The Suites Rio Vista

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for abuse, when facility staff intentionally struck R #1 with a pillow and a blanket while providing personal care. If the facility fails to provide an environment free from abuse, then residents are at risk for physical injury and psychological harm.

Inspectors wroteBased on record review and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for 1 (R #88) of 1 (R #88) residents reviewed when staff left R #88's bed in the highest position, and R #88 fell from the bed. This deficient practice likely resulted in R #88 sustaining a right femur fracture (long bone that connects the hip to the knee) and spinal compression fractures (a break in a bone in your spine) which required hospitalization. Failure to ensure residents' beds are maintained in the appropriate position while occupied increases the likelihood of avoidable accidents, and places residents at risk for serious injury, significant harm, and potential death.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) assessments for 2 (R #15 and R #69) of 2 (R #15 and R #69) residents reviewed for MDS assessments, when: R #15's hearing and oxygen (O2) use MDS sections were not accurate,R #69's functional status (resident's ability to complete essential activities to meet one's basic needs and maintain health) MDS section was not accurate and a significant change MDS was not completed. If MDS assessments are not coded accurately, then the resident is at risk of receiving inappropriate or inadequate care due to inaccurate representation of functional abilities and care needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 2 (R #3 and R #88 ) of 2 (R #3 and R #88) residents reviewed for PASARR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.

Inspectors wroteBased on record review and interviews, the facility failed to develop and update a comprehensive, person-centered care plan for 2 (R #8 and R #15) of 2 (R #8 and R #15) residents reviewed for care planning, when staff failed to:Update R #8's care plan to include wound care treatment. Update R #15's care plan to include hearing limitations and oxygen use. These deficient practices are likely to result in residents not having needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 4 (R #4, #14, #65, and #85) of 4 (R #4, #14, #65, and #85) residents reviewed when staff failed to: Complete an Abnormal Involuntary Movement Scale (AIMS; used to assess the severity of involuntary movements, particularly in patients taking antipsychotic medications) for R #4 and R #85. Assist R #14 with meals per physician orders and as directed in R #14's care plan. Use appropriate equipment to administer injectable medication (medications administered to body through means of syringe and needle) for R #65. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 (R #69, R #74, and R #88) of 3 (R #69, R #74, and R #88) residents reviewed when: Non-clinical facility staff was assisting residents with dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) or impaired physical functioning had completed required training and competency validation to safely provide feeding assistance for R #69. The facility failed to provide pre-operative instructions for R #74. The facility failed to transfer R #88 to the hospital after experiencing a femur fracture for multiple days. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the proper storage and security of medications and medical supplies located in the medication carts and medication storage rooms, when: R #14's medications were left unattended on top of the medication cart in the 500-hall. Lancets (small needles designed to puncture skin to obtain blood samples for testing) were removed from original packaging and placed in a large bin without labeling or expiration dates. This deficient practice is likely to result in exposure to infectious agents through the ingestion of expired lancets. Additionally, the failure to properly secure medications may result in unauthorized access or diversion by staff, residents, or visitors, potentially leading to adverse outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure advanced directives (documents providing an individual's wishes for emergency and lifesaving care) were accurate within the Electronic Health Record (EHR) for 1 (R #69) of 2 (R #60 and #69) residents reviewed for advance directives, when: The facility failed to ensure that the advance directive forms and face sheets contained matching and consistent information regarding the residents' end-of-life wishes. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change in condition (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #88) of 2 (R #60 and R #88) residents reviewed for falls with major injuries. This deficient practice likely resulted in an inaccurate assessment of a resident's injuries and a delay in treatment of a higher level of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS; a comprehensive review of the resident's health and functional status) assessments were submitted for finalization within 14 days for 1 (R #7) of 2 (R #'s 7 and 87) residents reviewed for Minimum Data Set. If MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #60) of 1 (R #60) residents reviewed when staff failed update R #60's plan of care to include an accurate advanced directive code status. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) for 1 (R #66) of 1 (R #66) resident reviewed when the facility failed to: Ensure hospital discharge orders for a wound VAC (vacuum-assisted closure; a medical device that uses negative pressure to promote wound healing) were implemented as prescribed. Prevent unauthorized modification of a wound VAC order without provider approval. These deficient practices resulted in R #66's wound care therapy not being delivered as intended, leading to ineffective wound care management.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 2 (R #15 and R #69) of 2 (R #15 and R #69) residents reviewed for respiratory care when the facility failed to: Administer oxygen (O2) therapy per physician orders for R #15. Provide the necessary respiratory equipment to ensure O2 was readily available for R #69. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident had access to dental services and was seen for routine and emergency dental care for 1 (R #69) of 1 (R #69) residents reviewed for routine dental services. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure medical records consistently reflected the correct code status for 1 (R #5) of 3 (R #5, #6, and #7) residents. If code status is not accurately documented in resident records, then the resident is at risk of a life-threatening medical error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident environment free from the potential for accidents and hazards when staff left: - An electrical junction box unsecured. - Electrical cords stretched across the hallway floor. - A fire alarm control panel open. These failures had the potential to affect all residents in the facility. If the facility fails to secure electrical panels and equipment and to remove tripping hazards from resident areas, then residents are at risk of injury.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the physical environment was free of hazards when staff failed to: - Ensure the electrical cord and cord protector for an electronic game table in a common area were secured to prevent tripping. - Ensure an outlet casing box was secured to the wall without electrical wires exposed. - Ensure a medication treatment cart was locked. If the facility fails to maintain a hazard-free environment, then residents are at increased risk for injury and compromised well-being.

