident 322's wound instead of a Tegaderm dressing, when facility staff packed the resident's wound with gauze instead of Aquacel Ag ribbon, when facility staff failed to reposition the resident every two hours, and when facility staff failed to ensure the resident was not setting in a chair for longer than two hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address pain for one resident (Resident #322) who had a pressure ulcer to the left buttocks, impaired mobility, and was dependent on staff for all activities of daily living. The facility staff failed to assess the resident's pain and document the resident's pain when the resident voiced pain, and failed to administer pain medication to the resident. The resident repeatedly stated, my butt sore and ow, with facial grimacing. The facility census was 72. Review of the facility's Pain Assessment and Management policy, revised March 2020, showed: -Procedure is used to help the staff identify pain in the resident; -Possible behavioral signs of pain are, verbal expressions such as groaning or crying, facial grimacing, guarding, or favoring a part of the body; [...]

Inspectors wroteBased on record review and interview, the facility failed to designate a physician to serve as the medical director. The facility census was 72. Review of the facility's policy for medical director, revised July 2016, showed: - Physician services shall be under the supervision of the medical director; - The medical director is a licensed physician in this state and is responsible for: ensuring adequate and appropriate physician services; reviewed practitioner credentials and overseeing physicians and those who perform physician-delegated tasks; reviewing physician performance and providing feedback to try to improve performance; overseeing and helping develop and implement care-related policies and practices; participating in efforts to improve quality of care and services; serving as a liaison with the community; and serving as a source of education, training, and information; [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee that contains the minimum required members. The facility census was 72. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy, dated February 2020, showed: - This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; [...]

Inspectors wroteBased on interviews and record review, the facility failed to consider concerns and recommendations of the resident council members and failed to communicate with the council regarding concerns as reported by 10 of 16 residents who participated in a group interview. The facility census was 72. Review of the facility's policy for filing grievances/complaints, dated April of 2017, showed: - Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman); - The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; - All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their rights periodically during the resident's stay both orally and in writing. This effected all 16 residents present during a resident group interview. The facility census was 72. Review of the facility's policy on Resident Rights, dated December of 2016, showed: - Federal and state laws guarantee certain basic rights to all residents of this facility; - Directions to ensure residents are supported by the facility in exercising his or her rights; - Directions to ensure residents are informed about his or her rights and responsibilities. Review of monthly resident council meeting minutes from 10/6/23, 11/10/23, 12/8/23, and 1/11/24 showed: - A section on each form for resident rights review; [...]

Inspectors wroteBased interviews and record review, the facility failed to ensure residents were informed they had the right to file grievances in writing, file anonymously, and obtain a written decision regarding a grievance. The facility census was 72. Review of the facility's policy for filing grievances/complaints, dated April 2017, showed: - Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman); - The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; - All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. [...]

Inspectors wroteBased on observations, interviews, and record, review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected two of 18 sampled residents, ( Resident #35 and Resident #38) and failed to ensure showers were completed for Resident #40. The facility census was 72. Review of the facility's policy for perineal care, revised February 2018, showed: - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - For the female resident: wash the perineal area, wiping from front to back; separate the skin folds and wash area downward from front to back; [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for three of 18 sampled residents (Resident #9, #11, and #374) when staff failed to effectively clean oxygen concentrator filters, properly label and date oxygen concentrator oxygen tubing, and properly fill and date humidified bottles. The facility census was 72. Review of the facility's Oxygen Administration policy, dated October of 2010, showed: - The purpose of the policy was to provide guidelines for safe oxygen administration; - Directions to verify that there is a physician's order for this procedure, review the physician's orders or facility, review the resident's care plan to assess for any special needs of the resident, and assemble the equipment and supplies as needed; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to assess the risk for entrapment prior to the installation of bedrails, failed to obtain written consent for the use of the bedrails, and failed to complete a bedrail assessment or complete a bedrail assessment correctly for 3 of 18 sampled residents, (Resident #13, #15 and #53). The facility failed to ensure one resident's (Resident #13) mattress fit the bed frame when the resident's foam mattress was approximately five inches smaller than the bariatric bed frame it was on. The facility census was 72. Review of the bed rail policy, dated December 2016, showed: - Bed rail assessment will be completed to determine the resident's symptoms, risk for entrapment, and the reason for the side rail use; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to discard expired medications and biologicals stored within the medication room and the medication carts, which affected three of 18 sampled residents, ( Resident #2, #39, and #499), failed to date an opened bottle of Lorazepam (used to treat anxiety) for Resident #30, and failed to date an opened vial of Novolin N insulin (an intermediate-acting insulin used to lower blood sugars) for Resident #16. The facility census was 72. Review of the facility's policy for storage of medications, revised November 2020, showed: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer guidelines for NovoLog insulin (fast acting) vial, at www.mynovoinsulin. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to serve food to the residents that was palatable, attractive, and served at a safe and appetizing temperature. This affected two out of 18 sampled residents (Resident #26 and #54). The facility census was 72. Review of the facility's Food and Nutrition Services Policy, dated 2001, showed: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preference of each resident; -Reasonable efforts will be made to accommodate resident choices and preferences; -The food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is serviced at a safe and appetizing temperature. