Viridian Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included but was not limited to a recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, a final summary of the resident's status, and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one of (Resident #59) of two residents reviewed for discharge. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #59 when he planned discharge home on [DATE]. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #4) reviewed for comprehensive care plans. The facility failed to ensure Resident #4's comprehensive care plans addressed their goals, needs, strengths, medical, nursing, mental, and psychosocial needs. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #4) of 5 residents reviewed for mobility. - The facility failed to make sure Resident #4 had heel protectors pressure relief boots on while she was in bed on 07/07/26 and 07/08/26. This failure could place residents at risk for complications that may be related to decreased ROM and/or mobility may include, pain, skin integrity issues, and decreased muscle strength and atrophy.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Treatment Cart #1) of one treatment cart reviewed for medication storage and supplies. The facility failed to ensure Treatment Cart #1 was locked when unattended on 07/07/26. This failure could place residents at risk of having access to unauthorized medications and supplies and lead to possible harm.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure a resident who was incontinent received appropriate treatment and services for 1 of 3 (Resident #1) reviewed for quality of care. The facility failed to ensure that CNA A provided perineal care according to professional standards of practice when she cleaned a female resident's (Resident#1) perineal area from back to front, rather than from front to back. This failure could place residents the risk of urinary tract infections and compromised health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for two of six residents (Resident #1 and Resident #2) reviewed for reporting of alleged violations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident of 1 of 4 residents reviewed for pharmacy services. The facility failed to ensure an expired Tylenol with Codeine tablet 300-30mg was removed from the 300 hall nurses' medication cart and disposed of. This failure could place residents at risk of receiving ineffective treatment, and potential medication error. Record review of Resident #1's Comprehensive MDS Assessment, dated 03/06/26, reflected Resident #1 was a [AGE] year-old male, admitted [DATE]. He had a BIMS score of 15, indicating intact cognition. The resident had diagnoses including muscle weakness, anxiety disorder, depression, seizures, and Post Traumatic Stress Disorder (PTSD). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen services. The facility failed to ensure that 1 of 1 container covered with plastic wrap was dated in the walk-in refrigerator. The facility failed to ensure that 56 of 56 containers in the reach-in refrigerator were labeledThe facility failed to ensure that 3 of 3 containers of salad were labeled and dated. The facility failed to ensure that 2 of 2 dietary staff properly use hair restraints during food preparation. This failure could place all residents at the facility by placing them at risk for food exposed to adulteration or potential contaminants. Findings Included:During an observation and interview on 02/17/26 at 9:19 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one (Resident #62) of five residents reviewed for dignity. The facility failed to ensure Resident #62's intravenous medications were covered with a privacy bag when he was eating lunch in the dining room area with several other residents. This failure could place residents at risk for a lack of privacy or dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 5 residents (Resident#63) reviewed for respiratory care. The facility failed to ensure that Resident #63's oxygen tubing's were bagged in a plastic bag and stored in a drawer which was consistent with professional standards and changed and dated per physician orders. This failure could place residents at increased risk of infections. Record review of Resident #63's MDS Assessment, dated 01/09/2026, reflected the resident was a [AGE] year-old female, admitted [DATE]. She had a BIMs score of 10 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 1 of 1 medication on 1 of 3 medication carts, reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident#18's Tylenol 300/30mg (controlled medication) by taping a narcotic medication. This failure could place residents at risk of drug diversion and risk of pills contamination due to broken seal. Record review of Resident #18's Quarterly MDS Assessment, dated 12/04/25, reflected the Resident #18 was a [AGE] year-old male, admitted [DATE]. He had a BIMs score of 15, indicating cognitively intact. The resident had diagnoses including seizure disorder, anxiety disorder, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for two (300 hall nurses cart and 300 hall Medication Aides cart) of four medication carts reviewed for medication storage. The facility failed to ensure Resident#19's IV antibiotic was initialed and date/time of administration. The facility failed to ensure Resident#19's IV tubing was dated indicating when it was initiated or last changed. The facility failed to ensure that an unopened vial of Rectacrit was observed stored unrefrigerated in the medication cart. The facility failed to ensure Zofran 4mg was labeled with the residents name. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC lines for 1 of 2 (Resident #19) residents reviewed for parenteral and intravenous care. The facility failed to ensure Resident #19's PICC line dressing was intact. This failure could place the residents at risk of contamination, infection, and complications with their PICC line needed for infusion therapy. Record review of Resident #19's annual MDS assessment, dated 11/22/25, reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMs score was 15, indicating her cognitive status was intact. Her diagnoses included wound infection, pressure ulcer of sacral region stage 4. [...]