Inspectors wroteBased on record review and interviews, the facility failed to report a significant medication-related event to the State Survey Agency (SSA) for 1 (R #1) of 1 (R #1) resident, when R #1 experienced a suspected opioid overdose which required an emergency administration of Narcan and Code Blue activation. If a facility fails to report suspected overdoses and life-threatening incidents to the State Survey Agency (SSA), then the SSA cannot ensure the health and safety of the residents.

Inspectors wroteBased on record review and interviews, the facility failed to provide a written discharge notice, including the reason for discharge, effective date, location, appeal rights, and contact information for the State Ombudsman to 1 (R #1) of 1 (R #1) resident. If the facility fails to provide a complete, written discharge notice to the resident, then the resident may be unable to appeal the discharge, lose access to their rights and due process protections, experience abrupt care discontinuity, or suffer from unsafe or uncoordinated transitions of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for abuse when facility staff pushed R #1 back inside the facility and swatted (hit) his hands as the resident tried to exit to the parking lot. This deficient practice likely caused R #1 to feel unimportant and to fear staff.

Inspectors wroteBased on record review and interview, the facility failed to complete an accurate investigation regarding allegations of abuse for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse. If the facility is not completing an accurate and thorough investigation of allegations of abuse, then the State Agency is unable to appropriately review the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1(R #1) of 3 (R #1, R #2 and R #3) residents reviewed for accuracy of assessments. If the MDS assessment is not accurate, then residents are likely to not receive the services they need.

Inspectors wroteBased on observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment cart while staff were away from the cart. This deficient practice had the potential to affect all 48 residents on the 600 Unit, as identified by the Resident Census provided by the Administrator. If staff fail to lock an unsupervised treatment cart, then residents could obtain medical equipment, which could result in injury or death.

Inspectors wroteBased on record review and interview, the facility failed to report the allegations of possible neglect/abuse for 3 (R #'s 1, #2 and #3 ) of 3 (R #'s 1, #2 and # 3) residents reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days for allegations of abuse and mistreatment for 3 (R #'s 1, 2, and 3) of 5 (R #'s 1, 2, 3, 4, and 5) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigations and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately review allegations for further investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Label and date open food items in the kitchen and in the unit nourishment refrigerators. - Store frozen food in the freezer in the kitchen. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illness. This failure had the potential to affect all residents who ate food from the kitchen and unit nourishment refrigerators/freezers.

Inspectors wroteBased on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to it for residents of the 300 unit, 500 unit and R #78 during random observations. If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for 3 (R #'s 31, 68, and 71) of 3 (R #'s 31, 68, and 71) residents sampled for a homelike environment by facility staff leaving used resident meal trays in residents rooms. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteBased on record review and interview facility failed to complete a resident centered, comprehensive care plan for 2 (R #45 and 195) of 2 R #45 and 195) residents. The facility failed to provide a plan for activities and the resident's perferred activities. This deficient practice is likely to result in residents mental and psychosocial needs not being met and residents being bored and uninterested.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 43, 58 and 88) of 2 (R #'s 43, 58 and 88) residents reviewed when staff failed to: 1. Update the care plan to include the amount of staff assistance required for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #43. 2. Update the care plan to include hospice services (a home providing care for the sick or terminally ill for R #'s 58 and 88. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a quality care that meets professional standards for 2 (R #'s 71 and 195) of 2 (R #'s 71 and 195) residents when the facility failed to: 1. Complete an assessment and provide physician orders to allow R #71 to check his own blood sugar and inject his own insulin with staff supervision. 2. Administer antiviral (medication that is meant to treat viral infections) on time and as ordered by the resident provider for R #195. This deficient practice is likely to result in residents not receiving antibiotics in a timely manner prolonging their infection and the physical effects (temperature, pain, discomfort) caused by the infection; and residents becoming at risk for improper medication administration without the proper self-administering assessments and orders provided.