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure staff prepared foods designed in a way to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected three residents identified by the facility as having orders for a pureed diet (Residents #9, #35, and #322). The facility census was 72. Review of the facility's Food and Nutrition Services Policy, dated 2001, showed: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preference of each resident; -Reasonable efforts will be made to accommodate resident choices and preferences; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to offer evening snacks to all residents. This affected four of 18 sampled residents (Resident #11, #32, #36, #38) and other residents who attended the resident group interview. The facility census was 72. Review of the facility's serving snacks (between meals and bedtime) policy, dated September 2010, showed: - The purpose of this procedure was to provide the resident with adequate nutrition; - Directions to review the resident's care plan and provide for any special needs of the resident; - Directions to check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; - Directions for the person performing this procedure to record the following information in the resident's medical record: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and to maintain the kitchen in a sanitary manner. The food facility census was 72. Review of the facility's General Sanitation of the Kitchen Policy, dated, 2021, showed: -Food and nutrition services will maintain the sanitation of the kitchen through a comprehensive cleaning schedule; -Cleaning tasks will be outlined in a written cleaning schedule; -Employees will be trained on how to perform cleaning tasks. Review of the facility's Cleaning of the Microwave Oven Policy, dated 2021, showed: -The microwave oven will be kept clean, sanitized and odor free; -The microwave oven interior should be cleaned after each use and as needed and at a minimum, after each meal service. Review of the facility's Food Storage Policy, dated 2021, showed: [...]

Inspectors wroteBased on record review and interview, the facility failed to secure hospice agreements for two of 18 sampled residents (Resident #26 and #34). The facility census was 72. Review of the hospice program policy, dated July 2017, showed: - Hospice providers who contract with the facility must have a written agreement with the facility outlining the responsibilities of the facility and the hospice agency. 1. Review of Resident #26's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/23/23, showed: - Brief Interview for Mental status (BIMS) score of 15, indicating no cognitive impairment; - Diagnoses included: Abnormal weight loss, muscle weakness and depression; - The resident was admitted to hospice services on 8/29/23. Review of the resident's Hospice care plan, dated 8/30/23, showed: - The resident chose hospice services; [...]

Inspectors wrote3. Review of Resident #35's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Dependent on the assistance of staff for toilet use, transfers, and dressing; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included congestive heart failure (accumulation of fluid in the lungs and other areas of the body), high blood pressure, diabetes mellitus, depression and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 12/26/23, showed: - Alteration in activities of daily living (ADL) mobility related to bilateral lower extremity pain due to neuropathy (weakness, numbness and pain from nerve damage) and diabetes mellitus; - Required the assistance of two staff with bed mobility. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff treated one of 18 sampled residents (Resident #38) in a manner that maintained their dignity when staff did not respond to Resident #38's call light in a timely manner and when staff checked Resident #322's incontinent brief while the resident was in the dining room. The facility census was 72. Review of the facility's policy for dignity, revised February 2021, showed, in part: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 18 sampled residents who had a diagnosis of Post Traumatic Stress Disorder (PTSD) (Resident #18) and a a diagnosis of Down Syndrome (Resident #322) had a Preadmission Screening and Resident Review (PASARR) completed and reviewed by the facility as part of the resident's admission into the facility. The facility census was 72. Review of the admission criteria policy, dated March 2019, showed: - The objectives of the admission criteria are to admit residents who can be cared for adequately by the facility staff; - Assure the facility receives appropriate medical and financial records prior to the residents admission; - All new admissions and residents that are readmitted are screened for mental disorders (MD) and intellectual disorders (ID) per the PASARR process; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure communication between the facility and dialysis center, failed to document assessments of one resident (Resident #322) before and after dialysis, and failed to follow the resident's care plan for dialysis/renal failure. Additionally, the facility failed to have an agreement with a certified dialysis facility that included all aspects of how the resident's care will be managed. The facility census was 72. Review of the facility's Care of a Resident with End-Stage Renal Disease policy dated, September 2010, showed: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care; -Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one resident (Resident #1) when the facility failed to follow up on an urgent x-ray order when the resident had bruising and swelling to left elbow. The facility census was 60. The facility did not provide a policy on following urgent physician orders. 1. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure staff offered a nourishing bedtime snack to every resident between the evening meal and breakfast. The facility census was 58. 1. Review of the facility's Food and Nutrition Services policy, dated October 2017, showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy interpretation and implementation directed the following: - The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen and failed to monitor sanitizer levels in the dishwasher. The facility census was 58. Review of the facility's policy for Proper Handwashing Procedures and Proper Use of Gloves, dated 2011, showed: - Instructions will be posted over each handwashing station outlining the proper procedure for washing hands; - All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoke breaks), and between all tasks. Handwashing should occur at a minimum of every hour. - Employees will wash hands before and after handling food, after touching any part of the uniform, face, hair and before and after working with an individual resident; [...]

