The Bellefontaine Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three (3) of 3 sampled residents (Residents 11, 43, and 139) meal trays that were appetizing and palatable (agreeable to one's sense of taste). This failure had the potential to result in dissatisfaction, decreased food intake and place Residents 11, 43, and 139 at risk for unplanned weight loss. During a review of Resident 11's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of osteomyelitis (infection of the bone and bone marrow) and protein-calorie malnutrition (a dangerous state of undernutrition caused by a lack of both dietary protein and total calories). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: Dietary Aide 1 (DA 1) wore a hairnet while inside the kitchen. Dietary Aide 2 (DA 2) perform hand hygiene between handling dirty dishes and clean dishes. One container of poultry seasoning was closed. One opened container of dill weed seasoning was labeled with an open and/or use by date. These failures had the potential for residents to be at risk for food-borne illness (illness caused by food contaminated with bacteria). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine drainage had an air gap (a vertical, unobstructed space between the ice machine's drain and the buildings drainage system that prevent contaminated drain water from flowing back into the machine's clean water supply. It is a safety measure, often a simple pipe fitting or a dedicated device, that acts as a barrier, with the most common requirement being a one to two - inch gap to comply with health and plumbing codes) to ensure no contact with outside contaminated (unfit for use, or unsafe) source as indicated in the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by a Resident to signal his or her need for assistance) was within reach for four (4) of six (6) sampled residents (Resident 37, 8, 113, and 137) who were reviewed for environment care area. This deficient practice had the potential to negatively impact on the psychosocial well-being (the individual's mental and emotional health and their social interactions and environment) of Residents 37, 8, 113, and 137 as a result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to ensure the resident was free from unnecessary medication (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when their potential risks outweigh the benefits) use for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications, by failing to have a specific indication for Resident 57's use of lorazepam (Ativan- a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) admission Comprehensive Assessment (a clinical evaluation required for all new admission in skilled nursing homes) was completed within the required timeframe of 14 days after admission for two (2) of 25 sampled residents (Resident 141 and 137). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 141 and 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate assessment and documentation of the resident's hearing ability were reflected in the resident's Minimum Data Set (MDS - a resident assessment tool) for one (1) of 1 sampled resident (Resident 73) reviewed for vision and hearing. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 73 to receive care and services to maximize and/or improve Resident 73's functional ability in hearing.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for two (2) of 25 sampled residents (Residents 73 and 2):Resident 73 did not have a care plan to address the resident's hard of hearing. Resident 2 did not have a care plan to address the resident's diagnosis of dementia (progressive state of decline in mental abilities). This deficient practice has the potential to delay in the necessary care and services for Resident 73 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a language communication board was placed at bedside for one (1) of (1) sampled resident (Resident 5) reviewed for language/communication area in accordance with the facility's policy. This deficient practice had the potential to result in Resident 5 experiencing a delay in receiving appropriate care and services due to the staff not being able to properly communicate with the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sample residents (Resident 73) reviewed for hearing care area received appropriate treatment to maintain the resident's hearing abilities by failing to ensure audiology (audiology is the branch of science and medicine concerned with the sense of hearing. Audiologists are health care professionals who diagnose, manage, and treat hearing, balance, or ear problems) appointment was arranged for the resident in accordance with physician's order. This deficient practice had the potential for Resident 73 to have increased hearing loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through the tiny holes) in accordance with the weight for one (1) of three (3) sampled residents (Residents 117) reviewed for pressure ulcer. This deficient practice placed Resident 117 at risk for development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the feet of one (1) of four (4) sampled residents (Residents 20) reviewed for accident were placed on the wheelchair's footrest during wheelchair transport. This deficient practice placed Resident 20 at risk of injury and serious harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a trauma informed assessment (a structured clinical approach that evaluates how an individual's past and present trauma impacts their overall functioning, relationships, and well-being) for one (1) of two (2) sampled residents (Resident 134) who has a diagnosis of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice has the potential to affect Resident 134's psychological (relates to the mind, mental processes, and behavior) well-being and affects the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 84) observed during medication pass received Metformin Hydrochloride (drug used to lower and control blood sugar levels in people with type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing)] ) with meals as indicated on the physician's order and facility's policy. This deficient practice placed Resident 84 at risk for gastrointestinal (GI, involves the mouth, esophagus, stomach, small and large intestines, rectum and anus) side effects which included nausea, diarrhea, and stomach cramping.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of four (4) dumpsters (a movable waste container) and 1 trash can were covered and closed per facility policy and procedure (P&P). This failure had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community. During an observation on 6/2/2026 at 7:35 AM outside to the left of the building next to the facility driveway, one gray trash can was observed overflowing with brown paper, plastic bags and a surgical mask with no cover or lid. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two (2) of 25 sampled residents (Residents 4 and 137) as indicated in the facility policy by failing to ensure:Treatment Nurse 2 (TN 2) changed gloves and performed hand hygiene (washing hands with soap and water for at least 20 seconds, or using alcohol-based sanitizer, to effectively eliminate germs and prevent disease spread) after touching the privacy curtain (a ceiling-suspended fabric partition used to temporarily section off patient beds, exam areas, or treatment spaces to protect patient dignity, ensure confidentiality, and create semi-private spaces) and before continuing wound treatment for Resident 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic surveillance (is the continuous tracking and analysis of how antibiotics (medicines used to treat bacterial infections by killing bacteria or inhibiting their growth] are used and how bacteria are becoming resistant to them) data collection form was completed for one (1) of two (2) sampled residents (Resident 134) who was receiving antibiotic therapy. This deficient practice had the potential for Resident 134 to be prescribed inappropriate antibiotic and increased the risk of developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics).

