Uptown Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to provide quality care that meets professional standards for 2 (R #2 and #4) of 2 (R #2 and #4) residents, when staff failed to: Obtain and review physician ordered laboratory testing (controlled testing performed on biological, environmental, or other health related samples to support diagnosis, monitoring, prevention, and research of diseases and health conditions) within a timeframe that meets professional standards for R #2 and R #4. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the environment was free of accident hazards for 2 (R #9 and #25) of 4 (R #5, #6, #9, and #25) residents, when the facility staff failed to:Ensure the residents' bed wheels were locked while the beds were in use to prevent falls. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 1 (R #16) of 1 (R #16) resident received necessary behavioral health care to meet their needs, when staff failed to refer them for behavioral health services after they experienced depression symptoms and voiced self harm statements. This deficient practice is likely to result in worsening behaviors and failure to receive the behavioral or mental health care needed to improve mood and reduce depression and anxiety.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #4) of 1 (R #4) resident, when:The facility staff did not ensure a physician's order was accurate for administering Lactated Ringer solution (LR; an intravenous fluid used to replace lost fluids and electrolytes and help correct acid base imbalances), and the LR solution was not administered as expected in accordance with professional standards of practice. If ordered intravenous fluids are not administered as intended, residents may receive substandard care and treatment, placing them at risk for preventable harm.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident did not receive unnecessary pain management medications for 1 (R #6) of 1 (R #6) resident. This deficient practice is likely to lead to unwanted drug effects and poor patient outcomes.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, when: The facility failed to ensure R #1 received a newly prescribed antibiotic, after staff were aware of the new antibiotic orders. If the facility fails to obtain and administer a prescribed antibiotic for a resident with an active infection, then residents are likely to experience a worsening infection, disease progression, and avoidable complications.

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food under sanitary conditions when dietary staff failed to wear hairnets while in the kitchen. This deficient practice is likely to affect all 120 residents listed on the resident census list provided by the Administrator (ADM) on 07/29/25 and are likely lead to foodborne illnesses in residents if food is not being prepared and safe food handling practices are not adhered to.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to maintain an effective pest control program (measures to eradicate and contain common household pests) so that the facility is free of pests and rodents. This deficient practice is likely to affect all 120 residents listed on the resident census list provided by the Administrator (ADM) on 07/29/25 and are likely lead to airborne illnesses, emotional distress, and may deteriorate quality of life in residents.

Inspectors wroteBased on observation and interviews, the facility failed to close or lock the computer screen on the medication cart making personal information inaccessible to unauthorized staff and other residents for 1 (R #18) of 1 (R #18). This deficient practice could cause other to view sensitive, private, medical information.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for 1 (R #15) of 1 (R #15) resident reviewed for diabetic medications. Failure to follow physician orders is likely to cause residents to not receive the care and treatment they require.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders when staff did not enter an order for a nebulizer (device that turns liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) treatment into the medical record for 1 (R #15) of 1 (R #15) resident. This deficient practice could likely result in a resident not receiving the treatment as ordered by the physician which could cause the resident's respiratory status to be compromised.

Inspectors wroteBased on observations and interviews, the facility failed to secure medications and make them inaccessible to unauthorized staff for one medication cart on the 300 hall, creating a risk of unauthorized staff or residents taking a medication not prescribed to them. This deficient practice had the potential to affect all 25 residents residing on 300 hall as identified by the Resident Census provided by the Administrator on 07/29/25. A. On 07/29/25 at 1:05 pm, an observation was made of Nurse #9 walking away from the medication cart without locking it. Nurse #9 was observed to walk into a resident's room. Other (unidentified resident and staff members) were also present on the hall. B. On 07/29/25 at 1:08 pm, an observation was made of the Unit Manager (UM) #2 walking down the hall. UM stopped at the medication cart and locked it. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 118 residents listed on the facility census provided by the Administrator on 04/28/25 when staff failed to: 1. Serve the food items listed on the menu. 2. Provide residents with the opportunity to select their choice from the menu or alternate menu in advance of meal service. If the facility is not providing meal as listed on the menu or offering residents the option to select their choice of meal in advance of meal service, then residents are likely to experience frustration, depression, weight loss, and feel unimportant.