Inspectors wroteBased on interviews, the facility failed to protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility for 1 of 1 facility reviewed for communication with privacy. The facility failed to deliver mail to residents on Saturdays. This failure infringes on the residents' rights to receive mail and communications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 6 (Resident #70, Resident # 23, Resident # 39, Resident # 36, Resident #25, Resident #63) of 6 residents reviewed for restraints. The facility failed to ensure Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were not inhibited from freedom of movement or activity in the secure unit when facility staff pushed two dining tables together and placed them in front of the single entrance to the dining area, to prevent the residents from leaving the area. This failure places the residents at risk of being restrained without medication indication. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of four medication carts (300 hall nurses cart and 400 hall Medication Aides cart) reviewed for medication storage. 1. The facility failed to ensure Resident #64's unopened liquid Lorazepam 2mg /ml was stored in the refrigerator. 2. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 facility kitchens reviewed for kitchen sanitation. The facility failed to ensure food items were properly stored in the facility's freezer. 2. The facility failed to ensure food and drink items were properly labeled. 3. The facility failed to ensure no outdated or spoiled foods were present. These failures could place residents at risk for food-borne illnesses. Findings Included: Observation of the facility's freezer on 09/14/24 at 9:12 AM revealed: - 2 bags of lettuce (each bag contained 6 heads of lettuce) visibly decomposed, brown discoloration, wilted and slimy, with liquid seepage. - 1 box lima beans were open and exposed to the air. - 2 gallon jugs of milk, were opened and were not labeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services with reasonable accommodations for 2 of 5 residents (Resident #8, and Resident #14) reviewed for call light system access. The facility failed to ensure Resident #8 had access to their call light by allowing it to remain on the floor at the side of the bed, out of the resident's reach. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain between the wall and mattress at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Resident #20 & #49) of five residents reviewed for environment. The facility failed to maintain the wall air conditioning unit in Residents #20 and #49's room free of dust buildup. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment.

Inspectors wroteBased on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #55) of five residents reviewed for PASRR services. The facility failed to ensure Resident #55 was properly screened for PASRR services. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #72) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #72. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident's #49 and #61) reviewed for ADL care. The facility failed to provide Residents #49, and #61 with showers based on their weekly shower/bathing schedule. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #17) of 5 residents reviewed for accidents and supervision. The facility failed to prevent Resident #17 from cleaning his fingernails with a rusted nail. This failure could place the resident at risk of injury or infection. Findings Include: Record review of Resident #17's MDS, dated [DATE], revealed a male resident who was admitted to the facility on [DATE]. Resident #17 had a BIMS score was 11, which indicated a moderate cognitive impairment. Resident #17's primary diagnosis which included acute and chronic respiratory failure with hypoxia (a sudden onset of severely low blood oxygen levels). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #6, Resident#64) reviewed for infection control. 1. The facility failed to ensure CMA C sanitized the blood pressure cuffs to prevent the spread of infections. 2. LVN B failed to don PPE prior to performing high contact resident care activities on Resident #6 who was on enhanced barrier precaution. These failures could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse and/or neglect. The facility failed to ensure Resident #1 was free from abuse when the call device was not functioning and available to call for immediate assistance when she was physically abused by Resident #2. A manual bell had been placed at Resident#1's door and in her drawer, but Resident #1 had not been instructed on how/when to use the bells. On 07/24/25 at 5:20 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2. On 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of three residents reviewed for pharmacy services. The facility failed to administer all physician ordered doses of Rifaximin (medication to treat liver failure) to Resident #3 between 01/09/25 - 01/20/25. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. An Immediate Jeopardy ( IJ) was identified on 06/05/25. Findings demonstrate that the Immediate Jeopardy began on 01/09/25 and was removed on 01/20/25. The noncompliance continued at a Pattern of Potential for More than Minimal harm that is not Immediate jeopardy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #1) reviewed for ADL care. The facility failed to ensure Residents #1 was repositioned every 2 hours on 06/04/25, resulting in moisture associated damage to Resident #1's right and left buttocks. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Residents #1 and #2) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 did not develop wounds on his toes and moisture associated skin damage on his buttocks. 2. The facility failed to ensure Resident #1 and Resident #2 were repositioned every two hours on 6/4/25. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of one resident (Resident #4) out of five who were reviewed for activities. The facility failed to consistently provide encouragement and assistance to participate in facility provided activities for Resident #4. This failure could place residents at risk for social isolation, depression, and a decline in psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #1 on 06/04/25.2. The facility failed to ensure CNA B and CNA D performed hand hygiene during incontinence care for Resident #2 on 06/04/25. This failure placed residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #4) of five residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide Habilitation Coordination, Independent Living Skills, Physical Therapy, Occupational Therapy, Speech Therapy. to Resident #4 as recommended and agreed upon by the Interdisciplinary Team (IDT) within the time frame set by PASRR. [...]