Inspectors wroteBased on record review and interview, the facility failed to assure that physicians responded to recommendations submitted during the pharmacist's written monthly review or obtain physician rational specific to the resident to agree or disagree with the pharmacist's monthly recommendations for 6 (R #7, R #20, R #26, R #27, R #42, R #43) of 6 (R #7, R #20, R #26, R #27, R #42, R #43) residents. This deficient practice is likely to cause resident medication regimen to not be properly evaluated resulting in possible over medication. A. Record review of documents submitted by the facility pharmacist consultant on 06/17/24 for review and action by each resident's provider: 1. R #26 Recommendation for additional lab testing of resident. The document indicates no Physician/Prescriber Response and is signed and dated on 09/03/24 by the former Director of Nursing (DON). [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% for 1 (R #74) of 5 (R #33, 71, 74, 75, 80) residents reviewed during medication administration. 34 medications were observed administered with 6 errors resulting in a medication error rate of 14.71%. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen (a prescribed systematic form of treatment for a course of drugs).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 1 (R #47) of 1 (R #47) residents reviewed by not ensuring R #47 had access to her call light. These deficient practices are likely to result in residents being unable to request assistance, such as needing help with transferring, after falling or other acute distress.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #71) of 1 (R #71) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received proper treatment to maintain vision 1 (R #71) of 1 (R #71) residents reviewed for vision. If the facility is not assisting residents in accessing treatment to maintain their vision, then residents are likely to lose their ability to see, which will compromise their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure that 1 (R #3) of 1 (R #3) residents reviewed was free from accidents and hazards by not securing an electric cord that is in a direct path to the residents bed. This deficient practice is likely to put residents at risk of unsafe situations.

Inspectors wroteBased on observation, record review and interview the facility failed to assure that 1 (R #195) of 1 (R #195) resident was provided respiratory care including provider orders to monitor, clean, use a C-PAP (Continuous Positive Airway Pressure) or Bi-PAP (Bilevel positive Airway Pressure) (a non-invasive devices that provide assistive breathing usually during rest and sleep). If the facility fails to assist, manage and maintain equipment as ordered then resident are likely to not get the therapeutic results needed.

Inspectors wroteBased on observation and interview the facility failed to ensure medication carts were locked when unattended. This deficient practice is likely to negatively impact the health of residents if they were to ingest medications not intended for them.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #36) of 1 (R #36) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection prevention measures for 2 (R #'s 71 and 75) of 6 (R #'s 33, 39, 44, 71, 75 and 80) residents observed when the facility: 1. Failed to store R #71's nebulizer mask (a drug delivery device used to administer medication in the form of mist) appropriately in a bag. 2. During medication administration when the Certified Medication Aide (CMA) used her bare fingers to pour mediations. This deficient practices are likely to result in the spread of infectious diseases.

Inspectors wroteBased on record review and interview, the facility failed to ensure that medical records were complete and accurate for 1 (R #1) of 1 (R #1) resident reviewed. This deficient practice will likely result in staff not knowing residents' daily care events, changes, and needs.

