Suites at Someren Glen Care Center, the

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were informed of the treatment, including the risks and benefits, of proposed care and to choose the alternative option if they preferred for three (#4, #9 and #76) of six residents reviewed out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #4's consent explained the risks versus benefits for psychotropic medications; -Ensure Resident #9 and/or Resident #9's representative were informed and agreed to an increase in the dose of the resident's psychotropic medication; and, -Ensure Resident #76 and/or the resident's representative consented to antibiotic therapy prior to the administration of antibiotics.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve, and demonstrate the facility's response to group grievances regarding long call light wait times.

Inspectors wroteBased on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for three of six allegations of abuse. Specifically, the facility failed to:-Report an allegation of verbal abuse between Resident #46 and Resident #56 on 2/18/26 within two hours of the incident;-Report an allegation of sexual abuse between Resident #82 and certified nurse aide (CNA) #6 on 12/19/25 within two hours of the incident; and,-Report an allegation of sexual abuse between Resident #79 and CNA #6 on 1/3/26 within two hours of the incident.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for three out of six allegations reviewed for abuse. Specifically, the facility failed to:-Thoroughly investigate a sexual abuse allegation by certified nurse aide (CNA) #6 towards Resident #82 on 12/19/25;-Thoroughly investigate a sexual abuse allegation by CNA #6 towards Resident #79 on 1/3/26; and,-Thoroughly investigate a neglect allegation involving CNA #5 on 4/1/26.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#82 and #79) of four residents out of 51 sample residents were treated with respect, dignity and care in a manner that promoted quality of life or recognized the residents' individuality. Specifically, the facility failed to ensure Resident #82 and Resident #79 were treated with dignity and respect during transfers.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for two (#53 and #79) of five residents out of 51 sample residents. Specifically, the facility failed to ensure assessments were conducted to determine whether the self-administration of medications was clinically appropriate for Resident #53 and Resident #79.

Inspectors wroteBased on observations and interviews, the facility failed to ensure one (#80) of one resident reviewed out of 51 sample residents was provided personal privacy in his room. Specifically, the facility staff failed to knock before entering Resident #80's room to protect the resident's right to personal privacy.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from chemical restraints for two (#4 and #79) of five residents out of 51 sample residents. Specifically, the facility failed to -Ensure Resident #4's use of an antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary (IDT) for continued medical necessity; -Ensure Resident #4 and Resident #79's behaviors related to the use of psychotropic medications were identified and monitored; and, -Ensure Resident #4 and Resident #79's care plans included resident-specific non-pharmacological care approaches for the residents' behaviors.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#93) of one resident reviewed for a safe and orderly discharge out of 51 sample residents. Specifically, the facility failed to ensure a discharge summary was completed at the time of Resident #93's hospital transfer.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a comprehensive care plan for two (#12 and #53) of two residents out of 51 sample residents. Specifically, the facility failed to:-Ensure Resident #12's care planned intervention for a positioning pillow was consistently implemented to support and elevate her right arm while seated in her wheelchair;-Ensure Resident #12's care plan was updated when the resident refused the wrist-hand-finger orthosis (WHFO) brace intervention for her right hand contractures;-Develop and implement a care plan focus for Resident #53's knee contracture, including identifying interventions to prevent worsening of the resident's contractures; and,-Include the interventions for physician-ordered heel booties on Resident #53's skin integrity care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#40) of five residents out of 51 sample residents were provided services that maintained professional standards of quality. Specifically, the facility failed to: -Ensure staff obtained a physician's order specifying personalized settings for air mattresses for Resident #40; and, -Ensure staff maintained air mattresses according to the manufacturer's recommendations for Resident #40.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for two (#48 and #82) of four residents reviewed for accident hazards out of 51 sample residents. Specifically, the facility failed to:-Ensure staff provided adequate assistance when transferring Resident #48 with a sit-to-stand lift (a mobility device designed to help individuals with partial weight-bearing capability transition from a seated to a standing position), which resulted in a fall for the resident; -Ensure staff notified the appropriate individuals when Resident #48 sustained a fall when staff were transferring her with the sit-to-stand lift; and,-Ensure staff transported Resident #82 in her wheelchair in a safe manner, which resulted in a skin tear to the resident's left forearm.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for one (#4) of two residents reviewed for oxygen services out of 51 sample residents. Specifically, the facility failed to ensure there was a physician's order in place for Resident #4's oxygen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one of three medication carts and two of two medication rooms. Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurately documented medical records for one (#106) of four residents reviewed out of 51 sample residents. Specifically, the facility failed to ensure Resident #106's electronic medical record (EMR) was amended to ensure the events that occurred at the time of the resident's death in the facility were accurately documented.

