Twin Pines Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the coordination of assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 4 residents (Resident #1) reviewed for PASRR services. Resident #1's NFSS form to request services was not completed and submitted within the required 20 business days of the IDT meeting conducted on 10/02/2025. This failure could place residents identified as intellectually or developmentally disabled at risk of not receiving specialized services and equipment to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 4 of 6 residents (Resident #8, #2, #75, and #43) reviewed for accuracy of records: 1. Nursing staff failed to document medication administration in the MAR for Resident #8 on 2/1/2026, 2/9/2026, 2/16/2026 and 2/17/2026.2. The facility failed to document wound care dressing changes on the TAR for Resident #2 on 02/06/2026, 02/07/2026, 02/10/2026, and 02/11/2026.3. The facility failed to ensure Resident #75's MAR accurately reflected when the resident's Fluticasone nasal spray was administered and when it was not for February 2026.4. The facility failed to document wound care dressing changes on the TAR for Resident #43 on 2/5/26, 2/6/26, 2/7/26, and 2/10/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 18 residents (Residents #48, #98, #83, and #43) reviewed for infection control: 1. The facility failed to ensure MA I sanitized the blood pressure cuff used between Resident #48, #98, and #83.2. The facility failed to ensure LVN D wore proper PPE while providing wound care to Resident #43 who was on EBP status. These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 18 residents (Resident #50, and #90) reviewed for dignity. 1. The facility failed to ensure the ADON was not standing while feeding Resident #50.2. The facility failed to ensure MA H was not standing while feeding Resident #90. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal medical records for 1 of 18 residents (Resident #84) reviewed for privacy and confidentiality: The facility failed to ensure RN C did not leave Resident #84's patient information exposed on her computer screen. This failure could place residents at risk of having personal medical information disclosed and placed them at risk for misuse of the information.

Inspectors wroteBased on interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for level II resident review upon a significant change in status assessment for 1 of 7 residents (Resident #3) reviewed for PASARR accuracy. The MDS Coordinator failed to refer Resident #3 after newly diagnosed mental illness for level II resident review. This deficient practice could place the residents at risk of not receiving the necessary mental health care and services.

Inspectors wroteBased on interviews, and record review, the facility failed to preadmissions screen for individuals with a mental disorder and individuals with intellectual disability for 2 of 7 residents (Resident #3 and Resident #36) reviewed for PASARR accuracy. The MDS Coordinator failed to accurately screen Resident #3 for mental illness upon admission to the facility. The MDS Coordinator failed to accurately screen Resident #36 for mental illness upon admission to the facility. This deficient practice could place the residents at risk of not receiving the necessary mental health care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #43) reviewed for care plans: The facility failed to ensure Residents #43's Care Plan reflected she was on EBP status related to a pressure wound. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 2 of 2 residents (Resident #58, Resident #71), reviewed for accidents, in that: 1. The facility failed to ensure Resident #58 did not have scissors in her room. 2. The facility failed to ensure Resident #71 did not have scissors in her room. These failures could place residents at risk of injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #75) reviewed for pharmacy services. The facility failed to ensure Resident #75 received Fluticasone Propionate Nasal Spray (a steroid spray used to treat nasal allergy symptoms) as prescribed by a physician. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed for storage of drugs and biologicals. The facility failed to ensure the 100-hall medication cart was locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 4 residents (Resident #66) reviewed for laboratory services: The facility failed to obtain a digoxin drug level (digoxin is a medication used to manage atrial fibrillation [rapid heart rate] or heart failure; obtaining digoxin levels determines therapeutic effects and toxicity effects) for Resident #66 as ordered by the physician. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and #2) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure a care plan was developed to address Resident #1 required a divided plate (a durable 3 or 4-section that have high sides and partitions to aide one-handed scooping, prevent spilling, and assist those with arthritis [joint inflammation] or dementia). 2. The facility failed to ensure a care plan was developed to address Resident #2 required a mechanical soft diet and a divided plate. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure comprehensive care plan was developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 5 residents (Resident #3) reviewed for comprehensive care plans. The facility failed to revise Resident #3's comprehensive person-centered care plan after her quarterly MDS assessment to reflect she required moderate assistance with the ADL of eating, needed a mechanically altered diet, magic cup with lunch and pureed meat with gravy. This deficient practice could place residents at risk of a lack of assistance with care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure the MDSN, and the ST knocked on Resident #1's door before entering the resident's rooms. This failure could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 2 of 14 residents (Resident #2 and Resident #3) reviewed for resident call system . The facility failed to provide a working communication system that was easily at reach, which would allow Resident #2 and Resident #3 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 5 residents (Residents #1 and #2) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan with interventions to address Resident #1's behavior of unbuckling the seat belt when transported in the facility van. On 6/13/2025, Resident #1 fell forward while being transported and sustained a laceration to her forehead. 2. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to transport Resident #1 to a scheduled appointment with an oncologist, MD F as ordered on 02/10/2025. This failure could place residents at risk for not receiving appropriate care and treatment and or a decline in their health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents have a right to personal privacy for 2 of 2 residents (Residents #70 and #78) reviewed for privacy, in that: 1. MA M did not close the computer screen exposing Resident #70's personal medical information. 2. LVN K and LVN L did not completely close Resident #78's privacy curtain while providing wound care. This failure could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. There were no foot-operated waste baskets near hand-washing station. 2. A tray of glasses filled with tea were uncovered. 3. Dietary Aide H was not wearing a hairnet that fully covered her hair. 4. Individual packets of salt and artificial sweetener were in the pantry floor. 5. An oily liquid substance was in the pantry floor under a container of fry oil. 6. Flour was in the pantry floor under a container of flour. 7. Dusty debris on the lower shelf of the food preparation counter. These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 (Hallway A and Hallway E) of 7 resident hallways reviewed for environmental concerns. 1. On resident hallway-A the facility failed to repair: [...]