Inspectors wroteBased on record review and interviews, the facility failed to assure they followed their policy when they failed to indicated residents' wishes and documented the residents' choice of code status in such a way to be readily accessible to staff in the event of an emergency. This affected 5 of 15 sampled residents (Residents #2, #26, and #57). The facility census was 58. The facility did not provide a policy for establishing a resident's wishes regarding code status or how the facility will notify the staff of the resident's code status. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated [DATE] showed: -Alert and oriented and able to make decisions -Independent with Activities of Daily Living (ADL's); -Diagnoses of anemia (low red blood cell), hypertension (HTN), and dementia. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the building in a safe, clean, comfortable home-like environment, when staff did not repair damaged walls, did not maintain resident bathrooms, did not keep exhaust vents clean and dust free, and did not keep floors throughout the building clean and stain free. The facility census was 58. Review of the Floor Waxing and Stripping Completions sheet showed: - No rooms on the 100 North hall had been stripped and waxed since September 2020; - Nine rooms on the 100 hall had not been done since they started using this form; four were done in 2018; seven were done in 2019; nine were done in 2020; of those nine, six were rooms that were completed in 2019. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was dated when changed and oxygen was humidified for four residents (Residents #49, #50, #52 and #209), and failed to ensure one resident (Resident #26) oxygen tank had oxygen and that the resident was receiving oxygen as ordered by the physician out of 15 sampled residents. The facility census was 58. Review of facility policy Oxygen Administration, dated October 2010, showed: -Verify that there is a physician's order for oxygen. -Humidifier bottle is necessary when administering oxygen. -Ensure there is water in the humidifying jar. -Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. -Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter).; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of unnecessary medications when staff did not discontinue orders for as needed (PRN) narcotics after 14 days for three of 15 sampled residents (Resident #1, #20 and #50). The facility census was 58. Review of the facility's Administering Medications policy, revised April 2019, showed medications are administered in a safe and timely manner and as prescribed. The policy directed: - The Director of Nursing Services (DON) supervises and directs all personnel who administer medication and/or related functions. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent. Staff made two medication errors of 25 opportunities for error, which resulted in a medication error rate of eight percent, which affected two of 15 sampled residents, (Resident #28 and # 48). The facility census was 58. 1. Review of the facility policy for Administering Medications dated 4/19 showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with the prescribed orders, including any required time frame; -The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure staff properly stored and discarded controlled substances (medications with the potential for psychological and/or physical dependence); and failed to discard medications after the medication expiration date. The facility census was 58. The facility did not provide a policy for discarding expired medication. Observation on [DATE] at 1:31 P.M. showed: -In the Certified Medication Technician (CMT) cart: a bottle of Carbamide Peroxide (is used to soften and loosen ear wax, making it easier to remove) ear drops with no date to show when the bottle was open or a date of when to discard the medication; - A bottle of Ofloxacin optho (eye) drops ( is used to treat bacterial infections of the eye) with an expiration date of [DATE]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received foods prepared in a way to conserve nutritive value, flavor and appearance and failed to serve foods that a safe and appetizing temperature. The facility census was 58. Review of the facility's Food and Nutrition Services policy, dated October 2017, showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy directed: - The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to assure all residents were offered and did not document the administration of the tuberculosis test, the influenza and the pneumonia vaccinations in a timely manner. This affected eight of 32 sampled residents (Residents #1, #2, #8, #12, #20, #26, #28 and #49). The facility census was 58. The facility did not provide a policy for pneumonia or TB vaccines. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff showed the resident was admitted to the facility on [DATE] with a readmission dated on 12/3/20. Review of the medical record showed: -No documentation of the offering or administration of the pneumonia vaccine in 2020; -No documentation of the yearly TB test in 2021. 2. Review of Resident #2's MDS showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for three residents with side rails (Residents #12, #26 and #51) to ensure the environment remained safe and free of accident hazards. The facility census was 58. 