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 (Resident #4) residents reviewed for care plans. The facility failed to implement Resident #4's comprehensive person-centered care planned interventions for speech and occupational therapies. Failure to implement the care plan as written could place residents at risk for unmet needs, avoidable decline, injury, or harm, as their individualized support measures are not being followed to ensure safety, health, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #2) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #2 received her Foley catheter change as ordered every month when RN E documented that he changed the Foley catheter on 05/13/25, but he only changed the bag and did not change the catheter. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one, Resident #1, of five residents reviewed for environmental concerns. The facility failed to ensure Resident #1's room was free of gnats on 06/04/25 which were landing on a cloth near his tracheostomy collar. This failure could place residents at risk of having pests in their rooms and insect bites.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. 1) The facility failed to ensure food items were properly labeled and dated with the product's name. 2) The facility failed to ensure food items were properly sealed when not in use. These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a safe, clean, comfortable, and homelike environment which included but not limited to receiving treatment and supports for daily living safely for 4 of 6 shower rooms (100, 300, 400 and 500 halls) reviewed for environment. 1. The facility failed to ensure the 100, 300, 400 and 500 hall shower rooms were clean and free of trash and soiled towels. 2. The facility failed to ensure the 100, 300, 400 and 500 hall shower rooms did not have broken and missing ceramic wall tiles. 3. The facility failed to ensure unnecessary items (one wheelchair, two hangers, two pillows, and two empty plastic storage bins) were not stored in the 300 hall shower room. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable and homelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 walk-in freezer reviewed for environment. The facility failed to ensure the walk-in freezer was maintained to prevent the vent in the ceiling from dripping which caused a chunk of ice to form on the floor. This failure could affect all kitchen staff by placing them at risk for falls and slipping hazards inside the freezer.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of five residents reviewed for pharmacy services. The facility failed to ensure that documentation of narcotic medications signed out on the narcotic count sheet were consistent with documentation of narcotic medications administered to Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 as reflected on their MAR and nursing progress notes. These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 5 shower rooms (300 and 500 halls) reviewed for environment. The facility failed to ensure the 300 and 500 hall shower rooms were clean and free of trash and soiled towels. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 5 Halls (200, 300 and 400 Halls) reviewed for environmental concerns. The facility failed to ensure residents overhead light fixtures illuminated in the resident's bedrooms on hall 200 (Rm# 206,212, and 222), hall 300 (Rm# 301, 303, and 310) and hall 400 (Rm#405, 406 and 419). This failure could place residents at risk of not having a safe and functional environment.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one resident (Resident#1) of 5 residents reviewed for ADLs. -The facility failed to provide showers or bed baths for Resident #1 according to the facility's ADL schedule. This failure could place all residents who require assistance with ADL care at risk for poor personal hygiene, odors, and a decline in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. The facility failed to accurately reflect Resident #1's use of high risk medications in his most recent quarterly MDS assessment. The failure placed residents at risk for having inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program, so the facility was free from pests and rodents for 2 of 2 residents (Resident #2 and Resident #3) reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of rodents and roaches in the facility kitchen and the rooms of Resident #2 and Resident #3. This failure could place residents at risk for an unsanitary environment in the kitchen and rooms of Residents #2 and Resident #3 and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Residents #1) of 1 resident reviewed for tracheostomy care. The facility failed to ensure an extension cord was kept in Resident #1's room for use during a power outage in accordance with his Care Plan. This failure placed residents at risk of serious injury or hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for staff for 1 of 1 walk-in freezers reviewed for environment. The facility failed to ensure the kitchen walk-in freezer door was maintained to ensure the water did not drip from the vent onto the floor. This failure could affect all kitchen staff by placing them at risk for fall and slipping hazard inside the freezer.