Inspectors wroteBased on Observations, Interviews, and Record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 out of 3 (Resident #5) reviewed for call light. The facility failed to ensure Resident #5's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #77's room) of 80 resident rooms reviewed, in that: A foul odor was emanating from the restroom of Resident #77's room. This failure could result in psychosocial harm due to diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #259) of 28 residents reviewed, in that: Resident #259's baseline care plan did not include his allergies or his physician-prescribed diet. This failure could result in improper care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 8 residents (Resident #42) reviewed for care plan revision and timing. The facility failed to ensure Resident #42's care plan was revised to reflect interventions made after an actual fall with injury on 09/06/2024. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident environment that remained as free of accident hazards as possible for one (Hallway A shower room) of four shower rooms observed for hazard free environment. The facility failed to ensure that the shower room on Hallway A remained a hazard free environment. This failure could place residents at risk encountering an accident hazard in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 18) reviewed for oxygen use. The facility failed to ensure Residents #18's, oxygen tubing and mask was bagged and stored off the floor. This failure could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls in 1 of 2 medication rooms (Annex Medication Room) reviewed for medication storage. The facility failed to ensure one unopened bottle of Latanoprost eye drops was refrigerated until opened. This failure could place residents at risk of medications not being therapeutically effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #1 who eloped from the facility on 06/21/24. The noncompliance was identified as PNC. The IJ began on 06/21/24 and ended on 06/22/24. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food that accommodates resident allergies, intolerances, and preferences for 1 of 8 residents (Resident #13) reviewed for resident allergies, intolerances, and preferences, in that: On 09/04/2024 Resident #13 was given meatloaf with egg causing an allergic reaction. Requiring Resident #13 to use emergency medication and be transferred to the hospital for further evaluation. The noncompliance was identified as PNC. The IJ began on 09/04/24 and ended on 09/05/24. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 out of 23 days (4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24, and 4/18/24) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care on from 6:00 PM - 6:00 AM on 4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24 and 4/18/24. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 5 errors out of 30 opportunities, which involved 2 of 4 residents (Resident #17 and Resident #18) reviewed for medication errors. 1. LVN F failed to administer medications as ordered to Resident #17 by administering Trazadone (a treatment for Depression) and Nortriptyline (a treatment for Depression)1 hour and 54 minutes after the scheduled time and not administering Melatonin (a treatment for Insomnia). 2. LVN F failed to administer a medication as ordered to Resident #18 by administering Donepezil (a treatment for Dementia) 3 hours after the scheduled time and Trazadone (a treatment for Bipolar Disorder) 2 hours after the scheduled time. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 medication carts (Medication cart #1, Medication cart #2, and Medication cart#3) reviewed for medication storage. 1. The facility failed to ensure the Medication cart by the nurses' station did not have a medication cup with pills sitting on top of the cart. 2. LVN F failed to ensure the Medication cart on 100 hall was not left unlocked with a resident standing next to it, while the LVN went into resident room to administer medications . 3. The facility failed to ensure the Medication cart on 300 hall was not left unlocked. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 of 10 residents (Resident #7, Resident #11,, and Resident #15) reviewed for dietary services.needs, in that: 1. The facility failed to ensure Resident #7 did not received a health shake, or a red glass as prescribed on 4/22/24. 2. The facility failed to ensure Resident #11 did not received the appropriate portion size of pureed spaghetti and meatballs and a red glass on 4/20/24. 3. The facility failed to ensure Resident #15 did not received a house shake on 4/25/24 or red glass on 4/25/24 and 4/26/24 . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 2 residents (Residents #5 and #15) reviewed for accuracy of records, in that: 1. The facility failed to ensure Resident #5's wound care and treatments as ordered by the physician were documented. 2. The facility failed to ensure Resident #15's wound care and treatments as ordered by the physician were documented. These deficient practices could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #5) reviewed for dignity, in that: The facility failed to ensure Resident #5 was not left exposed during wound care on 4/24/24. This failure could place residents at risk of poor self-esteem and decreased self-worth and quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs for 2 of 2 residents (Resident #5 and Resident #15) reviewed for accommodations of needs, in that. The facility failed to ensure Resident #5, and Resident #15 were able to press the call light when assistance was needed. This deficient practice could place residents at risk of not receiving care or attention when needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. These failures could place residents at risk of current needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. These failures could place residents at risk of current needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for pain management. The facility failed to adequately assess and treat Resident #15's pain. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure meals were prepared in a form designed to meet individual needs for 1 of 10 residents (Resident #6) reviewed for dietary services. The facility failed to ensure Resident #6 was served mechanical ground meat as prescribed. These deficient practices could place residents at risk for poor food intake, weight loss and not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 15 residents (Resident #16) reviewed for dietary services. The facility failed to ensure Resident #16's was not served he was allergic to and was served onions with the meal. This deficient practice could place residents at-risk by contributing to poor intake, weight loss and/or allergic reaction.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #5 and #15) reviewed for infection control, in that: 1. LVN C failed to maintain infection control practices when performing wound care for Resident #5. 2. LVN C and RN B failed to maintain infection control practices when performing wound care for Resident #15. These deficient practices could place residents at risk for delayed wound healing and infection.

