Troy Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store food items, failed to maintain the range hood free of a buildup of grease and debris, failed to ensure staff wore beard restraints, failed to ensure one ice machine was equipped with an appropriate air gap to prevent back siphonage, and failed to ensure the kitchen floor was clean. The facility census was 104. 1. Review of the facility policy, Safe Food Handling, dated 2015, showed all food, including bulk items, should be tightly sealed with an identifying label and date. Observation on 6/1/26 at 10:49 A.M. and at 3:01 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff changed gloves and washed their hands when providing care to three residents (Residents #18, #44, and #1) in a review of 28 sampled residents. The facility failed to follow enhanced barrier precautions (EBP, infection control measures used in long term care facilities to prevent the spread of multi-drug-resistant organisms, or MDROs, by requiring staff to wear personal protective equipment, or PPE of gown and gloves during high-contact care activities) as directed when staff provided care for one resident (Resident #1) with a urinary catheter. Staff failed to place a multi-resident use glucometer on a barrier as directed by facility policy for two residents (Resident #17 and #12) and three additional residents (Resident #41, #62 and #66) when performing blood sugar finger sticks. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to four residents (Resident #10, #12, #53 and #70), in a review of 28 sampled residents, and to one additional resident (Resident #103) or their representatives related to transfer that included the reason for transfer, the date of transfer, location being transferred to, the resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities), the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocate for residents with mental illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for four residents (Residents # 96, #2, #1, and #18), in a review of 28 sampled residents. The facility census was 104. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #19, #3 and #2), who required staff's assistance to perform activities of daily living (ADLs), in a review of 28 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 104. Review of the facility's undated policy for ADLs from the Nursing Guidelines Manual showed the guidelines did not direct staff when to assist residents with ADLs such as bathing, shaving, oral hygiene and basic grooming. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 04/11/26, showed the following:-Dependent on staff for showers/bathing;-Required partial/moderate staff assistance for personal hygiene. Review of the resident's Care Plan, revised on 06/01/26, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to destroy discontinued and course completed medications within 30 days for one resident (Resident #6), in a review of 28 sampled residents, and for four additional residents (Residents #81, #16 #83 and #82). The facility census was 104. Upon request, the facility did not provide a medication destruction policy. 1. Review of Resident #81's Physician Order, dated 05/20/25, showed an order to discontinue trazodone (a medication used to treat depression and anxiety) 50 milligrams (mg), one half tablet daily at bedtime related to anxiety disorder. Observation on 06/03/26 at 11:52 A.M., showed 30 and one-half tablets of trazodone, labeled for the resident, were stored in a medication destruction cabinet located in the 300/400 hall medication storage room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at an appetizing temperature. The facility census was 104. Review of the facility policy, Food Temperatures, dated 2015, showed the following:-Hot food should be at least 120 degrees F when served to the resident;-A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form. Review of the facility policy, Nursing Responsibilities at Meal Service, dated 2015, showed the following:-Nursing services will cooperate with the Dining Services Department to ensure each resident is served according to regulations;-Nursing services will distribute meals to residents in resident rooms, dining rooms and ancillary dining rooms. Meals will be passed in a timely manner. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs and risks to provide effective person-centered care that met professional standards of quality care within 48 hours of admission to the facility for one resident (Resident #106), in a review of 28 sampled residents, and one additional residents (Resident #69). The facility census was 104. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #17), in a review of 28 sampled, and two additional residents (Residents #62 and #66) who received insulin injections, were free from significant medication errors when staff failed to prime (remove the air from the needle) the resident's insulin (a hormone used to treat diabetes by controlling blood sugar levels) pen during the preparation of the medication, potentially affecting the amount of insulin dispensed with each dose. Staff failed to administer the insulin pen per the manufacturer's guidelines. The facility census was 104. The facility did not provide a policy on insulin pen administration upon request. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to post required nurse staffing information, which included the date, total actual hours worked by both licensed and unlicensed nursing staff to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA)s directly responsible for resident care and the resident census on a daily basis. The facility census was 104. During an interview on 06/04/26, at 10:11 A.M., the Administrator said the facility did not have a policy for posted nurse staffing information. 