U-City Forest Manor

Inspectors wroteBased on observation and interview, the facility failed to ensure facility staff used proper hand hygiene during meal service affecting seven Residents (Residents #54, #2, #47, #25, #29, #26, and #30) and failed to ensure hair restraints were worn properly while handling food in the kitchen. The sample size was 20. The census was 81. Review of the facility's handwashing policy, dated 1/2012, showed:-Policy: Handwashing facilities will be readily accessible and equipped with paper towels and soap. Staff will wash hands frequently as needed throughout the day following proper handwashing procedure;-Procedure: When to wash hands; after touching ears, nose, mouth, hair, etc. Any contact with infected or otherwise unsanitary areas of the body. Hand contact with unclean equipment or work surfaces. Hand contact with soiled clothing or other materials that are soiled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six discharged residents had their money returned after discharge within 30 days (Residents #89, #90, #91, #92, #93, and #94), and failed to ensure third party liability (TPL) letters were sent and followed up on to for two residents who expired with balances in their account (Residents #95 and #96). The census was 81. Review of the facility's resident trust policy, undated, showed:-The Business Office Manager(BOM) has the primary responsibility for ensuring that residents' funds held in the trust are kept safe, are properly accounted for, and that all payments from the residents' funds are appropriate and legitimate;-Procedure: discharged /deceased resident accounts need to be refunded to theresident or Medicaid no later than 30 days from date of discharge. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure common areas in the facility were maintained in a clean, comfortable and homelike environment. Concerns were identified with two of 20 sampled residents (Resident #45 and #39), the Memory Care Courtyard and resident hall shower rooms on the 100, 200 and 300 halls. The census was 81.1. Review of the facility's Night Shift Assignment Sheet, undated, showed wheelchairs should be cleaned nightly. 2. Review of the facility's housekeeping cleaning schedule for March of 2026, showed shower rooms on all resident halls were to be cleaned once weekly on Sundays. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to have a system in place to ensure controlled medications were securely stored under two locks for one out of one medication room observed. The facility also failed to label eye drops with an open and expiration date for two out of four medication carts reviewed. The census was 81. Review of the facility's Medication Administration policy, dated [DATE], showed:-Policy: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations;-All drugs classified as a controlled substance will be stored under double locks;-The policy did not address labeling of eye drops. 1. Observation and interview on [DATE] at 10:05 A.M. of the Central Medication Room, showed a refrigerator with no lock. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) during care and failed to follow acceptable infection control practices during wound care, medication administration and direct patient care related to hygiene, for three of three residents observed for wound care (Residents #5, #26 and #77). The facility also failed to follow acceptable infection control practices during blood glucose testing. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to treat residents with dignity while providing care to one resident (Resident #5). The sample size was 20. The census was 81. Review of the facility's Resident Rights policy, last revised 8/31/26, showed: The resident has a right to a dignified existence. The facility must treat each resident with respect and dignity. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed cognitive status not assessed. Review of the resident's medical record, showed diagnoses included Alzheimer's disease, dementia, and gastrostomy tube (G-Tube), a tube that is surgically inserted into the abdomen and is used for medications and liquid nutrition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for two residents (Resident #26 and Resident #5). The sample size was 20. The census was 81. Review of the facility's Answering the Call Light policy, last revised, July 2014, showed:-Purpose: The purpose of this procedure is to respond to the resident's requests and needs;-General guidelines: When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure these residents are checked on frequently. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure advance directive/code status forms (a legal document, often a Do Not Resuscitate (DNR) order, that tells medical professionals not to perform cardiopulmonary resuscitation (CPR) if the heart or breathing stops) were not documented, updated and/or reviewed annually for three of 20 sampled residents (Residents #7, #15, and #47). The census was 81. Review of the facility's Advance Directive policy, dated [DATE], showed:-Policy statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse when Restorative Aide/Certified Nursing Assistant (CNA) E grabbed the resident's right arm from behind him/her to put the arm on his/her lap. The resident was non-verbal and provided several non-verbal actions of refusal when Restorative Aide/CNA E pried the resident's fingers off the wheelchair (WC) wheel and pulled the arm forward so forcefully that it nearly caused the resident to fall forward out of the chair (Resident #34). The sample size was 20. The census was 81. Review of the facility's Abuse policy, dated September 2022, showed: Definitions:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status of having a life expectancy of less than six months when they received hospice services (a service provided when a resident has a condition indicating a life expectancy of less than six months as certified by the hospice physician) for two of eight residents identified by the facility as receiving hospice services (Residents #47 and #69). The census was 81. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents had a baseline care plan created within 48 hours of admission (Resident #15). The census was 81. Review of the facility's Baseline Care Plan policy, dated 8/2017, showed:-Policy: The facility will develop and implement a baseline plan of care for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 20 sampled residents received comprehensive care plans specific to their needs while admitted at the facility (Residents #26, #47 and #77). Resident #26's care plan did not include information and interventions for multiple falls in the facility, Resident #47's care plan did not include hospice services, and Resident #77's care plan did not include concerns regarding skin conditions. The census was 81. Review of the facility's Resident Assessment Instrument (RAI) policy, revised, 10/20/22, showed:-Within seven days of the completion of the resident assessment, a comprehensive care plan will be developed. Care plans shall be culturally competent and trauma-informed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #46) received care and services in accordance with professional standards by failing to notify the physician the resident was not wearing thromboembolic deterrent stockings (TEDS) (stockings used to prevent blood clots in the legs). The facility also failed to provide alternative interventions to address the resident's lower leg edema (swelling). The sample size was 20. The census was 81. Review of the facility's Obtaining and Following Physician orders, last revised, July 2017, showed:-Policy: Physician orders will be obtained by licensed personal and followed; If the licensed professional does not in his/her best judgement think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatments and assessments for two of two residents sampled for wounds (Residents #88 and #77). The facility failed to administer treatments on a consistent basis and failed to enter an order in the electronic medical record (EMR) for a newly identified wound for Resident #88. The facility failed to accurately document skin assessments for a resident with an ankle wound, so the facility and the Wound Doctor had the correct information to conduct wound follow-up and monitoring (Resident #77). The sample was 20. The census was 81. Review of the facility's Wound Management Policy, dated January 2023, showed:-Policy: Manage resident skin integrity through prevention, assessment and implementations and evaluations of interventions.-Procedure:--The facility is provided with Wound Care Protocols. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions for one resident with frequent falls (Resident #26) and failed to ensure one resident was assessed for safety while smoking (Resident #15). The sample was 20. The census was 81. Review of the facility's Fall Management policy, dated 3/28/25, showed:-Policy: It is the policy of the management company to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions;-Procedure: A fall risk assessment will be completed on all residents upon admission, re-admission, after each fall and quarterly thereafter. Residents identified as high risk will have fall prevention addressed on the plan of care. Review of the facility's Smoking policy, dated 10/21/22, showed:-Purpose: To ensure all residents are safe while smoking;-Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders for catheter (a thin flexible tube inserted into the body to drain fluids (usually urine) or inject fluids/medication) care was obtained for one of one resident sampled with a catheter (Resident #2). The census was 81. Review of the facility's Catheter Care policy, dated 7/2017, showed:-Purpose: the purpose of this procedure is to prevent catheter-associated urinary tract infections;-Maintain an accurate record of the resident's daily output, per facility policy and procedure;-Observe the resident for complications associated with urinary catheters. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained the head of the bed in an elevated position during gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids, and medications) feeding for one resident (Resident #5). This deficient practice had the potential to place the resident at risk for complications, including aspiration (choking). The sample was 20. The census was 81. Review of the facility's Tube Feeding, Bolus (large amount given at one time) policy, revised 3/28/25, showed:-Policy: It is the policy that residents' nutritional needs will be met by a tube feeding, when oral consumption is not possible and the resident consents;-Maintain the head of the resident's bed at a minimum of 30 degrees. [...]