Inspectors wroteDPS:Based on observation, interview and record review, the facility failed to administer an intravenous (IV -within a vein) medication at the prescribed infusion rate for one of two sampled residents (Resident 3). This failure resulted in Resident 3's Vancomycin (Vanco- a medication used to treat infections caused by bacteria) being administered slower than prescribed, with the potential to lead to ineffective treatment or bacterial resistance for Resident 3.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate documentation of the urine output for one (1) of 2 sampled residents (Residents 1) with indwelling catheter (a flexible tube that passes through the urethra [a tube through which the urine leaves the body] and into the bladder to drain urine) in the resident's Medication Administration Record (MAR) and urine output log in accordance with the facility's policy. This deficient practice had the potential to result in miscommunication among staff and resulted in the medical records inaccurate representation of care provided to Residents 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the ampicillin (drug used to prevent and treat several bacterial infections) six (6) grams (gm - unit of measurement) every 12 hours intravenous piggyback (IVPB- a way to give a patient a dose of medicine directly into the vein through the existing line) was reconciled (formal process of creating the most accurate and complete list of resident's current medications from the previous health care facility or from home, and comparing that the list with the medications being prescribed by the physician of the receiving healthcare facility) and administered for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility's policy and procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for one of two sampled residents (Resident 1) who had a diagnosis of other sequalae of cerebral infarction (the long-term conditions and complications that result from brain tissue damage due to reduced blood supply), other interval disc (a cushion of cartilage found between the vertebrae (bones) of the spine) lumbar region (the lower back region of your spinal column or backbone), other spondylosis with radiculopathy - lumbar region (a condition where the degenerative changes of spondylosis [osteoarthritis of the spine] lead to compression of spinal nerve roots, resulting in radiculopathy symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to ensure the advance directive was in the chart for two (2) of four (4) sampled residents (Resident 30 and Resident 222). This deficient practice had the potential for Resident 30 and Resident 222 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) or health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Foods are stored in a manner that prevents foodborne illness (illness that comes from eating contaminated food) for residents. 2. All personnels in the kitchen, which includes outside maintenance, working on kitchen equipment, wore hair nets. These deficient practices have the potential to result in foodborne illness in a population of 103 residents who consume the food prepared by the facility every day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for three of 22 sampled residents (Residents 175, 173 and 271) as indicated on the facility policy by failing to ensure: 1. Treatment Nurse 1 (TN 1) doff (take off) Personal Protective Equipment (PPE, protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after repositioning Resident 175 and before continuing wound care treatment. 2. Licensed Vocational Nurse 5 (LVN 5) doff PPE after administering medications to Resident 173 and before touching the medication cart. This deficient practice has the potential to spread infection to staff and residents. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 39) was treated with respect and dignity in accordance with the facility policy by failing to keep the resident's bed linen clean and free of food particles/ crumbs. This deficient practice had the potential to affect the resident's self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 22 sampled residents (Resident 223 and 53) were provided with the following in accordance with the facility's policy: 1. Resident 223's call light (device used by residents to call staff) was not within arm's reach. This deficient practice had the potential for Resident 223 not to be able to call the facility staff for help or assistance, especially during an emergency. 2. Facility failed to ensure Resident 53's bed had a footboard (a flat board placed at the foot of a resident's bed to help maintain proper positioning and alignment, thereby preventing the feet from slipping off the bed). This deficient practice had the potential to negatively impact Resident 53's comfort and physical well-being due to improper positioning of the foot.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) for one of 22 sampled residents (Resident 223) when Resident 223's medical records were left exposed by leaving the computer unattended and not turning off the computer screen on 5/1/2025. This deficient practice violated Resident 223's right to privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessment of resident's medication on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 22 sampled residents (Resident 50) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 50 to receive necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendation to obtain a PASARR level II (a detailed assessment performed on individuals identified during a Level I PASSR screening as potentially having a serious mental illness [SMI], intellectual disability [ID], developmental disability [DD], or related condition [RC]) evaluation for one (Resident 84) of three sampled residents after receiving a Level II Notice of Attempted Evaluation Letter, dated 11/7/2024. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 84.