1. Observation on 06/01/26 at 10:45 A.M. and 12:25 P.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents, was free from verbal abuse when Certified Nurse Assistant (CNA) A used derogatory language including cursing at the resident, while providing personal care and assisting the resident. This incident was witnessed by CNA B and CNA C. The facility census was 97. The administrator was notified of the past noncompliance on 05/30/25, which occurred on 05/03/25. On 05/05/25, the administrator became aware of a staff to resident abuse allegation involving Resident #1. Upon discovery, the facility began an investigation and terminated the staff member. In-servicing of staff members had begun on the facility abuse policy, including the different forms of abuse, when to report abuse and who to report allegations of abuse to. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a staff to resident allegation of verbal abuse to the State Agency per regulation and facility policy for one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents. Certified Nurse Assistant (CNA) B and CNA C witnessed CNA A yell and use demeaning and derogatory language, including cursing directed at the resident, while providing care. CNA B and CNA C left written statements under the administrator and Director of Nurses (DON) office door on 05/03/25, but did not report the abuse to the registered nurse (RN) D on duty. The administrator did not find the written statements until two days later, at which time it was reported to the State Agency, at least 40 hours following the occurrence of the alleged event. The facility census was 97. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely and thorough investigation of reported abuse for one resident (Resident #1), who resided on the dementia care unit, in a review of ten sampled residents, when certified nurse assistants (CNA) B and CNA C witnessed CNA A use demeaning and derogatory language including cursing directed at the resident while providing personal care. CNA B and CNA C left written statements under the administrator and Director of Nurses (DON's) door on 05/03/25. The administrator did not find the written statements until two days later. CNA A continued to work on the dementia unit with Resident #1 for the remainder of his/her shift on 05/03/25 and worked on 05/04/25 where CNA A had continued contact with Resident #1 and other residents on the dementia unit. [...]

Inspectors wroteRefer to QPGW12. Based on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 87.

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Residents #3, #5 and Resident #11), in a review of seven sampled residents, were free from abuse when Resident #1 caused physical harm to Resident #5 when he/she pulled him/her out of his/her wheelchair, resulting in a left shoulder fracture, and when he/she hit an additional resident, Resident #11, in the face and grabbed Resident #3's arm, causing the resident pain. The census was 85. Review of the facility policy, Abuse Prohibition, dated 11/2016, showed the following: -The purpose of the facility policy is to prohibit mistreatment, neglect or abuse of any resident; -Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents on the 200 hall (Room #'s 211, 212 and 200) had access to hot water in their rooms, including two residents (Resident #9 and #13) in a review of seven sampled residents. The census was 85. During an interview on 10/17/24 at 12:55 P.M. the Administrator said she could not locate a policy on hot water temperatures but the temperature range should be between 105-120 degrees Fahrenheit. 1. Review of Resident #9's care plan, last revised 08/14/24, showed the following: -Incontinent of bladder and bowel; -Provide peri-care routinely and as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 09/20/24, showed the following: -Partial to moderate assist with bed mobility; -Always incontinent of bladder and bowel. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 87. Review of the facility policy, Food Temperatures, dated April 2011, showed the following: -The Dietary Services Manager (DSM) or designee is responsible for seeing that all food is the proper temperature before trays are assembled; -Hot food should be at least 120 degrees Fahrenheit (F) when served to the resident; -Hot/cold foods should not be placed together on the same plate. During an interview on 11/18/24 at 11:40 A.M., Resident #5 said he/she always eats in his/her room and the food was never hot. During an interview on 11/18/24 at 2:10 P.M., Resident #6 said he/she always eats in his/her room and the food was not always hot when it should be, he/she just figured it was cold because the facility had so many people to feed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used appropriate infection control procedures, including handwashing and gloving, while providing resident care for two additional residents (Residents #9 and #10). The census was 85. Review of the facility policy, Implementing the Body Substance Precautions, dated 06/2006, showed the following: -Handwashing remains the single most effective means of preventing disease transmission. Wash hands often and well, paying particular attention to around and under the fingernails and between fingers. Wash hands whenever they are soiled with body substances, after using the toilet, before performing invasive