Warrenton Manor

Inspectors wroteBased on observation, interview and record review, facility staff failed to update the plan of care with changes in care needs for two residents (Resident #1 and Resident #2) out of three sampled residents. The facility census was 91.1. Review of the facility's Care Planning-Interdisciplinary Team policy, undated, showed the facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive plan of care for each resident. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/08/26, showed staff assessed the resident with moderate cognitive impairment, did not exhibit behaviors and did not reject care. Review of the resident's care plan, dated 03/02/26, showed the care plan did not contain direction for staff when resident rejects care. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Resident #8, #9, and #10) out of three sampled residents, who are dependent for activities of daily living received the necessary services to maintain personal hygiene. The facility census was 91.1. Review of the policies provided by the facility showed the facility did not provide a shower/bathing policy or grooming/hygiene policy. 2. Review of Resident #8's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/06/26, showed staff assessed the resident as: [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards of care when staff left narcotic pain medication unattended at one resident's (Resident #5) bedside and accessible to the resident's roommate. The facility census was 90.1. Review of the facility's Medication Administration policy, dated 02/07/13, showed after staff administer a medication to a resident, staff are to remain in the resident's room while the resident takes the medication. 2. Review of Resident #5's annual Minimal Data Set (MDS), a federally mandated assessment tool, dated 04/11/26, showed the resident's cognition intact, has almost constant pain, and received a scheduled pain medication in the last five days. Review of the resident's care plan, dated 02/28/26, showed the resident resists care which includes taking medications. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #3's medication Metformin (medication used to treat type two diabetes by lowering blood sugar levels) and Metorprolol Tartrate (a beta-blocker used to treat high blood pressure, chest pain and heart failure) to Resident #1. The facility census was 91.1. Review of the facility's Medication Administration policy, dated 02/07/13, showed medications are given to benefit a resident's health as ordered by the physician. Introduce yourself, call resident by name, and check picture identification in medication book. Review showed the policy did not contain documentation to direct staff on the five rights of medication administration.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to apply the appropriate Enhanced Barrier Precautions (EBP) during care for one resident (Resident #3) of three sampled residents with wounds and ensure Personal Protective Equipment (PPE) was in proximity of the resident room for three of three sampled residents with wounds (Resident #3, #2 and #11). The facility census was 91.1. Review of the facility's EBP to Infection Control Guidance, dated March 2024, showed:-EBP should be implemented for the period of the resident's stay or until wounds have resolved or indwelling medical devices have been removed;-EBP should be used with residents with an indwelling medical device including the following: [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report two separate allegations of resident-to-resident physical abuse involving one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe. The facility's census was 89.1. Review of the facility's Abuse Prevention Policy, dated 11/28/2016, showed physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete shiftily controlled drug counts with two staff members per facility policy to prevent misappropriation and assure correct controlled drug counts. The facility census was 92. The administrator was notified on 11/25/25 of past Non-Compliance which occurred on 10/25/25 when the administrator implemented new policies and procedures to ensure Certified Medication Technician (CMT) and nurses counted narcotics at the beginning and end of each shift with two staff members and documented on the Narcotic Count Form. Staff were in-serviced on 10/25/25 regarding counting narcotics at the beginning and end of each shift with two staff members and documented on the Narcotic Count Form.1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen tubing in a manner to prevent the spread of bacteria for two residents (Resident #14 and #15) out of three sampled residents. Facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for two residents (Resident #26, and #187) of two sampled residents. Facility staff failed to maintain proper infection control practices for two residents (Resident #26 and #187) out of two sampled residents with catheters. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity by not properly covering urinary catheter bags for two residents ( Resident #55, and Resident #187) out of 2 sampled residents. The facility census was 83. 1. Review of the facility's Resident Rights Policy, dated April 2006, showed: -Residents have a right to dignified existence; -Resients have a right to privacy and Respect. 2. Review of Resident #55's Quarterly Minimum Data Set (MDS), a federally mandated assessment too, dated 02/05/25, showed staff assessed the resident as follows: -Cognitively intact; -Indwelling catheter (tube inserted into the bladder to drain urine). Observation on 03/18/25 at 2:09 P.M., showed the resident in his/her room with the door open. His/Her catheter bag secured to the right leg below the knee containing urine in the a clear plastic bag. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for five residents (Resident #9, #15, #20, #34 and #53) out of twelve sampled residents. The facility's census was 83. 1. Review of the facility's Care Plan Comprehensive policy dated March, 2015 showed: -The interdisciplinary care plan team (IDT) with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for hospice services on two (Resident #53 and #187) of two sampled residents who receive hospice services, to obtain orders for an colostomy for one (Resident #187) out of one sampled residents, failed to document weekly skin assessments for three (Resident #15, #26, and #39) of four sampled residents. Facility failed to follow physician Liodcain Patch orders for one (Resident #11) of one resident. Faciliy failed to administer insulin appropriately for one (Resident #26) of four sampled residents. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a hospice policy. 2. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to provide assistance to maintain personal hygiene and grooming for eight (Resident #11, #34, #46, #51, #53, #55, #63, and #71) out of nine sampled dependent residents . The facility census was 83. 1. Review of the facility's Bath (Shower) policy, dated March 2015, showed the purpose of bathing was to maintain skin integrity, comfort and cleanliness. Review of the facility's Shaving the Resident policy, dated March 2015, showed the purpose of shaving was to remove facial hair and improve the resident's appearance and morale. Review of the facility's Nails, Care of (Fingers and Toes) policy, dated March 2015, showed the purpose was to provide cleanliness, prevent the spread of infection. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to support independence and interaction in the memory care unit. The facility census was 83. 1. Review of the policies provided by the facility showed the facility did not provide a policy for Activities. 2. Observation on 03/18/25 at 9:40 A.M., showed the Activity Calendar, dated March 2025, hung in the hallway of the memory care unit. The calendar showed the following: -03/18/25: 9:00 A.M., Catholic Services, 10:00 A.M., musical bingo and 2:00 P.M., horse racing; -03/19/25: 10:00 A.M., Hair dresser and 2:00 P.M., country store; -03/20/25: 10:00 A.M., Movie and snacks and 1:30 P.M., Bingo; -03/20/25: 9:00 A.M., Communion and 1:30 P.M., Music and groove. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide safe mechanical transfer for two residents (Resident #30, and #55). Facility staff failed to provided safe wheelchair propulsion for two residents(Resident #13, and #30). Facility staff failed to safely administer medication to one resident (Resident #51). Facility staff failed to lock medication carts when not in use and failed to store hazardous materials in a manner to prevent accidents. The facility census was 83. 1. Review of the facility's mechanical lift policy, dated March 2015, showed staff are directed to follow the manufacturer's instructions when using any type of mechanical lift and does not direct staff on holding onto the resident while suspended in the air. Review of the mechanical lift operating manual, dated 10/18/18, showed: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure four Nurse Aide's ((NA) NA H, NA I, NA J and NA K) out of fourteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The census was 83. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Newly Hired NA Audit Tool, showed NA H's hire date as 05/06/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of Newly Hired NA Audit Tool, showed NA I's hire date as 10/17/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 4. Review of Newly Hired NA Audit Tool, showed NA J's hire date as 09/06/24. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 83. 1. Review of the facility's policies showed staff did not provide a policy for Staffing and Scheduling Postings. 2. Observation on 03/18/25 at 10:49 A.M., showed staff did not post required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medication in a safe and effective manor in one medication storage room, and three medication storage carts. The facility census was 83. 1. Review of the facility's Medication, Storage Of policy, dated March 2015, showed: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy of destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 03/19/25 at 2:47 P.M., showed the 100 hall medication storage room contained: -One intravenous (IV) administration set with an expiration date of 02/19/25; -One bottle Vitamin B-6 100 milligram (mg) with an expiration date of 06/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control as the Infection Preventionist for the facility's infection prevention and control program. The census was 83. 1. Review of the facility's Infection Preventionist Control policy, undated, showed the IP will complete the Centers for Disease Control (CDC) Long Term Care IP module. Review of the current Infection Preventionist Certificate Of Completion, dated [DATE] showed: -4.0 credit hours; -Web training; -Covered introduction to infection control, transmission, prevention and control, hand hygiene, personal protective equipment, environmental controls, sharps and injection safety, occupational health and safety, and sepsis; -Expiration date of [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the activities program was directed by a qualified professional. The census was 83. 1. Review of the facility's Role of the Activity Director policy, dated March 2012, showed the policy does not contain direction or guidance for director certification requirements. During an interview on 3/21/25 at 10:54 A.M., the activity director said he/she was not certified and did not know he/she should be certified. He/She has been in the activity director role for a while. During an interview on 3/20/25 at 8:29 A.M., the Administrator said the activity director is not certified but is working on getting him/her scheduled. He/She was not aware until a couple of weeks ago the director was not certified and started working on getting scheduled for the class.