Inspectors wroteBased on observation and record review the facility failed to provide or obtain laboratory services to meet the needs of one resident (Resident #53). The sample was 20. The census was 81. Review of the facility's Laboratory Reports policy, last revised, July 2014, showed:-Policy: All lab reports will be reviewed by a nurse and reported to the physician as necessary;-Procedure: The night nurse will follow-up nightly through chart audit to ensure all labs have been performed as ordered, physician has been notified of results and reports are filed in the resident's record; If the nurse determines that a lab report has not been received, the nurse will obtain the lab results and notify the physician. Review of the facility's Obtaining and Following Physician orders, last revised, July 2017, showed:-Policy: Physician orders will be obtained by licensed personal and followed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental care to meet the needs of one resident (Resident #10). The sample was 20. The census was 81. Review of facility's Dental Examination and Assessment policy, last revised, July 2014, showed:-Policy: Each resident shall undergo a dental assessment by facility nurses as part of the Nursing assessment process upon admission;-Policy interpretation: Prior to, or within 90 days after admission, the resident shall undergo a dental examination; Dental examinations will be made b the resident's personal dental dentist or by the facility's consulting dentist; Records of dental care provided shall be made a part of the resident's medical record; Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dietary supplement as ordered and failed to increase the dietary supplement as recommended by the dietitian for one of three sampled residents (Resident #1) with weight loss. The census was 74. Review of the facility's policy on Weight Management Program, updated February 2025, showed the following:-Policy: It is the policy of Helia Healthcare to manage resident weight through prevention, assessment and implementation and evaluation of interventions;-Procedure: #12. The Minimum Data Set (MDS)/charge nurse will notify the physician of the resident's current condition and registered dietitian's recommendations, document the physician's order on the physician order sheet and the 24-hour report sheet. #13. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident #2's change of condition (nose bleed) was properly assessed and documented across all shifts and failed to ensure physician orders were followed by not administering saline nasal spray at the prescribed time. The sample was six. The census was 79. Review of the facility's change in condition policy, dated 2/2012, showed: -Policy: It is the policy that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner; -Definition: Change of condition is defined as an improvement or decline in the resident's physical, mental, or psychosocial status that effects less than two areas of activities of daily living; -Procedure: The staff person who first notices the change reports the resident change in condition immediately to the licensed nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, by not ensuring staff were within arm's reach of a resident with a diagnosis of dysphasia (trouble swallowing) and a history of choking (Resident #1). On 11/21/24, the resident choked during lunch while eating alone at a table in the dining room. Staff intervened and were unsuccessful with clearing the resident's airway and performed lifesaving measures until emergency medical staff (EMS) arrived. EMS staff were eventually able to dislodge a large piece of broccoli, a food that was not served on the resident's lunch tray. Resident #1 expired. The sample size was 5. The census was 81. The Administrator was notified on 12/6/24 at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on 11/21/24. The IJ was removed on 12/8/24, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans reflected current needs when staff failed to include speech therapy recommended choking strategies for one resident with a history of choking (Resident #1). The sample was five and issues were found with one. The census was 81. Review of the facility's Baseline Plan of Care policy, last revised 08/2017, showed: -The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary. Facility staff must implement the interventions to assist the resident to achieve care plan goals and objective; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The census was 75. Review of the facility's daily assignment sheets, showed there was no RN in the facility on 8/16, 8/17, 8/18, 8/20, 8/23, 8/27, 8/28 and 8/30/24, for a total of 8 out of 15 days. During an interview on 8/30/24 at 12:46 P.M., the Assistant Director of Nursing (ADON) said the facility only had one RN on staff who worked full time. The ADON is aware the facility is required to have an RN in the facility for eight consecutive hours per day, seven days a week. During an interview on 8/30/24 at 12:46 P.M., the Assistant Administrator (AA) was aware the facility has not had continuous RN coverage. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity when they failed to obtain proper Power of Attorney (POA, allows someone else to act on a resident's behalf) forms for two residents (Residents #2 and #1). The facility also failed to exercise patient rights of non-seclusion when they moved Resident #2 to a restricted environment without seeking alternative behavior interventions, assessments, or notifying a doctor. The sample size was three. The census was 77. Review of the facility's Resident Rights policy, revised [DATE], showed: -Policy: Employees shall treat all residents with kindness, respect and dignity; -Residents had a right to be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) care needs were met for dependent residents. The facility failed to provide perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) timely and appropriately after an incontinence episode for one resident (Resident #1) out of three sampled residents. The census was 77. Review of the facility Activities of Daily Living (ADL), Supporting policy, revised March 2018, showed: -Policy statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to control the presence of cockroaches in the facility when a cockroach was crawling on a resident's blanket while the resident was lying in his/her bed (Resident #1). This had the potential to affect all residents. The census was 77. Review of pest control company service report, dated 8/19/24, showed: -Service provided: Roach clean out in the kitchen and in the rooms for roaches. This service will continue to reduce and eliminate German roaches (a small, tan to black cockroach commonly found indoors) throughout the area, kitchen, therapy room and the room; -Treated with an ultra-low volume sprayer to knock down German Roach infestation. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by not retaining three years of grievance logs. The sample was 18. The census was 73. Review of the facility's Resident and Family Grievances policy, undated, showed: -Evidence demonstrating the results of all grievances will be maintained for a period of no less than three years from the issuance of the grievance decision. Review on 5/6/24 at approximately 2:00 P.M., showed the grievance binder with grievance logs from January 2024 to current. There were no grievance logs for 2022 or 2023. During an interview on 5/7/24 at 10:25 A.M., the Assistant Director of Nursing (ADON) said the facility had recently changed the process of how the grievances were logged. The facility had grievance logs from January 2024 to current. The ADON was unable to locate any other grievance binders. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide 24 hour protective oversight for two residents (Residents #42 and #53) with a history of elopements/wandering. The residents resided on a secured behavior unit and staff did not follow physician's orders to monitor the resident's wanderguard (electronic monitoring) devices as ordered, checking and documenting functionality of the wanderguards, when Resident #42 was discovered not wearing his/her wanderguard and Resident #53's wanderguard was not functioning. The facility also failed to ensure smoking assessments were completed for two residents (Residents #41 and #39) who smoked. The sample size was 18. The census was 73. Review of the facility Elopement Policy and Procedure, undated, showed: -Monitoring of the Wander-guard System; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage for 16 out of 92 days. This had the potential to cause unmet health needs for all residents. The census was 73. Review of the facility's Staffing policy, dated: 7/19, showed: Policy Statement: Our facility provides adequate staffing to meet needed care and services for our resident population; -Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed Registered Nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Review of the facility's [NAME] Payroll Based Journal (PBJ) Staffing Data Report (data collected by Center for Medicare and Medicare Services (CMS), dated fiscal quarter one, 2023, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified six medication/treatment carts and two medication rooms. Four of the six carts and one medication room were checked for medication storage. Issues were found in the three of four medication carts. Insulin pens were opened and dated more than 28 days. Multiple bottles of over the counter (OTC) medications were undated and expired. The census was 73. Review of the facility's Medication Storage Policy, dated June 2020, showed: -Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure code statuses were accurate, signed and updated in medical records for three of 18 sampled residents (Residents #52, #48 and #19). The census was 73. Review of the facility's Advance Directives policy, dated February 2012, showed: -Policy; -Advance directives will be respected in accordance with state and facility policy; -Procedure; -Prior to or upon admission of a resident to the facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #44 and #34). The sample size was 18. The census was 73. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a mental disorder had a DA-124 Level I screen (Pre-admission Screening and Resident Review (PASARR) used to evaluate for the presence of psychiatric conditions to determine if a PASARR Level II screen is required) as required, for three of eight residents sampled for the PASARR requirement (Residents #8, #41 and #3). The census was 73. 1. Review of Resident #8's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/24, showed: -Date of admission on [DATE]; -Moderate cognitive impairment; -Diagnoses included seizures disorder, depression, dementia (a group of thinking and social symptoms that interferes with daily functioning) and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge, for one of three residents investigated for discharge (Resident #74). The census was 73. Review of Resident #74's medical record, showed: -admitted [DATE]; -Diagnoses included high blood pressure, depression and stroke; -discharged on 2/5/24. Review of the resident's progress notes, showed: -On 2/2/24 at 1:26 P.M., the nurse was informed by the Social Worker of resident needing a discharge order. The physician was at the facility today and given report on resident. Resident given order to discharge home and will be receiving services from Home Health. Appointment information given to resident's emergency contact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) care for two of 18 sampled residents who were dependent on staff for