procedures and when each resident's care is completed; -Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated one resident (Resident #4), in a review of seven sampled residents, and one additional resident (Resident #8) with dignity and respect. Without saying anything, staff pulled back the covers and yanked on Resident #4's arm and it hurt and scared him/her. Staff yelled Resident #8's name and spoke angrily toward the resident, frightening the resident. The census was 85. Review of Resident Rights, found in the employee handbook, last revised 10/01/17, showed treating residents with dignity and respect was not only the facility's policy, but also the law. Treat all residents with consideration, respect and dignity at all times. Your behavior must reflect your beliefs in this right in your daily interactions with the residents, families and visitors to our facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a staff to resident allegation of abuse to the state agency for one resident (Resident #4), in a review of seven sampled residents. Resident #4 alleged, and Resident #12 witnessed and reported, an allegation of abuse by a staff member that occurred on 9/30/24 to the Assistant Director of Nursing (ADON) on 9/30/24. Certified Medication Technician (CMT) B reported the allegation of abuse to the Director of Nursing (DON) on 9/30/24. Neither the ADON or the DON reported this allegation to the administrator or state agency per facility policy. The census was 85. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for one resident (Resident #4) in a review of seven sampled residents. The census was 85. Review of the facility policy, Abuse Prohibition Protocol Manual, dated 03/2012 showed the following: Investigation Guidelines: -It is the purpose of this facility to investigate events that may indicate abuse; -All events listed under the Identification section of this manual will be initially investigated on the facility's incident report forms. This is done by the charge nurse, Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Administrator; -Review of an investigation form, that was to be completed with an investigation, showed it was to include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff repositioned one resident appropriately (Resident #9), in a review of seven sampled residents. The census was 85. Review of the facility policy, Positioning the Resident, dated 03/2015, showed the following: -To move the resident up in bed when a resident is helpless with two staff lifting: -A nurse stands on each side of the bed or both on the same side; - Flex the residents' knees; -One nurse supports the head, shoulders and back by placing one arm across the back to the opposite axilla (arm pit). With the nurse's free hand, he/she lifts and arranges the resident's head so that it rests comfortably on his/her arm. Nurse places his/her arm across the small of the resident's back; -The second nurse places one arm across the back, the other under the thighs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for five residents (Resident #27, #29, #59, #501, #502 and #503) in a sample of 23 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #27 and #29 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #29 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their life for four residents (Residents #6, #34, #58, and #70), in a review of 23 sampled residents, and for one additional resident (Resident #89), who were cognitively impaired and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning based on a get up list without consideration of the resident's preferences for waking and for staff convenience. The facility census was 95. Review of the facility's undated Policy for Resident Rights showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five residents (Resident #1, #4, #34, #27 and #28) who required assistance with activities of daily living (ADL), in a review of 23 sampled residents, received the amount of assistance needed to complete ADL tasks. The facility census was 95. Review of the facility undated oral hygiene policy showed the following: -Purpose was to cleanse the mouth, teeth, and dentures; -Staff was expected to offer oral hygiene before breakfast, after each meal, and at bedtime. Review of the undated facility shower policy, showed the following: -Purpose was to maintain skin integrity, comfort and cleanliness; -Staff was expected to offer showers and encourage the resident to do as much of his/her own care as possible and supervise and assist as necessary. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being for three residents (Resident #4, #34, and #82) who resided in the facility's special care unit (SCU) and two residents who resided in the general population (Resident #1 and #58), of 23 sampled residents. The facility census was 95. Review of the facility policy, Activity, Volunteer, and Recreational Services, dated March 2012, showed the following: -The activity director, assistants and volunteers of this facility, believe that everyone has the right to achieve the maximum of his or her potential; have opportunities for social involvement on an individual or group basis; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the safety of six residents (Resident #2, #4, #19, #34, #56, and #79), of 23 sampled residents. Staff failed to follow care plan interventions for fall prevention, including placement of proper footwear and fall mat use, and failed to ensure residents were transported safely in their wheelchairs when staff failed to place foot pedals on the wheelchair prior to transport. Staff also failed to prevent an elopement by not ensuring staff provided protective oversight for one resident (Resident #56), and failed to protect two residents (Residents #2 and #300) from Resident #79, who had a history of verbal and physical aggression toward other residents. The facility's census was 95. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess resident's need for bed rail use and and obtain informed consent with description of the risks of bed rail use prior to installing and using bed rails for three residents (Residents #25, #58, and #62), in a review of 23 sampled residents. The facility census was 95. Review of the facility's undated policy, Bed Rails, showed the following: -Once the bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative; -After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well; (The policy did not address the frequency of bed rail assessments.) 1. Review of Resident #25's face sheet showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate amount of staff to provide care and protective oversight for residents on the special care unit (SCU). Residents on the unit had impaired cognition, were at risk for falls and behaviors including resident to resident altercations. The facility utilized nurse aides (NAs) on the unit with no certified nurse assistant (CNA) to work with the uncertified NA. The facility census was 95. Review of an electronic notification from the administrator on 3/26/24 at 7:22 A.M. showed she was unable to locate the facility's staffing policy. Observation of the SCU on 3/18/24 at 11:47 A.M. (day shift starts at 6:00 A.M.) showed the following: -The census of the SCU was 15; -Two NAs and one activity aide were present on the unit. The unit was staffed with two NAs (NA E and NA L) and one activity aide. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three nurse aides (NA) completed a certified nurse aide (CNA) training program within four months of their employment. The facility census was 95. Review of an electronic mail communication on 3/22/24 at 7:22 A.M., the Administrator said she could not locate a policy on Nursing Assistant and Certified Nursing Assistant training program. 1. Review of the facility provided list of employees hired since last annual survey showed NA E's date of hire was 7/5/21. Review of NA E's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. Review of the staffing schedule dated March 2024 showed NA E was scheduled to work as an NA on 3/1/24, 3/2/24, 3/3, 3/4/24, 3/5/24, 3/6/24, 3/8/24, 3/11/24, 3/12/24, 3/13/24, 3/15/24, 3/16/24, 3/17/24, 3/17/24, and 3/19/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scoops were not stored inside bulk containers with food items, failed to ensure food items were sealed when not in use, failed to maintain the exhaust vent over the dish machine to be free of a buildup of debris, failed to ensure two microwaves were easily cleanable and free of a buildup of debris, and failed to ensure the light bulb in the walk-in freezer was shielded. The facility census was 95. 1. Review of the facility policy, Receiving and Storage of Food, dated May 2015, showed the following: -The dining services manager is responsible for receiving and storing food and nonfood items; -Keep all foods in clean, undamaged wrappers or packages. Reseal open boxes effectively. Observation on 3/18/24 at 10:41 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Resident #25, #58, and #62), in a review of 23 sampled residents who used bed rails/assist bars. The facility census was 95. Review of the facility's undated Bed Rails policy, showed the following: -Overview of FDA potential zones of entrapment with FDA dimension recommendations; 1. Zone 1: Within the rail; a. Any open space between the perimeters of the rail can present a risk of head entrapment; b. FDA recommended space: less than 4 ¾ inches; 2. Zone 2: Under the rail, between the rail supports or next to a single rail support a. The gap under the rail between the mattress, may allow for dangerous head entrapment; b. FDA recommended space: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of individual needs by ensuring call lights were in reach at all times for two residents (Resident #31 and #70), in a review of 23 sampled residents, and failed to accommodate Resident #31's need for an alternative means to contact staff when the resident could not physically use the type of call light provided in his/her room. The facility census was 95. Review of the facility's undated policy, Use of Call Light, showed the following: -When providing care to residents, be sure to position the call light conveniently for the resident's use; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for one resident (Resident #27), in a review of 23 residents. The facility census was 95. Review of the facility undated policy for comprehensive care plans showed the following: -An individualized comprehensive care plan that included measurable goals and time frames would be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan would be based on a thorough assessment that included, but was not limited to, the minimum data set (MDS; a federally mandated assessment to be completed by the facility); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for oxygen use and maintain equipment according to the facility policy for two residents (Residents #28 and #54), in a review of 23 sampled residents. The facility census was 95. Review of the undated facility policy, Physician Orders, showed the oxygen orders include the specific rate of flow, route, and