Inspectors wroteBased on interview and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency in accordance with state law through established procedures for one of two incidents (Resident #1) reviewed for abuse, neglect, and misappropriation. 1. The facility failed to report to the State Survey Agency when Resident #1 eloped from the facility on 12/31/24. This failure could place the residents in the facility at risk of continued abuse and neglect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for catheter care. The facility failed to ensure LVN A followed relevant clinical guidelines and provided appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. This failure could place the resident at risk of urethral tears or dislodging the catheter and urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC lines for 1 of 2 (Resident #2) residents reviewed for parenteral and intravenous care. The facility failed to ensure Resident #2's PICC line dressing was intact. This failure placed the residents at risk of complications with their PICC line needed for infusion therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for two months (December 2024 and January 2025) of two months reviewed of resident council meetings and facility-received grievances. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #2 and Resident #3) of five residents reviewed for ADLs. The facility failed to provide showers or bed baths consistently for Residents #2 and #3 per the facility bathing schedule in January 2025. This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received all physician ordered wound care 10 out of 31 days in December 2024. 2. The facility failed to ensure Resident #1 received all physician ordered wound care 5 out of 30 days in January 2025. This facility failure could place residents at risk of developing infections or worsening of their wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for one hall (Hall 400) of six halls reviewed for physical environment. The facility failed to ensure the water heater supplying heat to three resident rooms on Hall 400 was in operating condition (including Residents #2, #3 and #4). The residents in the rooms did not have hot or warm water available as a result of the broken water heater.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. 1. The facility failed to ensure the dressing on Resident #1's Midline catheter (used to deliver intravenous medications directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 15 days. 2. The facility failed to have orders for Midline catheter dressing changes. The failures could affect residents by placing them at risk for infections and cross-contamination.

Inspectors wroteBased on, observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services in that: The facility failed to ensure Resident #1's Ketoconazole External Shampoo (used to treat hair loss and dandruff) was available and applied as ordered between 11/27/24 and 12/2/24. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Resident #24 and Resident #56) of 8 residents reviewed for quality of care. The facility failed to identify wounds and provide needed care and services to Residents #24 and #56. This failure could prevent the resident from receiving treatments and worsening of their wounds. An IJ was identified on 11/18/24. Administrator B and DON were notified and an IJ Template was provided on 11/18/24 at 1:48 PM. While the Immediate Jeopardy was removed on 11/19/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Resident #54 and Resident #56) of eight residents reviewed for resident rights. 1. The facility failed to assist Resident #54 to get out of bed. 2. The facility failed to provide Resident #56 clothing. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received their mail that is delivered on Saturdays. The facility failed to ensure resident's Saturday mail was delivered on the day it was received. This failure could affect 80 residents by placing them at risk of not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 2 of 2 residents, #41 and #45. The facility failed to ensure Resident's #45, #41 had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. These failures could affect the Resident's and their representatives' abilities to file a grievance in a timely manner and inhibit their right to request a written decision regarding the resolution of their grievance. Findings Included: 1. Record Review of Resident #45's Quarterly MDS dated [DATE], revealed Resident #45 was a [AGE] year-old who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #54) of eight residents reviewed for resident rights. 1. The facility failed to assist Resident #54 to get out of bed. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Residents #73) out of 7 residents reviewed for sufficient staff. The facility failed to have adequate staff to prevent Resident #73 from wandering out of the secured unit and into the main area of the facility. An assigned Charge Nurse and CNA were both off the unit at the time Resident #73 left the unit. This failure could place residents at risk of not receiving the necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 4 residents (Resident #55) reviewed for unnecessary medications. The facility failed to ensure Resident #55 did not receive duplicate medication therapy for Bupropion (anti-depressant medication). This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the duplicate use of these medications) and receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5 percent. There were 5 errors out of 32 opportunities which resulted in a 15 percent error rate for three (Resident #8, #58, and #45) of three residents reviewed for medication errors. 