Inspectors wroteBased on observation and interview, the facility failed to ensure all garbage and refuse containers had lids or were covered when not in use. This deficient practice could likely affect all 118 residents identified on the resident census list provided by the Administrator on 04/28/25. This deficient practice could likely result in the unintentional sheltering and feeding of pests.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide complete documentation of an infection surveillance plan (ISP, a system for tracking and monitoring infections) for identifying, tracking, monitoring, and reporting of infections, communicable diseases (an illness that can spread from one person to another), and outbreaks (the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time) among residents and staff. This failed practice has the potential to affect all 118 residents in the facility. This deficient practice is likely to lead to a higher risk of patient harm, difficulty identifying and addressing outbreaks, and difficulty tracking the effectiveness of infection prevention measures (basic practices to stop the spread of germs).

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 118 residents in the facility. Residents identified on the matrix provided by the Administrator on 04/30/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a clean, safe, and comfortable environment for residents when staff failed to: 1) Repair damaged and broken blinds in resident rooms #103, #109, #206, #305, #309, and #311. 2) Repair broken wall tiles in resident bathrooms in rooms #103, #106, and #107. 3) Paint over unpainted drywall in resident rooms #101, #102, #103, #107, #302, #303, and #305. 4) Clean dust from ceiling fans above the dining room eating area. 5) Replace stained tablecloths in the dining room. 6) Ensure the cleanliness of vending machines in the common area. 7) Maintain the conference room in a clean, uncluttered, and hazard-free condition. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plans for 2 (R #7 and R #24) of 2 (R #7 and R #24) residents reviewed. Staff failed to update the care plans to reflect each resident's current needs regarding the use of appropriate utensils during mealtime. Appropriate utensils refer to those assessed as safe and suitable for the resident based on their physical and mental condition (e.g., plastic utensils instead of metal for residents with a history of self-harm). If care plans are not updated to reflect residents' current needs, then staff may provide inappropriate items or assistance, which could result in unmet care needs and safety risks.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a safe environment free of the potential for accidents and hazards for all residents when staff failed to: - Ensure accurate smoking supervision assessments were completed for R #7; - Ensure residents did not have lighters in their rooms; - Ensure staff did not store personal belongings in resident rooms; - Prevent unsecured bleach cleaning wipes from being left in resident bathrooms. This deficient practice placed residents at risk for burns, fire-related injuries, chemical exposure, and ingestion of unsafe substances.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of the opening date for 5 (R #5, R #27, R #47, R #71, R #82) of 5 (R #5, R #27, R #47, R #71, R #82) residents reviewed. This deficient practice is likely to result in all five residents receiving medications that are less effective or expired.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when they failed to: - Ensure food was stored in a manner to prevent cross contamination and outdated use. - Maintain the kitchen in a clean and sanitary manner. - Ensure employees wore hair restraints. - Ensure staff did not serve drinks with their hands on the rim of the cup. This deficient practice could likely affect all 118 residents identified on the resident census list provided by the Administrator on 04/28/25. If food was not stored, prepared, and served under sanitary conditions then residents are at an increased risk of contracting food born illness, having weightloss, and may feel unimportant.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to: - Ensure call lights were in working order when staff failed to report and repair two broken call lights on the 400 hall shower room; - Ensure a call light was within reach for 1 (R #120) of 1 (R #120). If the facility is not ensuring a working call light system or maintaining the call light is not within residents' reach, then residents are unable to request immediate assistance when needed.

Inspectors wroteCeiling Tiles H. Record review of the facility's policies and procedures revealed the facility did not have a policy regarding the maintenance of ceiling tiles. I. On 05/02/25 at 01:25 P.M., observation of the 100 hallway revealed the following: - A ceiling tile located near resident room [ROOM NUMBER] had open space. - A ceiling tile located outside the business office had a 1 inch triangular hole. - A ceiling tile located in the dining room near the exit door had a 1/2 inch hole. - A ceiling tile located in hallway 100, at the entrance doors, had two 1 inch circular holes. J. On 05/02/25 at 12:05 P.M., observation of the Dining Room revealed the following: - A cracked ceiling tile with unsealed space around a sprinkler head. - A cracked ceiling tile with a 1/4 inch unsealed space around the base of a ceiling fan. K. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #42) of 1 (R # 42) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #42) of 1 (R #42) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to date the oxygen tubing for 1 (R #325) of 1 (R #325) residents reviewed for oxygen. If the facility is not dating and initialing the oxygen tubing and humidifiers (provide moisture when delivering oxygen) then staff may be unaware as to when the tubing and humidifier should be changed and could cause the tubing to become dirty leading to reduced oxygen flow.