rationale. Review of the undated facility policy, Cleaning Guidelines-Oxygen Equipment, showed tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and PRN (as needed) and marked with date and initials. Review of the undated facility policy, Oxygen Administration, showed the following: -Set the flow meter to the rate ordered by the physician, then place the oxygen cannula on the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #59), in a review of 23 sampled residents, was free of significant medication errors when staff failed to transcribe a new order to increase the resident's trazodone (a sedative/anti-depressant medication) and administered the incorrect dose for ten days. The facility census was 95. Review of the facility undated policy, Medication Administration Guidelines, showed residents are to receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on a pureed diet received food in the proper form in accordance with their physician's orders. The facility census was 95. Review of the facility policy, Types of Diets, dated May 2015, showed the following: -Pureed Diet: This diet is for the edentulous resident and residents with swallowing difficulties; -Foods are blended to mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. Review of the facility's Order Report by Category from 2/18/24 through 3/18/24, printed by staff on 3/18/24, showed two residents had a physician-ordered pureed diet. Review of the Diet Spreadsheet menu for the lunch meal on 3/18/24 showed staff were to serve residents on a pureed diet the following items: -Pureed roasted new potatoes; -Pureed corn O'Brien; [...]

Inspectors wroteBased on interview and record reviews, the facility failed to notify three residents (Resident #4, #24, and #48), in a review of 23 sampled residents, or their representatives in writing of transfer to the hospital, including the reasons for the transfer. The facility failed to send a copy of the transfer notice to a representative of the Office of State Long-Term Care Ombudsman. The facility census was 95. Review of the facility's undated policy, Discharge/Transfer of Resident, showed the following: -Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care; -If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; -Explain and give copy of bed hold form to the resident and/or representative. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents (Resident #4, #24, and #48), in a review of 23 sampled residents. The facility census was 95. Review of the facility's undated policy, Discharge/Transfer of Residents, showed staff was to explain and give a copy of the bed hold form to the resident and/or representative. 1. Review of Resident #48's face sheet showed his/her family member was his/her responsible party. Review of the resident's nurses notes, dated 11/17/22 at 2:43 PM, showed the physician gave the order to send the resident to the emergency department. Review of the resident's census showed the resident returned to the facility from the hospital on [DATE]. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction), when the facility failed to consistently and accurately assess and monitor pressure ulcers, provide routine dressing changes and prevent new ulcers from developing for two residents (Resident #5 and #7) in a review of nine sampled residents. Facility staff failed to implement and follow new orders for Resident #5 for seven days, causing the resident's wound to increase in size. Facility staff also failed to change a dressing for Resident #. The dressing was saturated with yellow to tan drainage. The facility census was 91. [...]

Inspectors wrote3. Review of Resident #51's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact; -Delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Verbal behavioral symptoms directed towards others two to four days out of seven; -Independent with mobility. Review of the resident's Physician Orders Sheet, dated 9/14/19, showed the physician prescribed Provera (a hormone used for sexual behaviors) 5 milligram (mg) three times a day for sexual dysfunction not due to a substance or known physiological condition. Review of the resident's care plan, dated 9/27/19, showed the following: -Resident has impaired decision making and low cognitive score; -Goal: the resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one additional resident (Resident #74) was free from physical restraints when staff held the resident's wrists with arms out stretched over the resident's head while staff provided personal cares. The resident reacted and resisted by yelling out at staff, moving his/her legs and attempted to move his/her arms that staff held down. The facility census was 111. Review of the facility policy Resident Rights undated showed the intent of the facility is to promote and ensure that highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our residents and families we serve. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor a resident's weight, ensure interventions to address weight loss, including supplements and snacks, were consistently implemented, re-evaluate interventions for effectiveness, and ensure meals were set up for one resident (Resident #51), with a significant weight loss (18.9% loss), of 27 sampled residents. The facility census was 111. Review of the facility's policy for nutrition from Nursing Guidelines manual dated March, 2015 showed the following: -The facility would provide nutrition as determined by the physician and in cooperation with the dietician for all residents according to state and federal guidelines; -Residents would be provided meals three times a day at the facility's determined times; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility census was 111. Review of the facility policy, In Room Dining Distribution, dated May 2015, showed at the time of service to the resident, food must be at least 120 degrees Fahrenheit (F). (Inappropriate food temperatures are cause for a deficiency.) 