1) LVN A failed to administer to Resident #8 his famotidine dose via J-tube (tube inserted into the small intestine to deliver food or medications) during the medication administration observation. 2) MA B failed to administer to Resident #58 his Baclofen tablet and pregabalin tablets and failed to administer the correct dose and type of Colace during the medication administration observation. 3) MA B failed to administer to Resident #45 her Flonase during the medication administration observation. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #54, Resident #33, and Resident #24) of eight residents observed for infection control. 1. The facility failed to ensure Residents #54 and #33 were placed on enhanced barrier precautions. 2. LVN G failed to change her gloves and perform hand hygiene during incontinence care for Resident #24. These failures place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #54) of 3 residents reviewed for catheter care. 1. The facility failed to ensure Resident #54 had a catheter stabilization device. These failures could place residents at risk of urinary tract infections and urethral damage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 residents (Residents #1, #2, and #3) reviewed for respiratory care. The facility failed to change and date Residents #1, #2 and #3's oxygen and nasal cannula tubing and humidifier bottle every week. This failure could place residents at risk for respiratory infections . Findings Include: 1. Record review of Resident #1's face sheet, dated 10/15/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 4 (Residents #1, #2, #3 and #4) of 4 residents reviewed for activities. The facility failed to provide individualized and group activities for Residents #1, #2, #3 and #4 on the secure unit. The facility failed to ensure Residents #1, #2, #3 and #4 had an individualized activity care plan. These failures could place residents at risk for decline in quality of life, social and mental psychosocial wellbeing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents receives adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #1 and Resident#16) reviewed for supervision. 1. The facility failed to ensure Resident #1, who was known for seeking alcohol and becoming intoxicated, was adequately supervised to prevent him from leaving the facility without signing out. 2. The facility failed to ensure Resident#16, who was known for seeking alcohol and becoming intoxicated, was adequately supervised to prevent him from leaving the facility without signing out at the front representative desk on 08/09/24. Resident#16 left out the back gate where the residents took smoke breaks at 10:00 PM during staff shift change. An Immediate Jeopardy (IJ) was identified on 07/16/24 at 3:00 PM. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined the facility did not have a functional communication system for some residents to call staff for assistance for four (100 hall, 300 hall, 400 hall, and 500 hall) of five halls in the facility. On 08/06/24, some of the rooms on hall 500 did not have working call lights. There was no other option put in place by the facility for all residents to call for assistance. On 08/07/24, some of the rooms on hall 100, hall 300, hall 400 did not have working call light. There was no other option put in place by the facility for all residents to call for assistance. On 09/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Residents #15) of 4 residents reviewed for quality of care. 1. Resident #15 did not receive care on the overnight shift (10PM-6AM) on 08/05/24. Resident #15's entire, right leg hung from the bed throughout the night and was observed swollen. Resident #15 was in distress, discomfort, pain, shed tears and had a flushed face (blood vessels below the skin dilate and fill with more blood, making the skin appear pink, red.) Resident #15 call light and bathroom call light did not work properly. Resident #15 yelled and cried out for help continuously for thirty minutes at 7:00 AM on 08/06/24. On 08/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure that baseline care plans were completed within 48 hours of the resident's admission for 3 out of 5 residents (Resident #6, Resident #7, Resident #8) whose care was reviewed for baseline care plans. The facility failed to ensure that baseline care plans were completed within 48 hours for Resident #6, Resident #7, and Resident #8. This failure could place the resident at risk for not having continuity of care among nursing home staff to safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview and record review the facility failed to provide both facility-sponsored group activities individual activities that are designed to meet the residents' interests, and support the physical, mental, and psychosocial well-being of 4 out of 6 residents (Resident #2, Resident #3, Resident #4, and Resident #5) whose care was reviewed in the facility's secured unit. 1. The facility failed to post a designated activity calendar outlining the monthly activities for residents in the facility's secured unit and in each of the residents' designated rooms within the facility's secured unit. 2. The facility failed to ensure that a designated activity program was created and implemented in the facility's secured unit. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to determine and outline in the facility's, facility assessment, the necessary amount of emergency food and water necessary for their facility population during an emergency for 1 of 1 facility. 1. The facility failed to outline in their facility assessment, the amount of food and water necessary to maintain their resident population. These failures placed residents at risk of not having emergency water and food. Findings Included: Record Review of the facility's, facility assessment, no date indicated on the assessment, revealed the following sections: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that survey results were posted and, in a place, readily accessible to residents and visitors at the facility. The facility failed to ensure that survey results were posted and accessible for review on 07/15/24. This failure could impact the residents and visitors' ability to freely review the facility's outcome of regulatory compliance surveys without asking staff for survey results. Findings Included: Observation on 07/15/24 at 12:05 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility. Observation on 07/15/24 at 1:34 PM during rounds revealed no survey results binder or sign indicating location of results was posted anywhere in the facility. [...]

Inspectors wroteBased on interview, and record review, the facility failed to coordinate the assessment with the pre-admission screening and resident review (PASRR) program for one (Resident #10) of five resident assessments reviewed for PASRR evaluations. The facility did not correctly identify Resident #10 as having a mental illness diagnosis, failed to correct his PASARR Level One screen accurately to reflect the information, and failed to appropriately complete Form 1012, Mental Illness/Dementia Resident Review, in a timely manner to be signed by the attending physician for Resident #10. This failure could place residents with psychiatric diagnoses with Dementia as their primary diagnosis at risk for missed assessments, interventions and services.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #10) out of 6 residents reviewed for care plans. The facility failed to ensure that Resident #10's comprehensive care plan included his diagnosis of bipolar disorder. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs. Findings Included: Record Review of Resident #10's demographic sheet, dated 07/18/24, reflected he was a [AGE] year-old male, admitted to the facility originally on 5/4/07 and then re-admitted to the facility recently on 8/9/23. Resident #32's diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the facility residents received proper treatment and care to maintain mobility and good foot health for 2 (Resident #11 and Resident #12) of 5 residents reviewed for foot care services. 1. The facility failed to provide podiatry services to Residents #11 and #12. This failure could lead to increased potential negative outcomes related to foot health. Findings Included: Record Review of Resident #11's demographic sheet, dated 07/18/24, revealed he was a [AGE] year-old male with an initial admission date to the facility of 11/1/2023. Resident #11's active diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facilities. The facility failed to post the daily nursing staffing information on 07/15/24. This failure could affect residents, facility visitors, vendors and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: Observation on 07/15/24 at 11:05 AM during rounds revealed no posted nursing staffing information was anywhere in the facility. Observation on 07/15/24 at 1:34 PM during rounds revealed no posted nursing staffing information was anywhere in the facility. An interview on 07/15/24 at 2:45 PM with the ADON revealed that the DON was responsible for the scheduling and posting of the daily nursing staff information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure that food in the kitchen was labeled with the product name, dated with a opened date or use by date and sealed. The facility failed to ensure that kitchen equipment was clean and free of debris. These deficient practices could affect 69 residents who received meals and/or snacks from the main kitchen and place them at risk for food borne illness. Findings Included: Observation of the kitchen on 7/16/2024 at 2:30 PM, revealed that inside the refrigerator included: an open container of whipped topping that was on the shelf and it was not dated with an open date or use by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that take into account nonsmoking residents for one (Resident #15) of three residents reviewed for smoking. The facility failed to ensure Resident #15 had a smoking evaluation. This failure could place residents at risk for injury, burns, and an unsafe smoking environment. Findings Include: 1. Review of Resident #15's admission MDS assessment, dated 06/28/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognition was intact. Her diagnoses included high blood pressure, diabetes, and paraplegia (inability to voluntarily move the lower parts of the body). The resident did not use tobacco. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 1 (Residents #1) of 1 resident reviewed for injuries of unknown origin. The facility failed to report to the State Survey Agency on 05/10/24 when Resident #1's x-ray results reflected a fractured right knee, and the cause of the injury was unknown. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of infection for 5 (Residents #2, #3, #4, #5, and #6) of 12 residents reviewed for infection control. 1. On 04/30/24 MA A, CNA B, and CNA C brought Residents #2, #3, #4, #5, and #6 to the locked unit dining room and fed them and did not wash their hands nor the hands of the residents. 2. On 04/30/24 CNA B assisted Residents #2, #3, and #4 with their noon meals, he cut up their food and fed them and did not sanitize his hands. 3. On 04/30/24 CNA C touched the hand of Resident #5 and assisted him to his seat then touched his eating utensil without sanitizing her hands. 4. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 8 (Resident #2) residents reviewed for transfer and discharged rights. The facility failed to ensure Resident #2 was given a safe discharge on [DATE]. This deficient practice could place residents at risk of improper discharge or transfer.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis. This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #5, #14, and #62) of 7 residents reviewed for respiratory care, in that: The facility failed to: A.) Label and date the oxygen tubing and concentrator water bottle for Resident #5 and Resident #62. B) Label and date Resident # 14 oxygen tubing These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident #5 Record review of Resident #5 face sheet dated 1/24/24 reflected a [AGE] year-old female admitted on [DATE], diagnosis include Chronic Respiratory failure with Hypoxia (low oxygen). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents staff and the public for one (room [ROOM NUMBER]) of nine resident rooms reviewed for environment. The facility failed to ensure the AC/heating unit located in room [ROOM NUMBER] was clean. This failure could place residents at risk for diminished quality of life due to a lack of a well-kept environment and reduced air quality in the room.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 4 residents reviewed for discharge planning. The facility failed to develop a discharge plan for Resident #1 after he expressed his desire to return home on [DATE]. Resident #1 made his own arrangements and left the faciity on [DATE] with no documented discharge plan in place. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents fed by enteral feeding received the appropriate treatment and services to prevent complications of enteral feedings for 2 of 2 residents (Resident #1 and Resident #2) reviewed for gastrostomy tube management. The facility did not ensure Resident #1's and Resident #2's enteral feeding was infused as ordered by the physician. This failure could place 2 residents who had G-tube feedings at risk for dehydration, weight loss, and/or metabolic abnormalities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 (Residents #34, #14, #48, and #16) of 8 residents reviewed for assistive devices. The facility failed to ensure they had a plan to provide Residents #34, #14, #48, and #16, with emergency oxygen if they needed it in case of a power outage. An Immediate Jeopardy situation was identified on 08/30/23 at 4:15 PM. The IJ template was provided to the facility on [DATE] at 4:15 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse and neglect for one (Resident #39) of one resident reviewed for abuse. The facility failed to immediately report an incident of abuse to the State Survey Agency when on 07/11/23, Resident #39 made an allegation of CNA K spitting in his food. This failure could place residents in CNA K's care at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for 1 (Resident #39) of 1 resident reviewed for Abuse and Neglect in that: LVN J, CNA K and LVN L failed to report possible abuse to the Administrator when Resident #39 alleged CNA K spit in his food. Because the Administrator was not informed, the abuse allegation was not reported to the State Agency within two hours. This failure could place the residents at risk of abuse, neglect, exploitation and misappropriation of resident property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #34 and #16) of 8 residents reviewed for care plans. 1. The facility failed to ensure Resident #34 had a care plan for suctioning. 2. The facility failed to ensure Resident #16 had a care plan for oxygen use. 3. The facility failed to ensure Residents #34 and #16, who were using oxygen, had a comprehensive care plan identifying reasons for the oxygen and interventions to ensure the residents received the oxygen therapy they needed in case of a power outage. [...]