Inspectors wroteBased on record review observation and interviews, the facility failed to ensure residents obtained routine dental care for 2 (R #15 and R #48) of 2 (R #15 and R #48) residents reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for 1 (R #2) of 3 (R #2, 3 and 4) residents reviewed for diabetic medications. Failure to follow physician orders is likely to cause residents to not receive the care and treatment they require.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff treated residents with dignity and respect for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed when staff failed to consider a resident's feelings due to her pain levels. This deficient practice could likely cause the resident to feel like she was not being heard and did not matter.

Inspectors wroteBased on record review and interview, the facility failed to report to the State Survey Agency (SSA) an allegation of staff to resident abuse for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If the facility fails to report allegations of abuse to the SSA, then corrective measures may not be acted on and the SSA will not be unable to ensure residents are free from abuse.

Inspectors wroteBased on record review and interview, the facility failed to manage a resident's pain for 1 (R #1) of 1 (R #1) resident reviewed for pain management. This deficient practice could likely cause a resident to experience a decline physical and emotional health if the resident's pain was not managed and effectively controlled.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide a podiatry consult and care for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for foot care. This deficient practice likely caused R #1 not to receive foot care as ordered by a physician which could result in more serious foot problems.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated with necessary documents and accurate for 2 (R #1 and #2) of 2 (R #1 and #2) residents reviewed for foot care. This deficient practice could likely result in staff not knowing residents' daily care events, changes, and their needs.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 116 residents who resided in the facility when staff failed to offer baths or showers to residents as scheduled. These deficient practices are likely to negatively impact resident comfort.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for all residents who resided on the 400 Unit and were sampled for a homelike environment. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 2 (R #7 and R #9) of 4 (R #5, #7, #8 and #9) residents when staff: 1. Did not provide care or assess R #7 for several hours upon admission. 2. Did not offer R #7 hydration or a snack for several hours upon admission. 3. Nursing staff did not obtain physician orders for R #9's Peripherally Inserted Central Catheter (PICC; a long, thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line care, monitoring, and dressing changes. 4. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 5 (R #5, #8, #9, #10, and #11) of 5 (R #5, #8, #9, #10, and #11) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, and the facility failed to ensure the medical records for residents were accurate and complete for 2 (R #1 and R #7) of 2 (R #1 and R #7) residents randomly selected and reviewed when staff failed to ensure residents' medication was available and documented they administered prescribed medications when the medications were not available or when resident refused. This deficient practice is likely to result in staff confusion as to when or if residents have consistently received prescribed medications and if residents are receiving their intended medication effectiveness.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's belongs were safeguarded from loss for 1 (R #2) of 1 (R #2) residents reviewed for personal property when they failed to offer R #2 a safe place for her belongings until after theft occurred. This deficient practice is likely to result in unaccounted property for the resident and family resulting in frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control practices for 2 (R #5 and R #6) of 2 (R #5 and R #6) residents reviewed for wound care when staff failed to: 1. Change gloves after cleaning a wound and before placing a clean bandage on wound. 2. Ensure clean bandages and gloves did not touch a non-clean surface (bed, bedside tray table). 3. Dispose of soiled bandages in a receptacle for items that contained biohazards waste. If the facility is not using proper infection control practices the residents are likely to acquire infections.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's Power of Attorney (POA) before transferring 1 (R #5) of 2 (R #5 and R#1) residents to a different facility. This deficient practice could likely result in the resident's POA not being aware of the resident's location.

Inspectors wroteBased on observation and interview, the facility failed to discard food after it reached its shelf life or after it expired. This failure was likely to affect all 122 residents listed on the census provided by the Director of Nursing (DON) on 02/16/24. This deficient practice could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being discarded timely.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was homelike, free of clutter and broken items for residents eating in the dining room and living on 100 hall. This deficient practice could likely result in any of the 122 residents identified on the facility census provided by the Center Nursing Executive on 02/12/24 feeling like their environment was filled with unusable items that needed to be disposed of, causing frustration.

Inspectors wroteBased on record review, observations, and interview, the facility failed to meet professional standards of quality for 5 (R # 26, 55, 84, 102, and 165) of 5 (R #26, 55, 84, 102, and 165) residents sampled for nutrition and skin issues, when staff failed to: 1. Maintain accurate weights for R #26, R #84, and R #165; 2. Float the resident's heels per physician orders while in bed for R #102. 3. Ensure a resident on dialysis received a meal per physician orders prior to leaving to their appointments for R #55. These deficient practices could likely result in resident nutrition not being accurately assessed, causing a potential for weight gain or weight loss to go unnoticed, the deterioration (worsening) of overall health and well-being of residents, and places the resident at risk of developing a pressure sore which could lead to infection.