1. Review of the facility policy for Proper Use of Side Rails dated 12/16 showed: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as a restraint unless necessary to treat a resident's medical symptoms; -Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed); -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #40 was safe to self-administer medications were seven pills were left in a medication cup on the residents' bedside table unattended by licensed staff. This affected one of fifteen sampled residents. Facility census was 58. Review of facility policy, Self-Administration of Medications, dated December 2016, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Advanced Beneficiary Notices (ABN) to two of three sampled residents (Residents #28 and #47) when the residents discharged from Medicare part A services. Facility census was 58. The facility did not provide a policy on ABN notices. Review of Resident #28's Beneficiary Protection Notification Review form showed: -Last day of covered services was 3/12/21. -The facility initiated the discharge when benefit days were not exhausted. -ABN notice not provided. -Notice of Medicare Non-coverage (NOMNC) form was provided. Review of Resident #47's Beneficiary Protection Notification Review form showed: -Last day of covered services was 6/5/21. -The facility initiated the discharge when benefit days were not exhausted. -ABN notice not provided. -Notice of Medicare Non-coverage (NOMNC) form was provided. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they provided residents with a discharge notice before transferring or as soon as practicable to one of 15 sampled residents (Resident #42) to the hospital in a facility-initiated discharge. The facility's census was 58. The facility did not provide a policy for issuing discharge letters when residents transfer to the hospital. Review of Resident #42's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/21, showed the facility discharged the resident to the hospital with a return anticipated. Review of the resident's nursing notes showed staff documented they discharged the resident to the hospital due to critical labs. Staff sent him/her out to emergency room on 6/4/21 at 7:30 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff issued a notice of their bed-hold policy prior to transferring one of 15 sampled residents (Resident #42) to the hospital. The facility's census was 58. Review of the facility's Bed Hold policy, dated December 2006, showed the facility shall inform residents upon admission and upon transfer for hospitalization or therapeutic leave of the bed-hold policy. The policy included the following: - Upon admission and when a resident is transferred for hospitalizations or for therapeutic leave, a representative of the facility will provide information concerning our bed-hold policy; - Upon admission a Bed Reservation Agreement will be completed by the resident or their representative to identify if they request to pay to hold the bed while the resident is on therapeutic leave or out to the hospital. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure accurate assessments when dialysis was not coded on the Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) for one of fifteen sampled residents (Resident #50). Facility census was 58. Review of facility policy, MDS Completion and Submission Timeframes, dated July 2017, showed nothing specific to the completion accuracy. 1. Review of Resident #50's admission MDS, dated [DATE], showed: -Dialysis not marked. -Diagnosis include: renal failure (kidneys don't function properly to filter blood). During an interview on 6/8/21 at 11:00 A.M. Resident #50 said: -He/she goes to dialysis three times a week. During an interview on 6/11/21 at 1:37 P.M. MDS Nurse A said: -Dialysis should be on the MDS. -Resident #50 goes to dialysis three times a week, been on dialysis since admission. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was care planned for three of three sampled residents (Resident #49, #50, and #208). The facility census was 58. 1. Review of Resident #49's admission minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 5/16/21, showed: -Resident receives oxygen therapy. Observation on 6/8/21 at 1:30 P.M. showed -Resident #49 with oxygen on. Oxygen tubing not dated. Oxygen tubing not connected to a humidifier bottle. Review of Resident #49's electronic chart on 6/8/21 showed: -Oxygen at 2 liters via nasal cannula continuous. Order date 5/10/21. -No care plan for oxygen. 2. Review of Resident #50's admission MDS, dated [DATE] showed: -Resident receives oxygen therapy -Brief interview for mental status (BIMS) score 15. This indicates no cognitive impairment. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop, review and revise comprehensive care plan and assessments that addressed the weight loss for one resident (Resident #26) out of 15 sampled residents. The facility census was 58. The facility did not provide a policy for care plan timing and revisions. 1. Review of the resident's care plan for nutrition dated 3/12/21 showed: -Problem: resident has had a recent weight loss due to poor intake; -Goal: Resident will maintain current weight; -Approaches in part of: heart healthy mechanical soft diet, dietitian to evaluate quarterly and as needed, weekly weights. Review of Resident #26's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/18/21 showed: -Alert and oriented, difficulty with making decisions; [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure staff followed professional standards of practice when staff failed to utilize the electronic medical record to verify orders when providing wound treatment and obtaining blood sugar and administering insulin for two of 15 sampled residents, (Resident # 11 and #28) and failed to allow Resident #28's fingertip to air dry before obtaining the blood sample. The facility also failed to to ensure physician orders were followed when labs were not obtained twice a week as ordered for one sampled resident out of fifteen (Resident #50), and failed to ensure residents received oxygen as ordered by the physician out for one of 3 sampled residents (Resident #50). The facility census was 58. 