Inspectors wroteBased on interview and record review, the facility failed to follow the fluid restriction for one (1) of three (3) sampled residents (Resident 102) as indicated on the physician's order. This deficient practice has the potential for Resident 102 to have fluid overload (a condition where the body has too much fluid which could lead to various symptoms, including swelling, shortness of breath, and weight gain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper application of resting hand splint (provide support and rest to the hand and wrist, particularly during periods of rest or sleep to help reduce pain, swelling, stiffness, and contractures [shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints]) and elbow splint (a support or brace that helps stabilize and protect the elbow joint) for one (1) of four (4) sampled residents (Resident 56) with limited range of motion (ROM - movement of the joints) as indicate on the physician's order. This deficient practice had the potential to cause complications such as pain, swelling, and contractures) to Resident 56's right arm, fingers and wrist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to post a No Smoking sign outside the room of one of two sampled residents (Resident 222) while the oxygen was in use. This deficient practice had the potential to cause fire which could harm the residents, staff, and visitors at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 62) in accordance with the facility policy by failing to administer cholecalciferol (a dietary supplement used to treat Vitamin D deficiency) and Miralax (a medication used to treat occasional constipation [difficult bowel movement]) as indicated on the physician's order. This deficient practice had the potential for Resident 62 to experience constipation, muscle weakness, and bone and joint pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order; manufacturers specifications / accepted professional standards and principles) out of 33 opportunities (observed administered medications) for error which yielded a facility medication error rate of 6.06 percent for one of three sampled residents (Resident 62) observed during medication administration (med pass). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly provide dental services for one of two sampled residents (Resident 46) as in accordance with the facility's Dental Services policy. This deficient practice resulted in Resident 46 having pain when wearing dentures, poor food intake from inability to effectively chew food and had the potential to result in weight loss, lack of energy, and loss of muscle mass.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food brought in by family met the prescribed diet and ensure food safety requirements for one (Resident 66) of three sampled residents. This deficient practice had the potential to result in electrolyte (crucial for various bodily functions, including maintaining fluid balance, regulating muscle and nerve function, and supporting heart health) imbalances, fluid overload (medical condition where there is too much fluid in the body), and food borne illnesses (food poisoning) to Resident 66 that can lead to other serious complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the bed was in locked position for one (1) of two (2) sampled residents (Resident 1) who fell on 4/4/2025 around 9 am and was high risk for fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support) as indicated on the resident ' s care plan. This deficient practice had the potential to result in serious injuries or death in an event of another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for two (2) of three (3) sampled residents (Resident 2 and 3). This had the potential to result in a delay in care for Resident 2 and 3 and not receive the necessary care and services which can lead to illness or serious injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for one (2) of four (4) sampled residents (Resident 3 and 4) by not ensuring that Resident 3 and 4's trash can was not overflowing, and there were no clutters on the floor. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of three (3) sampled residents (Resident 1) was switched on. This deficient practice had the potential for Resident 1's pressure ulcer to worsen and for the resident to develop new pressure injury.

Inspectors wrote2. A review of Resident 84's admission Record indicated the facility admitted Resident 84 on 3/18/2021 with diagnoses which include muscle weakness, lack of coordination, hypertension (when the pressure in the resident ' s blood vessels is too high). A review of Resident 84's MDS, dated [DATE], indicated Resident 84 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 84 substantial/ maximum assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provide more than half the effort) on toilet hygiene, shower /bathe self, personal hygiene. A review of Resident 84's Order Summary Report, dated 2/25/2024, indicated Low bed to decrease potential for injury. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care for two (2) of 2 sampled residents (Residents 79 and 85) who are on oxygen therapy (supplemental oxygen, a treatment that provides you with extra oxygen to breath) by: 1. Facility failed to ensure Resident 79's nasal cannula (NC; a device that delivers extra oxygen through a tube and into your nose) oxygen tubing connected to their oxygen tank was stored in a bag and not sprawled out along the Resident 79 ' s wheelchair seat and touching the wheelchair wheels and failed to ensure that the resident ' s humidified (increased moisture) oxygen nasal cannula tubing was not touching the floor when in use. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Narcotic and Hypnotic Record (also known as CS) accountability logs for March 2024 and May 2024 did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN), as indicated on the facility policy and procedures. [...]