personal care (Residents #27 and #67). The census was 73. Review of the facility Activities of Daily Living (ADL) Policy, dated 1/2024, showed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to; -Bathe, dress, and groom; -Policy Explanation and Compliance Guidelines: -Conditions which may demonstrate unavoidable decline in ADLs include natural progression of the resident's disease state; - Deterioration of the resident's physical condition associated with the onset of a physical or mental disability while receiving care to restore or maintain functional abilities; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who received routine dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to) treatment had accurate physician's orders in place, consistent communication and a dialysis contract with the dialysis provider. This affected one of one resident sampled for dialysis review (Resident #41). The sample size was 18. The census was 73. Review of the facility's Care of a Resident with end-stage renal disease (ESRD) policy, updated November 2017, showed: -Policy Statement; -Residents with ESRD will be cared for according to currently recognized standards of care; -Policy Interpretation and Implementation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, two errors occurred, resulting in a 7.41% error rate (Residents #44 and #20). The census was 73. Review of the Novolog FlexPen U-100 Insulin (rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes) insulin pen injection; 100 unit per milliliters (unit/mL) (3 mL), manufacturer's instructions for use, revised 2/2023, showed: -Pull off the pen cap. Wipe the rubber stopper with an alcohol swab; -Remove the protective tab from a disposable needle. Screw the needle tightly onto the insulin pen. It is important that the needle is put on straight. Never place a disposable needle on the pen until ready for injection; -Pull off the big outer cap; -Pull off the inner needle cap and throw it away; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when the facility failed to clean shared medical equipment between resident use with an approved Environmental Protection Agency (EPA)-registered disinfectant for two sampled residents (Residents #44 and #20). In addition, staff failed to remove all gloves and perform hand hygiene when providing wound care for two of two residents sampled for wound care (Residents #14 and #69). The sample was 18. The census was 73. Review of the facility's glucometer's (a device for measuring the concentration of glucose in the blood) manufacturer's instruction, showed: -Cleaning and disinfecting procedures for the meter: The meter should be cleaned and disinfected between each patient; -Cleaning Instructions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they followed their abuse and neglect policy by failing to conduct a thorough investigation into one resident's (Resident #3) allegation a Certified Nursing Assistant (CNA) slapped him/her in the face on the day shift of 1/18/24. The resident reported the allegation on 1/20/24. The facility initiated an investigation on 1/20/24, but failed to interview all staff from all departments that worked the day shift on 1/18/24. The census was 76. Review of the facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 4/2022 and revised on 9/2022, showed: Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate immediate discharge notice to Resident #1 who was transported to the hospital for a psychiatric evaluation. An appeal was filed on behalf of the resident and the appeals unit determined the discharge notice failed to include the location to which the resident was being discharged to and the facility was ordered to allow the resident to return. The facility did not reevaluate the resident's status to determine if they were able to meet the residents needs after treatment and refused to readmit the resident back pending the appeal hearing. The census was 76. Review of the facility's Resident's Rights: What You Need to Know form, showed: -As a resident of a long-term care facility, you have rights that are guaranteed and protected by law. These residents' rights support the principles of dignity and respect. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow acceptable standards of nursing practice, when staff failed to transcribe a treatment order for one of three residents identified with a pressure ulcer, resulting in the order not being followed for several days (Resident #2). The census was 76. Review of the facility's Wound Management Policy, updated 1/20/23, showed the following: -Policy: It is the policy of the facility to manage resident skin integrity through prevention, assessment and implementation and evaluation of interventions; -Procedure: 1. Physician's order should be obtained and followed for each resident. 2. The facility will use the Braden Scale on each resident at admission, weekly for four weeks post admission and readmission and and quarterly to assess skin breakdown risk. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure as needed (PRN) narcotic pain medication was available and/or administered as ordered for one of 7 sampled residents (Resident #6). The facility failed to notify the resident's physician the narcotic pain medication needed a signed prescription and was not delivered. The census was 76. Review of the facility's policy on Controlled Substance Administration and Accountability, undated, failed to address the Charge Nurse's responsibility when a controlled medication required a signed prescription. Review of Resident #6's hospital discharge record, dated 1/23/24, showed the following: -Diagnoses of lower extremity weakness, ankylosing spondylitis (inflammatory arthritis affecting the spine and large joints), lower extremity cellulitis, hamstring injury and hip osteoarthritis; -Discharge medications: [...]