Inspectors wroteBased on record review and interviews, the facility failed to meet all the requirements for the provisions of hospice care for two (#75 and #38) of two residents reviewed for hospice care services out of 51 sample residents. Specifically, the facility failed to:-Ensure hospice notes were readily available in Resident #75 and Resident #38's electronic medical records (EMR);-Ensure Resident #75 and Resident #38's comprehensive care plans were developed with a delineation of care responsibilities between the facility staff and the hospice care services team; and, -Ensure there was a designated hospice care services coordinator.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas; -Ensure housekeeping staff performed hand hygiene and glove changes appropriately; and,-Ensure staff followed chemical dwell times and appropriately disinfected the blood pressure device between residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of six residents out of six sample residents. Specifically, the facility failed to administer Resident #1's blood pressure medication per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for one (#6) of three residents out of seven sample residents. Specifically, the facility failed to ensure Resident #6 experienced a dignified learning experience when certified nurse aide (CNA) #1 provided inappropriate redirection to the resident after the resident spilled a drink.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain personal hygiene for two (#7 and #3) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to offer toileting or timely incontinence care for Resident #7 and Resident #3.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. [...]

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of those reviews for five of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #4, CNA #5, CNA #6, CNA #7 and CNA #8, in order to determine potential training needs.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure expired medications were not stored with current medications in the medication carts; -Ensure insulin pens (medication used for glucose control) were labeled with resident names and open dates; and, -Ensure medications were not stored in a dormitory style refrigerator/freezer combination.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Ensure a foley catheter was stored in a sanitary manner; and, -Ensure mechanical lifts were cleaned between residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure one CNA (#9) of five CNAs received 12 hours of annual training.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for two (#85 and #300) of four residents reviewed for falls out of 34 sample residents. Record review and interview revealed the facility failed to effectively and consistently develop and implement care plan interventions to ensure the residents were provided the assessed levels of supervision recommended by nursing and therapy staff. Resident #85 had a history of falls with fractures. The facility was aware upon Resident #85's initial admission on [DATE], that she had a history of falling and had a prior fracture to her right femur. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of three kitchens; one of one nourishment room and one of three dining rooms. Specifically, the facility failed to ensure: -Proper thawing practice was done for frozen meat; -Cold foods were stored at the proper temperature; -Cleanliness was maintained in the kitchen; -Foods were covered; and, -Nutritional shakes were dated as to when they were taken out of the freezer. I. Facility policy and procedure The Food Handling Guidelines undated, provided by the executive director (ED) on 2/12/2020 at 11:03 a.m., revealed in part, Thaw frozen meat/poultry/seafood: [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective infection control program. Specifically, the facility failed to: -Develop a water management program to test for legionella; and -Ensure alcohol-based hand rub (ABHR) was not used beyond its expiration date.

Inspectors wroteBased on observation, record review, interview the facility failed to ensure the timeliness revisions of each resident's person-centered, comprehensive care plan, for thee (#296, #12, and #24) out of 24 sample residents. Specifically, the facility failed to provide timely updates to the resident's comprehensive care plan related to: -Resident #296s change in ability to participate in skilled rehabilitative services resulting in a temporary change in service type form skilled nursing services to long term care nursing service; -Resident #12s care needs and medication status affecting anticoagulant therapy; and, -Resident #24s care needs affecting a medical diagnosis of osteoarthritis.

Inspectors wroteBased on record review and interviews; the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (#32) out of three residents investigated for pain out of 34 sample residents. Specifically, the facility failed to ensure the resident ' s pain was controlled at a tolerable level and non-pharmacological approaches were ordered, evaluated for effectiveness and tracked to promote pain management. I. Facility policy and procedure The assistant director of nurses (ADON) was interviewed on 2/12/2020 at 2:58 a.m. and she said the facility did not have a policy related to pain. She said they followed the pain assessment and management form for guidance. [...]