1. During an interview on 10/12/20 at 10:57 A.M., Resident #58 said the food is always delivered cold; this is a consistent problem. During interview on 10/12/20 at 11:00 A.M., Resident #40 said the food was cold most of the time, especially breakfast. During an interview on 10/12/20 at 11:48 A.M., Resident #90 said the food was frequently served cold. During interview on 10/13/20 at 2:00 P.M., Resident #5 said the food frequently did not come to residents warm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were not stored directly on the floor, failed to label, date, and cover food items, failed to keep trash cans covered when not in use, failed to wear hair restraints in the kitchen, failed to maintain floors to be free of an accumulation of debris, failed to use sanitary practices when handling eating utensils, failed to use sanitary practices when preparing and serving ready to eat food items, failed to ensure food items were not prepared on the steam table, failed to hold food at the proper temperature on the steam table, failed to utilize proper handwashing procedures, failed to maintain a freezer at 0 degrees or colder (to keep food items frozen solid) and failed to ensure the ice machine was properly maintained. The facility census was 111. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage dumpsters were covered at all times. The facility census was 111. Observation on 10/12/20 at 10:20 A.M. showed the following: -The facility had two garbage dumpsters located outside the facility; -One of two dumpsters was uncovered and both lids were open; -The open dumpster contained garbage bags of trash and was mostly full. Observation on 10/12/20 at 2:56 P.M. showed the following: -The facility had two garbage dumpsters located outside the facility; -One of two dumpsters was uncovered and both lids were open; -The open dumpster was mostly full and contained garbage bags of trash. Observation on 10/15/20 at 8:15 A.M. showed the following: -One of two dumpsters was uncovered and one of two lids was open; -The open dumpster contained garbage bags and boxes piled high up over the edges of the dumpster; [...]

Inspectors wroteBased on interview and record review the facility failed to report to the state survey agency three known incidents of resident to resident sexual abuse as required within two hours of the alleged sexual abuse allegation when staff witnessed resident (Resident #92) on top of a resident (Resident #33) attempting to have sexual intercourse, failed to report the resident groped another resident's breasts and placed his/her hands down the resident's pants. The facility also failed to report multiple staff witnessed incidents of one resident (Resident #51), groping one resident (Resident #33) in a sample of 27 residents and two additionally sampled residents (Resident#70, and #45). Further review showed the facility failed to report an allegation of staff to resident abuse within two hours of the reported allegation to the state survey agency for one resident (Resident #59). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete investigations as the facility policy directed for allegations of abuse, that failed to prevent further abuse involving eight residents (Resident #33, #40, #45, #51, #59, #70, #92, and #109) in a review of 27 sampled residents, for the protection of the residents'. The facility census was 111. Review of the facility undated facility policy, titled Abuse Prohibition Protocol Manual showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer with required information to the resident and/or resident representative for one resident (Resident #93) in a review of 27 sampled residents, two additional residents (Residents #114, and #216), and one closed record (Resident #117) when the facility initiated transfer to the hospital. The facility also failed to notify the ombudsman of facility initiated transfer/discharges to the hospital from March through October 2020. The facility census was 111. Review of the facility document Emergency Transfer Notice showed an example of a written letter which read in part: This letter is to serve as your emergency notice of transfer from (facility name) due to your need for urgent medical care which cannot be met in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and resident representatives of their bed hold policy, or the duration of their bed hold at the time of transfer to the hospital for one resident (Resident #93) in a review of 27 sampled residents, three additional residents (Resident #114 and #216). The facilty census was 111. Review of the facility policy Bed Hold Guidelines, undated, showed: This facility will notify all residents, and /or their representative of the bed hold policy guidelines. This notification shall be given: 1. Upon admission to the facility, 2. At the time of the transfer to the hospital or leave; and 3. At the time of non-covered therapeutic leave. It is strictly voluntary for the resident or resident representative to reserve the room and pay a bed hold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, develop, maintain, and update a plan of care consistent with residents' specific condition, needs, and risks