Inspectors wroteBased on interview and record review, the facility failed to perform an annual review of code status, full code (if the heart stops beating or breathing ceases, all life-saving methods are performed) or no code (do not resuscitate [DNR], no life prolonging methods are performed), for 9 of 24 sampled residents (Residents #47, #53, #56, #6, #75, #18, #1, #52 and #63). The facility also failed to ensure code status elections were available and accessible to staff in the electronic medical record. The census was 77. Review of the Communication of Code Status policy, dated 2/2022, showed: -Policy: It is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -Explanation and guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for one resident who sustained an injury of unknown origin due to not wearing a helmet and did not have physician's orders for a helmet (Resident #72). The facility failed to administer medications and treatment as ordered (Residents #56 and #1). The facility failed ensure an abnormal involuntary movement scale (AIMS) test was completed for one resident administered anti-psychotic medications (Resident #42). In addition, the facility failed to ensure staff document the administration of physician medications and treatments (Residents #9, #41, #46, #52, #79, and #49). The sample size was 24. The census was 77. Review of the facility's medication administration policy, dated February 2022, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize recipes approved by a registered dietician (RD) for the residents' dietary needs and preferences and failed to obtain RD approval to ensure menu is of equal nutritive value after switching food items on the menu. The facility failed to have a system in place for food not in stock. The census was 77. 1. Review of the facility's regular menu, dated 10/17/22, showed: -Lunch: Beef barley casserole, corn, tossed salad, and red velvet cookie; -Dinner: Three bean soup, saltines, egg salad sandwich, and mixed melon salad. Observation on 10/17/22 at 11:47 A.M., showed the residents were served pork chops, augratin potatoes, green peas, and fruit crisp for lunch. 2. Review of the facility's regular menu, dated 10/18/22, showed: -Lunch: Roast pork, scalloped potatoes, and lima beans; -Dinner: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The census was 77. Review of the facility's facility's assessment policy, dated August 2022, showed: -Policy: This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day to day operation and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process; -The facility's assessment will, at a minimum, address or include: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete and readily accessible in accordance with accepted professional standards and practices. The facility implemented a new electronic medical records (EMR) system on October 1, 2022, which failed to transfer all of the residents' medical records, leaving portions of the residents' EMR inaccessible to staff. This affected all residents admitted to the facility prior to October 1, 2022 (Residents #4, #13, #18, #1, #55, #41, #38, #43, #42, #46, #47, #49, #52, #59, #79 and #81). The sample size was 24. The census was 77. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/2, showed: -Rarely understood; -Required extensive assistance of one person with transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($5,301.85) or when the resident's account was over the SSI limit ($5,301.85). This affected 6 residents reviewed who received Medicaid benefits (Residents #2, #35, #77, #38, #39 and #58). The census was 77. Review of the facility's undated admission Agreement, showed the facility shall notify each resident that receives Medicaid benefits when the amount of the resident's account reaches $200.00 less than the SSI resource limit for one person and if the amount in the account is addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient to ensure protection of resident funds. The census was 77. Review of the facility's Resident Trust General Ledger (cash sheet) for the period of September 2021 through September 2022, showed an average monthly balance of $132,000.00, which would require a bond of $150,000.00. Review of the Department of Health and Senior Services' approved bond list, showed the facility had an approved bond for $100,000.00. During an interview on 10/19/22 at 11:40 A.M., the Business Office Manager said he/she was aware that the bond was not enough. He/she provided an email he/she sent to the paralegal department of the prior owners on 7/19/22; however, he/she did not find a response to the email. The bond was increased on 9/30/22 to $150,000.00. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nine of nine certified nurse aides (CNAs) received the required annual 12 hour resident care training. The census was 77. Review of the CNA individual service records, showed the following: -CNA G hired 1/18/21, with six hours of in-service education; -CNA H hired 3/15/16, with six hours of in-service education; -CNA I hired 10/25/21, with six hours of in-service education; -CNA J hired 7/14/16, with six hours of in-service education; -CNA K hired 8/19/17, with six hours of in-service education; -CNA L hired 2/19/17, with six hours of in-service education; -CNA M hired 7/18/21, with six hours of in-service education; -CNA N hired 2/24/21, with six hours of in-service education; -CNA O hired 2/18/98, with six hours of in-service education. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two of two carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 77. Review of the controlled substance administration and accountability policy, dated 2/2022, showed: -Policy: to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion and accidental exposure; -Explanation and guidelines: -All controlled substances are accounted for in one of the following ways: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities for error, five errors occurred resulting in a 20% medication error rate (Residents #49, #46, and #15). The census was 77. Review of the medication administration policy, dated 6/2022, showed: -Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so, as ordered by physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Explanation and guidelines: -Review medication administration record (MAR) to identify medication to be administered; -Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time; [...]

Inspectors wroteBased on observation and interview, the facility failed to properly store medication by not keeping the treatment cart locked, by not disposing of expired medications, by not properly labeling insulin pens and vials, and by not properly disposing medications by leaving a paper bag full of medications in the medication room. The census was 77. Review of the Medication Storage policy, dated 2/2022, included: -It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -General Guidelines: -All drugs and biologicals will be stored in locked compartments under proper temperature controls. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment and food related items in a clean and sanitary manner to prevent cross-contamination and outdated use. In addition, the facility failed to have a policy on handling, storing, and labeling food and cleaning kitchen equipment. These deficient practices had the potential to affect all residents who ate at the facility. The census was 77. 1. Observation on 10/17/22 at 11:47 A.M., showed: -Double refrigerator showed one opened container of thickened lemon flavored water, one opened container of golden fruit punch, and one opened container of orange juice. There was no date on the containers. The back of the containers showed to use up to seven days after opening; -Walk in refrigerator showed a box filled with thawed strawberry and chocolate health shakes. There was no date labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to produce an on-site policy regarding the acceptance, usage and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The census was 77. Review of the facility's policies provided, showed no documentation of a policy regarding foods brought in for residents by family and other visitors. During an interview on 10/21/22 at 8:25 A.M., the dietary manager said there is no policy for food brought in by visitors; however, the families are aware of the resident's diet. The staff also check the food as well. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care to residents to prevent the spread of infection and provide a safe and sanitary environment for two residents (Residents #22 and #49) when staff did not change gloves during care and failed to appropriately clean dirty bandage scissors prior to use (Resident #52). The census was 77. Review of the Infection and Control Program policy, dated 8/2022, showed: -Policy: The facility has established and maintains 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 as per accepted national standards and guidelines; -Explanation and compliance guidelines: -All staff are responsible for following all policies and procedures related to the program; [...]