Inspectors wroteBased on record review and interview, the facility failed to conduct annual performance reviews for 2 Certified Nurse Assistants (CNAs; CNA #1 and CNA #2) of 3 (CNA #1, CNA #2, and CNA #3) CNAs. This deficient practice could likely result in staff not maintaining the competencies to perform their daily tasks and may lead to inappropriate care, service, and a failure to meet the needs of all residents.

Inspectors wroteBased on observations and interviews, the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies in the medication room. These deficient practices are likely to result in all 31 residents residing in hall 200, as identified on the census list provided by the facility Administrator on [DATE], receiving expired medication and having expired medical supplies used in their treatments.

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow dietary orders for double entree's and include all items on the resident's meal ticket for 1 (R #105) of 1 (R #105).

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #84) of 3 (R #'s 31, 55 and 84) residents reviewed for care plan revisions by not revising a care plan after there was documented significant weight loss for R #84. This deficient practice could likely result in residents not receiving the care or treatment needed to ensure their overall safety or ability to maintain their highest practicable well being.

Inspectors wroteBased on record review and interview, the facility failed to ensure quality care and treatment for 3 (R #84, 87 and 262) of 3 (R #84, 87 and 262) residents reviewed for appointments, activities of daily living (ADL) care, and following dietary orders to obtain weekly weights. This deficient practice could likely result in a resident not receiving the care and services that were ordered and did result in a resident feeling embarrassed and frustrated due to not being assisted to the bathroom and going in her brief.

Inspectors wroteBased on observation and interview, the facility failed to maintain oxygen equipment according to safety precautions and prohibitions for oxygen use for 1 (R #4) of 3 (R #4, R #20, and R #48) residents reviewed for respiratory care when staff failed to post caution and safety signs indicating the use of oxygen in the resident's room. This deficient practice could likely result in staff not recognizing that oxygen is being used in a resident's room, and this could result in a dangerous (able or likely to cause harm or injury) fire hazard (material, substance, or action that increases the likelihood of an accidental fire occurring). Resident #4 A. Record review of physician's orders for R #4 revealed the following orders related to oxygen use: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures when staff did not: 1. Wear the proper personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) before entering the room of a resident under covid precautions (set of measures to prevent the transmission of bacteria and viruses that are spread through respiratory liquid). This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the 28 residents in the 400 hall.

Inspectors wroteBased on record review, observation , and interview, the facility failed to: 1. Serve food in a timely manner according to established meal times; 2. Maintain the holding temperature of cooked food (greater than 140 degrees Fahrenheit) . These deficient practices are likely to affect all 119 residents listed on the census provided by the Director of Nursing (DON) on 01/03/24. These deficient practices could likely lead to: 1. Foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if food is not held at a temperature outside the danger zone (the temperature range where bacteria grows at a rapid rate, between 40 degrees (°) Fahrenheit (F) and 140° F); 2. Residents feeling frustrated as they wait for meals to be served and/or receive cold food.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were not left on a beside table in a resident's room for 1 (R #2) of 1 (R #2) resident. This failure could likely result in resident injury if staff do not confirm residents take their medications.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide pericare (the cleaning of a patient's private area) in a timely manner for 3 (R#1, R #2, and R #10) of 4 (R#1, R #2, R #10, and R #14) residents reviewed for brief maintenance. This deficient practice could likely result in residents feeling upset as they must sit in a soiled brief longer than expected.

Inspectors wroteBased on interview and record review, the facility failed to ensure meals were served at an appetizing temperature and were attractive and palatable (pleasant to taste) for 5 (R #'s 8, 14, 15. 28 and 31) of 5 (R's #'s 8, 14, 15, 28 and 31) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and they could likely lose weight.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was free of flies for 3 (R #26, 27 and 28) of 3 (R #26, 27 and 28) looked at for environment and pest control. This deficient practice could likely result in residents feeling frustrated and uncomfortable if the facility fails to maintain an effective management of flies in the building.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure nursing staff followed the process for monitoring medications in the treatment cart for all 30 residents residing in the 400 hall, as listed on the resident census on 10/20/23. This deficient practice could likely result in resident medications not being monitored and at risk for misappropriation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care for 1 (R #30) of 1 (R #30) resident reviewed for pain management. This deficient practice could likely cause the resident to not have her pain adequately controlled if she is not receiving all prescribed pain medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents at risk of elopement (residents who have been identified as a danger to themselves if they exit the facility unattended) remained in the facility after a wander guard (a medical device/bracelet that alarms when residents attempt to exit the building) alarm was activated. This deficient practice affected 1 (R #6) of 6 (R #'s 1, 2, 3, 4, 5, and 6) residents reviewed for elopement risk. This deficient practice could likely result in residents exiting the building unattended without the ability to return.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy, the facility failed to protect the right of one of one resident reviewed for abuse (Resident (R) 51) to be free from physical abuse by R111. R51 suffered two events of physical abuse by R111 when R111 was not adequately supervised following the first event of abuse. The second event resulted in R51 being hospitalized for a fractured arm and a head laceration requiring stitches. Immediate action to ensure staff provided adequate supervision and/or monitoring to any resident threatening the health and safety of themselves or others was required to prevent recurrence of the situation. [...]