1. Review of the facility's policy for administering medications , revised December 2012, showed, in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provided incontinent care in a timely manner for one resident (Resident #26) out of 15 sampled residents. The facility census was 58. 1. Review of Resident #26's care plan for Activities of Daily Living (ADL's) dated 3/12/21 showed: -Need help with toileting and grooming; -Provide encouragement and assistance. Review of the comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/18/21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained the highest practicable physical well-being when restorative nursing program was not completed as ordered for two of fifteen sampled residents (Residents #40 and #54). Facility census was 58. Review of facility policy, Restorative Nursing Services, dated July 2017, showed: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence. -Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. -The resident will be included in determining goals and plan of care. 1. Review of Resident #40's admission minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 5/9/21 showed: -Brief interview for mental status (BIMS) score 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they provided adequate supervision and an environment free form the possiblity of accident hazards for one of 15 sampled residents (Resident #19) when the facility staff allowed him/her to use an E-cigarette vape pen. Staff wrapped the pen up in a washcloth, placed the pen on the resident's chest and allowed him/her to use the pen in the resident's room while he/she lay in bed. The facility census was 58. Review of the policy for Resident Smoking dated 7/17 showed: -This facility shall establish and maintain safe resident smoking practices; -Residents shall be informed of the facility smoking policy, including designated smoking areas; -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a meal tray to a resident at risk for malnutrition. This affected one of fifteen sampled residents (Resident #40); and the facility staff failed to monitor weights, notify the physician of the Registered Dietician's (RD) recommendations and of the resident's weight loss for one resident (Resident #26). The facility failed to notify the physician of a significant weight loss of 13.6% in one month and a weight loss of 22.28% in four months. The facility census was 58. Review of facility policy, Nutrition and Hydration to Maintain Skin Integrity, dated October 2010 showed: -The following information should be recorded in the resident's medical record: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure communication between the facility and dialysis center and standards of practice when staff failed to document an assessment before and after dialysis. This affected one of fifteen sampled residents (Resident#50). Facility census was 58. Review of Resident #50's admission Minimum Data Set (MDS), a federally mandated assessment instrument complete by staff, dated 5/21/21, showed: -Dialysis not marked. -Diagnosis include: renal failure (kidneys don't function properly to filter blood). -Brief interview of mental status (BIMS) score 15. This indicates no cognitive impairment. During an interview on 6/8/21 at 1:40 P.M. Resident #50 said: -Goes to dialysis multiple times a week. Review of Resident #50's care plan, dated 5/26/21 showed: -Resident needs dialysis related to end-stage renal disease. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services in order to provide medications as ordered when staff failed to receive medications ordered resulting in multiple missed doses of eye drops after cataract surgery for one of fifteen sampled residents (Resident #12). Facility census was 58. Review of Resident #12's electronic chart showed: -Resident had cataract surgery on 5/15. -Imprimis (eye drops for patients following cataract surgery) ordered four times daily in left eye due to cataract surgery. Order start date 5/15/21. -Multiple days of Imprimis eye drops documented as not given due to medication unavailable. Review of Resident #12's nurses notes dated June 2021, showed: -No documentation regarding missed doses of Imprimis. Review of Resident #12's medication treatment record dated June 2021, showed doses not administered on: [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime an insulin pen prior to administrating insulin which affected one of 15 sampled residents, (Resident #28 ). The facility census was 58. 1. Review of the facility policy for Administering Medications dated 4/19 showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with the prescribed orders, including any required time frame; -The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. Review of the website, www.humalog.com showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not change gloves and wash hands between dirty and clean tasks during wound care and perineal care and failed to provide a clean barrier to place wound supplies on which affected two of 15 sampled residents, (Resident #11 and #28). Facility census was 58. Review of the policy for Hand Washing/Hand Hygiene, dated 9/19, showed: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap and water for the following situations: -when hands are visible soiled; [...]