Inspectors wroteCross referenced with 656 Based on interview and record review, the facility failed to include appropriate monitoring to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of five sampled residents (Resident 119) by failing to monitor Resident 119 for sign and symptoms of bleeding for the use of Eliquis (a medication used for atrial fibrillation [a condition with irregular, fast heart rate caused by poor blood flow,]) for 15 days. This deficient practice had the potential to cause Residents 119 to receive suboptimal (less than the highest standard or quality) care, experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by failing to ensure: 1. Food in the kitchen were labeled with item name, date opened and expiration date. 2. Prepared food are dated correctly. 3. Various food containers are sealed properly. 4. Expired food was removed from the shelves and discarded. 5. Juice machine log was updated. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure titled, Advance Directive (a written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate) for two of seven (7) sampled residents (Residents 102 and 324) by not ensuring a copy of the resident's Advance Directive was readily accessible in their medical chart. This failure had the potential to cause conflict with the residents' wishes regarding health care and nursing staff not knowing if Resident 102 had specific wishes to follow in case of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean comfortable, sanitary, and home like environment for one (1) of nine (9) sampled residents (Resident 47) by not ensuring that Resident 47 ' s bathroom toilet was free of fecal matter. This deficient practice caused an unsanitary environment and had a potential for Resident 27 to be placed at risk for infection injury.

Inspectors wroteCross referenced with F656 and F758 Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a standardized assessment and care planning tool) by including a diagnosis of schizophrenia (a mental disorder characterized by disordered thinking, behaviors, and emotions that impairs daily functioning) for one of two residents sampled (Resident 119) without evidence to support this as an established diagnosis in the resident's clinical record. The deficient practice increased the risk for Resident 119 not to receive the care and treatment according to resident's needs possibly leading to a decline in overall health and well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan for two of 23 sampled residents (Residents 103 and 119) as indicated on the facility policy and procedure by failing to ensure: 1. Resident 103 had a care plan to address Resident 103's use of Donepezil (medication used to treat dementia [a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities]) and monitoring of cerebrovascular accidents (CVA, an interruption in the flow of blood to cells in the brain by thinning the blood) prophylaxis (PPX, action taken to prevent disease) use of plavix (medication used to prevent CVA and Deep Vein thrombosis [DVT, a condition when a blood clot forms in one or more of the deep veins in the body]) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services for two (2) out of three (3) sampled residents (Residents 323 and 53) in accordance with the facility ' s policy and procedure when: 1. Facility did not inform the primary physician of Resident 323 ' s rashes on both arms and back on 5/12/2024 and was not referred to dermatology (involves the study, research, diagnosis, and management of any health conditions that may affect the skin, fat hair, nails, and membranes) for further treatment as indicated in the care plan. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Physician Order and implement care plan interventions to provide care and services for one (1) of four sampled residents (Resident 68) by failing to ensure: Resident 68's head of bed (HOB) was elevated to at least 30 degrees while receiving g-tube (gastrostomy tube-a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feedings. This failure had the potential for Resident 68 to be at risk for aspiration (a condition in which food, liquids, saliva, or vomit enters the airway or lungs) pneumonia which could result in harm, serious illness, or death.

Inspectors wroteBased on interview and record review, the facility failed to address the use of Trazadone (used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety disorders [persistent and excessive worry that interferes with daily activities], and insomnia [hard to fall asleep, hard to stay asleep]) order, on the medication regimen review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of five sampled Residents (Resident 61) in accordance with the facility policy. This deficient practice had the potential for unnecessary medication administered to Residents 61, which could result to serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 119 and 61) were free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure : 1. Resident 119 had a specific, measurable target behaviors related to the use of Quetiapine (antipsychotic [medication used to treat mental illness]) to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five (5) of seven (7) cereal prepared in a bowl were accurately measured using a measuring cup. These deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss or gain of the five residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 20) had the mental capacity (ability to understand the nature and consequences of a decision and to communicate a decision) to understand the terms of the facility's arbitration agreement (a private agreement that allows individual parties to resolve disputes rather than in a lawsuit) and failed to explain the arbitration to Resident 20's legal representative. This failure resulted in Resident 20 and his legal representative, the conservator (a judge-appointed person to act or decide for a conservatee [a person who needs help]), not understanding their rights to make informed decisions and choices about important aspects of Resident 20's health, safety, and welfare.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one (1) of three (3) washing machines in good repair. This failure had the potential to result in the washing machine not being in a safe operable condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 23 sampled residents (Resident 324). This deficient practice had the potential for Resident 324 not being able to call the facility's staff for help or assistance especially during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Posted Nurse Staffing (Nurse Staffing Information) posted was accurate in accordance with the facility's policy and procedure by failing to reflect the correct total number and actual hours of licensed and unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential for the Nurse Staffing Information not to be available to the residents and visitors at any given time.