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure that one resident (R) R21 was properly transferred with a two-person assist instead of a one-person assist, which resulted in causing harm to R21. R21 sustained a fractured left tibia during a transfer. In addition, the facility failed to ensure that four residents (R11, R37, R54 and R262) were properly supervised from keeping smoking materials (lighters) on their person and smoking in undesignated area.

Inspectors wroteBased on observations, interview, record review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to 114 out of 115 residents (one resident received nutrition via a feeding tube and took nothing orally). Specifically, staff failed to change gloves between tasks when serving meals; the dish machine area was unsanitary and not adequately maintained; refrigerator temperatures were too high; and food was not stored in a manner to prevent cross contamination.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the dumpster area remained free of garbage to prevent the harborage of pests and rodents on three of three days in which observations were made during the survey. This had the potential to affect staff, visitors, and all 115 residents residing in the facility.

Inspectors wroteBased on observation, interview, review of resident council minutes, and policy review, the facility failed to ensure the menus were followed for residents attending the resident council, and for 11 (Resident (R)262, R68, R39, R8, R35, R53, R76, R85, R7, R91, and R38) out of 35 sampled and supplemental residents, creating the potential for dissatisfaction and decreased nutritional intake. Specifically, tray tickets were not followed; residents were served less food or smaller portions than what the menu/tray tickets called for. Foods were omitted without replacements being made.

Inspectors wroteBased on observation, interview, review of resident council minutes, record review, and policy review, the facility failed to ensure the food was palatable for 10 (Resident (R)262, R9, R165, R68, R51, R100, R462, R43, R20, R263) out of 35 sampled and supplemental residents, and residents attending resident council meetings. Specifically, the food was poorly prepared, did not taste or look appetizing, and was not at an acceptable temperature when residents received their meals.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure staff followed adequate transmission-based precautions (TBP) to prevent the spread of COVID-19. Five Certified Nurse Aides (CNAs) entered the rooms of residents (Resident (R) 25 and R33) out of six residents on TBP for COVID-19 without adequate use of personal protective equipment (PPE). These five CNAs were assigned to provide care to residents with COVID-19 and residents without. These failures placed the 21 residents and staff on the 400 unit at risk for transmission of COVID-19. The facility further failed to ensure proper hand hygiene was implemented when completing a dressing change for one (R9) out of one observation of a dressing change.

Inspectors wroteBased on resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of misappropriation of property for one (Resident (R) 68) of one resident reviewed for personal property was thoroughly investigated. This failure had the potential to contribute to a feeling of helplessness and anxiety over a lost wheelchair and further misappropriation of property in the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the comprehensive assessment assessed the pain status for one resident (Resident (R) 68) of 28 sampled residents. This failure had the potential to lead to a lack of adequate interventions to address and control the presence, location, intensity, and effects of R68's pain.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to oxygen use directing measurable goals and interventions for one (Resident (R) 100) of a total sample of 35 residents. This failure placed the resident at risk for unmet care needs and the inability meet their maximum practicable level of functioning related to use of oxygen.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure two (Resident (R) 68 and 99) of six sample residents reviewed for rehabilitation/restorative services received appropriate treatment and services as ordered to maintain, restore, or improve the functional ability This failure had the potential to lead to increasing disabling effects of chronic conditions for R68 and R99.

Inspectors wroteBased on observation, interview, record review, and review the facility's policy, the facility failed to ensure one of 35 sample residents (Resident (R)9) received assistance with activities of daily living (ADLs), including personal hygiene, baths and/or showers. This failure had the potential to contribute to a lack of good personal hygiene and an overall sense of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure a physician's order was in place for the use of oxygen for one (Resident (R) 100) of a total sample of three residents reviewed for oxygen use. This failure placed the resident at potential risk due to no parameters of how much oxygen to administer, or if it needed to be continuous, or as needed.