for four of 27 sampled residents (Resident #60, #73, #97, and #463) and one additional resident (Resident #13). The facility census was 111. Review of the facility's policy Care Plan Comprehensive, from Nursing Guidelines Manual, March, 2015 showed the following: -An individualized comprehensive care plan that includes measurable goals and time frame will be developed to meet he resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for five residents (Residents #10, #13, #79, #85, and #302), in a review of 23 sampled residents. The facility failed to administer medications according to physician orders for Residents #10, #13, #79, and #85; failed to follow instructions to rinse Resident #302's mouth following administration of a steroid inhaler; and failed to ensure extended release medication was not broken or crushed prior to administration to Resident #79. The facility census was 95. Record review of the facility's undated policy for personalized medication schedule showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided 14 residents (Resident #4, #18, #26, #43, #52, #56, #58, #69, #73, #80, #90, #93, #97 and #463) of 27 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 111. Review of the facility's policy for ADLs from Nursing Guidelines Manual dated March of 2015 showed no documentation that directed staff when to assist residents with ADLs such as bathing, shaving, oral hygiene, and basic grooming. Review of the facility's policy for bathing (tub/whirlpool) from Nursing Guidelines Manual dated March of 2015 showed the purpose of bathing was to maintain skin integrity, comfort, and cleanliness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four residents ( Resident #13, #43, #56, #110) in a review of 27 sampled residents, who had orders for restorative therapy received therapy as ordered. The facility census was 111. During interview on 10/20/20 at 5:30 P.M. the Director Of Nursing (DON) said the facility did not have a policy for the restorative nursing program, or a policy for prevention of contractures (shortening or hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 1. Review of Resident #43's Face Sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's Functional Maintenance Program, dated 6/26/19, showed the following: - Maintain range of motion and mobility of BUE(bilateral upper extremities) and BLE (bilateral lower extremities); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess and reassess the safety and effectiveness of 1/8th length bed rails in use for three residents (Resident #52, #93, and #97) and 1/4 length bed rail for one resident (Resident #56) in a review of 27 sampled residents who had bed rails in place on their beds. The facility census was 111. During interview on 10/20/20 at 5:30 P.M., the Director of Nursing said the facility did not have a side rail policy. Review of the Food and Drug Administration's Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: [...]

Inspectors wroteMO#00171896, MO#00172103, MO#00173330, MO#00173553, MO#00177333, MO#00177375 Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for 14 residents (Resident #4, #18, #26, #43, #56, #58, #69, #73, #90, #93, #97, #104 #110 and #463), in a review of 27 sampled residents and for one additional resident (Resident #13). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors, failed to respond timely to call lights, and failed to provide restorative therapy when the restorative aide (RA) was pulled to work as a Certified Nurse Aide (CNA) and was unable to complete duties for the restorative therapy nursing program. The facility census was 111. Review of the Facility Assessment, dated January 2020, showed it did not address the number of staff needed to meet resident needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each certified nurse aide (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified 14 CNA's employed by the facility for more than a year. Four CNAs were sampled and four out of four did not have the required 12 hours of in-service education. The facility census was 111. Review of the Facility Assessment, dated January 2020, showed the CNAs, at the least, required the mandated twelve in-service hours per year. 1. Review of CNA X's employee file and training log, showed the following: -Date of hire (DOH) 3/27/19 ; -Did not include evidence of any completed education. 2. Review of CNA E's employee file and training log, showed the following: -DOH 5/29/19; -Did not include evidence of any completed education. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the failed to administer medication with an error rate of less than five percent (%) for one resident (Resident #97) of 27 sampled residents and two additional residents (Resident #102 and #271). There were 27 opportunities for errors with three errors, which resulted in an error rate of 11.11%. The facility census was 111. Review of the facility's policy, Medication Administration from Nursing Guidelines Manual, dated March of 2015 showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Read the label three times before administering medication to the resident: first when comparing the label with the medication sheet, second when setting up the medication, and third when preparing to administer medication to the resident; -Administer medication; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes for residents on regular, mechanical soft, and pureed diets as directed by the dietary spreadsheet for the lunch meal on 10/12/20. The facility census was 111. Review of the facility policy, Dining Services Department, dated May 2015, showed the purpose of the department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of regular, texture altered and/or therapeutic diets in accordance with the attending physician's orders. Review of the facility policy, Food Preparation and Distribution, dated May 2015, showed measured utensils are used to serve proportions as described on menu. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with nourishing, well-balanced diet, taking into consideration each resident's preferences. The facility failed to respect each resident's right to make choices about his/her diet and be provided with acceptable alternative choices or substitutions. The facility census was 111. Review of the facility policy, Dining Service, dated May 2015, showed this facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council. Review of the facility policy, Dining Services Department, dated May 2015, showed the following: -The purpose of the department is to provide a program that meets the nutritional needs of all residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to permit entry of hospice providers into the facility to provide direct care for one resident (Resident #52), who was to receive hospice services and did not allow new contracts for provision of hospice care for any other resident considering hospice. The facility census was 111. 1. Observation on 10/12/20, at 10:10 A.M., showed a sign at the facility's designated COVID (Coronavirus Disease 2019 - COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) entrance screening station, that read, Hospice staff is not allowed in the building without approval. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic, by not providing a safe environment for residents. The facility failed to maintain a surveillance log monitoring symptoms and testing for residents and staff. The facility also failed to complete a COVID-19 assessment on one resident (Resident #22), who was exhibiting symptoms that were not identified by the facility and subsequently tested positive for COVID-19. The facility also failed to follow transmission based precautions for one resident (Resident #35) and one additional resident (Resident #7) who were exhibiting respiratory symptoms and were tested for COVID-19. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Resident #52, #56, #93, and #97) of 27 sampled residents. The facility census was 111. During interview on 10/20/20 at 5:30 P.M., the Director of Nursing said the facility did not have a side rail policy. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and January 1, 2009, 803 incidents of patients caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported 480 died and 138 had non-fatal injuries; -Most patients were frail, elderly or confused; [...]

Inspectors wroteBased on interview and record review the facility did not make notification to responsible parties, including next of kin and the primary care physician, for one resident (Resident #13) in a review of 27 sampled residents. The facility census was 111. Review of the facility policy Condition Change, Resident dated 3/15 showed the purpose was to observe, record and report any condition change to the attending physician so that proper treatment can be implemented. Guidelines: After all resident falls, injuries or changes in physical or mental function, monitor. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. Complete an incident, accident or risk management report per facility guidelines. Notify resident's responsible party. Monitor resident's condition frequently until stable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor one resident (Resident #98) in a sample of 27 residents, who the facility identified as wandered and at risk for elopement, who exited the facility without staff knowledge. Another resident heard Resident #98 yelling for help from outside and alerted staff. The resident was found on the ground in a puddle and cold. The facility census was 111. Review of the facility policy Elopement-Missing Resident dated 3/15 showed staff were to determine when resident was last seen and by whom, description of clothing and where they were last seen. Notify all departments and begin a thorough search of the facility and grounds, including bathrooms, closets, storage areas and crawl spaces. Search streets and neighborhood adjacent to the facility. Notify the Director of Nursing and Administrator, attending physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one dialysis resident (Resident #13) in a review of three sampled dialysis residents, by not completing and documenting a daily weight as ordered by the physician and failing to properly assess and document the resident's dialysis access site. The facility census was 111. Review of facility policy for care of a resident receiving dialysis from the Nursing Guidelines Manual dated March, 2015 showed the following: -Staff would utilize the following guidelines to provide care for a resident that was receiving dialysis; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (Resident #10) on a vegetarian diet (regular with no meat) with nourishing and palatable food items in accordance with the spreadsheet menu. The facility census was 111. Review of the facility's policy, Dining Service, dated May 2015, showed this facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council. Review of the facility's policy, Dining Services Department, dated May 2015, showed the following: -The purpose of the department is to provide a program that meets the nutritional needs of all residents. [...]