Inspectors wrotePast non-compliance Based on interview, record review, and observation, the facility failed to ensure patient care equipment was in safe operating condition for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice likely resulted in the collapsing of the shower gurney (a special bed made to be used in a shower) while R #2 was on the gurney and being transferred from his room to the shower room. If the facility does not ensure that residents' equipment is safe and operating, then residents are at risk of injury.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents when staff: 1. Did not know where the gastrostomy tube (G-Tube; a tube inserted through the belly that brings nutrition directly to the stomach) equipment for R #1 was located. 2. Did not provide R #1 with proper hydration for 22 hours via a G-Tube. 3. Did not provide R #1 medications upon admission for 17 hours via G-Tube. 4. Did not document R #1's blood glucose (sugar) levels checks. If the facility is not providing hydration and medications via resident G-Tubes then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to report and provide follow-up report within 5 working days from the date of the incident to the State Survey Agency for 2 (R #'s 8 and 91) of 2 (R #'s 8 and 91) residents reviewed for abuse and neglect related incidents. If the facility fails to provide a 5 day follow-up report to the State Agency for abuse and neglect related incidents, then the State Agency will be unable to assure residents are safe and have a hazard free environment.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a thorough investigation and implement corrective actions regarding allegations of physical and verbal abuse (any type of harm including physical or emotional injuries, sexual assault, or financial exploitation experienced by residents) and neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness) for 2 (R #'s 8 and 91) of 2 (R #'s 8 and 91) residents reviewed for abuse/neglect allegations by not: 1. Completing a thorough investigation and documenting that investigation for R #8. 2. Completing a thorough investigation, documenting that investigation, and implementing corrective actions for R #91. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for baths and showers for 2 (R #39 and 91) of 2 (R #39 and 91) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an on-going program of activities designed to meet the interests and well-being for 2 (R #'s 22 and 25) of 4 (R #'s 22, 25, 49, and 83) residents reviewed for activities when staff failed to: 1. Offer one-to-one activities to residents that stay in their rooms. 2. Provide meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend or participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on record review, observation, and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #148) of 1 (R #148) resident randomly sampled, when they failed to administer R #148's Cefazolin (an antibiotic medication) intravenous (IV; a tube that is inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) medication in a timely manner as per physician's order. This deficient practice is likely to cause R #148 to have adverse side effects such as injury of the liver and kidneys and reduce the effectiveness of the antibiotic medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored properly and not left on beside tables in residents' rooms. These deficient practices is likely to affect all 100 residents as identified by the facility census, dated 12/08/23, and is likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff served meals at preferred temperature for 6 (R# 15, 39, 49, 53, 63 and 83) of 6 (R# 15, 39, 49, 53, 63 and 83) residents reviewed meal temperatures. If food is not served at preferable temperature for the resident (hot foods are served hot and cold foods are served cold and in accordance with resident preferences). Residents are likely to not eat their meals and be at risk for weight loss.

Inspectors wroteBased on observation and interview, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for 3 (R #34, 83 and 148) of 3 (R #34, 83, and 148) residents observed during dining food service. This deficient practice is likely to result in weight loss due to residents not eating or experiencing allergic reactions.

Inspectors wroteBased on record review, observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Staff wore beard guards or hair restraints when in the facility kitchen. 2. Kitchen was clean and sanitary. This deficient practice was likely to affect all 100 residents listed on the resident census list provided by the Administrator on 12/04/23. This failure was likely to cause foodborne illnesses in residents if the kitchen was not clean or hair in the food if staff are not wearing proper hair restraints in the food preparation areas of the facility kitchen.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures for 3 (R #22, 62 and 89) of 3 (R #22, 43, and 89) residents when staff failed to: 1. Ensure oxygen tubing was labeled and dated. 2. Ensure urinary catheter tubing did not drag on the bare floor. 3. Ensure staff changed the dressing on a PICC line (peripherally inserted central catheter; a distinctive long tube inserted into a blood vessel of the arm then passed to the larger vessels near the heart to allow the administration of IV medications) in a timely manner. If the facility is not adhering to infection control practices then residents are likely to be at risk for infections and other illnesses.

Inspectors wroteBased on record review and interview, the facility failed to promote care with dignity and respect for 1 (R #14) of 1 (R #14) resident found sitting in a hallway in her wheelchair through the entire night. This deficient practice likely resulted in resident feeling sore, stiff, and as if their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #56) of 1 (R #56) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised and updated the care plan for 1 (R #39) of 1 (R #39) residents reviewed for revising care plans when staff failed to remove the use of CPAP/Bi-PAP (continuous positive airway pressure//bilevel positive airway pressure; a machine that used mild air pressure to keep breathing airways open while you sleep) from the resident's care plan. This deficient practice is likely to result in residents care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 (R #56) of 1 (R #56) residents received proper assistive devices to maintain her vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of one Certified Nurses Aide (CNA #8) of 5 (CNA's #1, 6, 7, 8, and 9) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care and services, and the CNA's may not meet the needs of all residents.

Inspectors wroteBased on an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or (D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure food was prepared in a form that met a resident's required textured diet (an appropriate consistency of food that can be easily chewed and swallowed) for 2 (R #33 and 49) of 2 (R #33 and 49) resident observed during random observation. This deficient practice could likely result in a choking incident.

Inspectors wroteBased on observations and interviews, the facility failed to provide milk per resident preference or as ordered by physician for 4 (R# 33, 35, 49 and 51) of 4 (R# 33, 35, 49 and 51) residents reviewed. If the facility is not providing drinks as per resident preference or as ordered residents, then are likely to not meet their nutritional needs.