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff failed to maintain the ice machine in a sanitary manner to prevent cross-contamination. Facility staff failed to maintain the kitchen equipment and surfaces in a sanitary manner to prevent the growth of bacteria and cross-contamination. Facility staff also failed to perform hand hygiene as often as necessary to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 84. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair and clean. The facility census was 84 with a capacity of 120. Review of the policies provided by the facility showed they did not have a policy for environment, maintenance repairs, and cleaning. 1. Observation on 04/15/24 at 10:01 A.M., showed occupied room [ROOM NUMBER] the wall above the bed with chipped paint. 2. Observation on 04/15/24 at 11:28 A.M., showed occupied room [ROOM NUMBER] walls with multiple large areas gouged. 3. Observation on 04/15/24 at 11:31 A.M., showed occupied room [ROOM NUMBER] with gouged dry wall and missing paint next to the first bed. 4. Observation on 04/15/24 at 11:35 A.M., showed occupied room [ROOM NUMBER] the walls with gouged dry wall and missing paint. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy for five (Residents #18, #19, #23, #340, and #355) of 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Bed Hold Guidelines, undated, showed: -The facility will notify all residents and/or their representative of the bed hold guidelines; -This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for seven residents (Residents #1, #241, #347, #363, #366, #368 and #376) of 22 sampled residents. The census was 84. 1. Review of the policies provided by the facility showed they did not contain a policy for MDS assessments. Review of the RAI manual 3.0 version 1.18.11, dated October 2023, the RAI-Omnibus Budget Reconciliation Act (OBRA) required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type; 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, had been completed no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual, manual used for guidance to complete assessments, for nine residents (Resident #4, #14, #19, #22, #30, #347, #363, #368, and #385) of 22 sampled residents. The facility census was 84. 1. Review of the facility policies provided did not contain a policy for MDS assessments. Review of the RAI manual 3.0 version 1.18.11, dated October 2023, the RAI-Omnibus Budget Reconciliation Act (OBRA) required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; [...]

Inspectors wroteBased on interview and record review, the facility failed to encode resident assessment data within seven days after a facility completed a resident's assessment and transmit the assessment timely for fourteen residents (Residents #1, #4, #14, #19, #30, #239, #241, #340, #363, #366, #368, #376, #383, and #385) of 22 sampled residents. The census was 84. 1. Review of the Minimum Data Set (MDS, a federal mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) user manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS completion date must be no later than 13 days after the entry date; -Encoding data: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #3, #18, #22, #33, #241, #340, and #376) out of 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed staff were directed as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure residents that were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to ensure residents remained clean, dry and free from odor for three residents (Residents #10, #18, and #347) and failed to provide hair care to two residents (Resident #376, and #383) of 22 sampled residents. The facility census was 84. 1. Review of facility's policy titled, Activities of Daily Living (ADL), dated March 2015, showed: -Purpose is to assist resident in achieving maximum function; -Gives step-by-step guidance with dressing residents. Review of the facility's policy titled, Shaving the Resident, dated March 2015, showed: -Purpose is to remove facial hair and improve the resident's appearance and morale; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to lock the medication and treatment carts, and failed to store medications and chemicals in a safe manner. The facility census was 84 with a capacity of 120. 1. Review of the facility's policy titled Storage of Medication, dated March 2015, showed staff were directed to: -All medications must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile carts; -All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely; -All poisonous substances and other hazardous compounds, such as sterilization solutions, irrigation solutions, antiseptics, diagnostic agents, etc must be kept in a locked container; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a medication error rate less than five percent (%) out of 29 opportunities observed, six errors occurred which resulted in a 20.7% error rate which effected four residents (Resident #15, #18, #23, and #347) of the six sampled residents. The facility census was 84. 1. Review of the facility's policy titled Medications, Errors and Drug Reactions, dated March 2015, showed staff were directed to: -Report all medication errors and drug reactions immediately to the physician, Director of Nursing (DON), and administrator; -Provide emergency care to the resident; -Follow physician's orders; -Complete event report; -Chart in the resident's clinical record. Review of the manufacturer's recommendations for Kwik-Pens (ightweight pen that's prefilled with insulin), dated 10/18/15, showed staff were directed to: [...]