Inspectors wroteBased on interview and record review, the facility failed to promote the resident's self-determination through support of resident choices when staff failed to follow a resident's choice to be a no code (do not resuscitate [DNR], no life prolonging methods are performed), when staff performed cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) when the resident was found not breathing and without a pulse, (Resident #82). The sample size was 24. The census was 77. Review of the Communication of Code Status policy, dated 2/2022, showed: -Policy: It is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -Explanation and guidelines: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was maintained in good repair. The census was 77. Observations on the 500 hall secured unit, on 10/16/22 through 10/21/22, during the survey, showed the following: -Inside resident room [ROOM NUMBER], a bedside table, next to sink, with a portion of the veneer top missing. The remaining piece of veneer was elevated from the table base, with its jagged edges of broken veneer exposing the top of the wooden table underneath; -Inside room [ROOM NUMBER], the closet to the left of the entrance to the room, a closet door was missing. The resident room sink vanity, of the eight vanity drawers, five were missing, and two broken vanity drawers fronts sat underneath the sink; -Inside room [ROOM NUMBER], the resident room sink vanity, of its eight drawer vanity, one drawer was missing; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #59) was free from exploitation of property when a staff person admitted to borrowing $100 from the resident then refused to return the money. The census was 77. Review of the Abuse, Neglect, and Exploitation policy, implemented 2/2022, included: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with bed mobility and eating; [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the Department of Health and Senior Services (DHSS, the State Survey Agency) an allegation of abuse and an injury of unknown origin for two sampled residents (Residents #52 and #72). The sample was 24. The census was 77. Review of the facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 4/27/22, showed: -Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes; -Injuries of unknown source: Includes circumstances when both the following conditions are met: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to thoroughly and timely investigate alleged violations for 1 of 3 residents reviewed for abuse/neglect investigations. The facility failed to thoroughly investigate a resident to resident altercation (Resident #52 and Resident #4). The census was 77. Review of the facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 4/27/22, showed: -Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes; -Injuries of unknown source: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with an indwelling urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) had current physician orders for their indwelling urinary catheter. Facility staff also failed to monitor the resident's output and perform catheter care as ordered, and failed to address the catheter use on the resident's current care plan. The resident developed a urinary tract infection (UTI). The facility identified one resident with an indwelling urinary catheter. The one resident was sampled and problems were identified with that resident (Resident #52). The census was 77. Review of the facility's Indwelling Catheter Use and Removal policy, dated 2/2022, included: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, monitoring and ongoing communication with the dialysis (process for removal of waste and excess water from the blood due to kidney failure) center for one of two residents who received dialysis (Resident #18). The census was 77. Review of the facility Hemodialysis Policy, dated 1/2022, showed: - Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis; -Purpose: [...]

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing in a prominent place, readily accessible to residents and visitors on a daily basis. The census was 77. Observations from 10/16 22 through 10/21/22, showed the facility did not post the nurse staff sheet in a prominent place, readily visible and accessible to residents and visitors. There was no information that contained the facility name, date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: number of registered nurses, licensed practical nurses, certified nurse aides, and the resident census. During an interview on 10/21/22 at 10:29 A.M., the administrator and the Director Of Nursing said they had posted the nurse hours; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to complete a gradual dose reduction (GDR) and failing to ensure that as needed (PRN) orders for psychotropic medications were administered for the intended use and limited to 14 days for three of five residents reviewed for unnecessary medications (Residents #46, #47 and #52). In addition, the facility failed to monitor hypnotic medication used to treat insomnia (Resident #46). The sample size was 24. The census was 77. Review of the facility's Use of Psychotropic Medication policy, implemented 2/2022, included: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow their puree recipes for two of two purees observed which affected five of five residents receiving pureed diets. In addition, the facility did not have a policy regarding pureed diets. The census was 77. Observation and interview on 10/19/22 at 9:10 A.M., showed dietary aide S added canned, diced carrots to the food blender. He/she poured an unmeasured amount of hot water into a small container and poured the hot water into the blender. He/she did not measure the water before adding it to the blender. Dietary aide S said the amount of water added depended on the consistency of the carrots. If it was too thick, he/she would add more water. He/she also added Italian seasoning for flavor. The carrots were blended together until it had an applesauce consistency. Observation and interview on 10/19/22 at 9:20 A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the opportunity to receive the pneumococcal vaccine, unless documentation showed the vaccine was medically contraindicated, refused or the resident was already immunized by failing to offer the pneumococcal vaccine to three residents of 5 residents sampled for the pneumococcal vaccine (Residents #12, #13 and #49). The census was 77. Review of the facility Pneumococcal Vaccine (Series) policy, dated implemented 1/2022, showed: -It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: -Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. [...]