Inspectors wroteBased on observation and interview the facility failed to post the current nurse staffing information for 1 of 1 facility reviewed for postings. The facility failed to ensure the nurse staffing information was posted upon entrance on 4/19/24 and 4/20/24. This deficient practice could place residents at risk by not providing adequate staffing information to ensure resident care needs were met.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to accurately reflect the resident's status on the quarterly MDS for three residents (Residents #34, #90 and #104) of 24 residents reviewed for MDS assessments in that: 1. Resident #34's quarterly MDS assessment did not reflect he had a Stage IV (full thickness tissue loss with exposed bone, tendon, 1or muscle) pressure sore. 2. Resident #90's significant change MDS assessment and admission MDS assessment did not reflect she was edentulous (lacking teeth). 3. Resident #104's discharge MDS did not reflect he was discharged home. This deficient practice affects residents who receive MDS assessments and could result in missed information or inaccurate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. In the reach-in cooler, there was: a. A clear, plastic 2-qt. container of food, contents unknown, without a label or date. b. Two pies without labels or dates indicating when they were stored or a use-by date. c. An 8-oz. plastic container of food covered with disposable plastic lid without a label or date indicating when it was stored or a use-by date. d. A 2% gallon of milk, open, half-full, no label indicating the date it was open or a use-by date. 2. In the dry storage room, on a rack, there were: a. A plastic 12 qt. container with traces of flour and particles of dry cereal on the lid. Inside the container was a trace amount of flour and a clear plastic cup. b. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #90) reviewed for care plans, in that: Resident #90's cognitive communication deficit was not addressed in her comprehensive care plan. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for one resident (#38) out of 8 residents reviewed for comprehensive care plans in that: Resident #38's continent status was not accurately reflected on her comprehensive care plan following 2 MDS assessments. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one resident (#70) out of 2 residents reviewed who received enteral feedings in that: Resident #70's head of the bed not kept at 30 degrees while his enteral feeding was infusing. This deficient practice affects residents who receive enteral feeding and could result in aspiration pneumonia.

Inspectors wroteThe facility failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (#23, and #92) out of 25 residents observed during dining in that: 1. Resident #23 did not have double portions of meat on her lunch plate as was ordered by the physician. 2. Resident #92 did not have large portions of food on her plate as was ordered by the physician. This deficient practice affects residents who are ordered therapeutic diets and could result in weight or nutritional loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal observed in that: 1. The facility failed to ensure all residents received potato salad with their lunch meal on 09/28/2023. 2. The facility failed to ensure Baked Potato Salad was prepared by the recipe. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's a right to a dignified existence for 1 of 13 residents (Resident #1) reviewed for dignity, in that: Resident #1 appeared to have urinated on himself and was observed around the facility with his pants wet between his inner upper thighs and groin area This failure could lead to residents' loss of self-esteem and feelings of dignity.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 (Resident #1) residents reviewed in that: Resident #1's call light was not within reach while he was in bed. This could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Residents #1) of 1 resident reviewed for abuse, neglect, and misappropriation of property, in that; [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's need for assistance in applying a hearing aid was on her comprehensive care plan. This failure could place residents at risk of not having their care needs met.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (Resident #4) of four residents reviewed for accurate assessments in that: Resident #4's MDS did not accurately reflect Resident #4's indwelling catheter. This failure could affect residents who receive MDS assessments and could result in disruption of continuity of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 out of 1 resident (Resident #4) reviewed for indwelling catheters. Resident #4's indwelling catheter collection bag was lying on the floor of the resident's room, not in a protective container, and was not secured to prevent pulling and/or tugging to the urethra. This failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of (Resident #4) of 5 residents observed for infection control, in that: Resident #4's catheter bag was on the floor and not contained. This failure could place residents at risk for infections and cross contamination.