Inspectors wroteBased on observation, record review, and interview the facility staff failed to count narcotic medications each shift for three of three medication cart, failed to reconcile one resident's (Resident #242) liquid lorazepam (narcotic antianxiety medication) of 84 sampled residents, failed to separate treatments in one treatment cart of one sampled cart, failed to date medications when opened for ten residents (Resident #238, #240, #18, #351, #21, #27, #348, #345, #350) out of 84 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Narcotic Count, dated March 2015, showed staff were directed to: -Complete a physical inventory of narcotics at each shift change to identify discrepancies; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infections when staff failed to perform hand hygiene in a manner to reduce the spread of infection for four residents (Resident #15, #18, #23, and #347) of four sampled residents, and failed to disinfect a multi-use glucometer (a medical device for determining the approximate concentration of glucose in the blood) between two residents (Resident #15, and #23) of two sampled residents. The facility census was 84. 1. Review of the facility's policy titled, Blood Glucose Monitoring, dated March 2015, showed staff were directed to: -Place the equipment on a clean surface such as a clean towel; -Put on gloves; -Obtain blood sugar; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity by leaving one resident (Resident #12) exposed to the hallway and failing to properly cover a urinary drainage bag for one resident (Residents #355) of 22 Sampled residents. The facility census was 84. 1. Review of the facilities policies showed the policies did not contain a policy for dignity. 2. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/28/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required maximal assistance from staff for dressing, personal hygiene and bed mobility; -Dependent on staff for transfers. Review of the resident's care plan, dated 04/15/24, showed staff documented the resident with impulsive behaviors and impaired decision making due to cognitive deficits. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for three residents (Resident #33, #36, and #383) out 22 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Care Plan, Temporary, dated March 2015, showed: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) process. 2. [...]

Inspectors wroteBased on interview and record review, facility failed to ensure two Nurse Aides ((NA) NA DD and NA P) of three sampled staff completed the nurse aide training program within four months of employment in the facility. The facility census was 84. 1. Review of the facilities policies did not contain a policy for NA training or qualifications. Review of NA DD's personnel file showed a hire date of 05/18/23. The file did not contain documentation NA DD completed the nurse aide training program. Review of NA P's personnel file showed a hire date of 08/28/23. The file did not contain documentation NA P completed the nurse aide training program. Review of the facility's payroll, dated April 2024, showed NA DD and NA P worked at the facility as NA's. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident (Resident #1's) out of six sampled residents family and physician of a fall which resulted in an injury. The facility census was 81. 1. Review of the facility's physician notification, unknown date, showed the facility will immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is an accident which resulted in injury to the resident and has the potential in requiring physician intervention. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/9/24, showed diagnoses of Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors), pain, and insomnia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure menus were followed when staff did not prepare all food items as directed by the recipe. The facility census was 65. 1. Review of facility's Food Preparation and Distribution policy date April 2011 showed recipes should be followed on each item prepared. Review of the Philly cheese steak sandwich recipe showed ingredients for 100 servings as follows: -12 pounds plus eight ounces of Philly beef steak -Seven pounds plus four ounce of sliced onions -Six pounds plus four ounces of sliced American cheese Observation on 12/29/2022 at 2:40 P.M., showed [NAME] N added a two pound bag of chopped green peppers to a pan of cooked beef steak. He/She poured an unmeasured amount of Mozzarella cheese from two previously opened bags into the pan of beef and stirred. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain correct dishwasher water temperatures and follow proper procedures for ware washing in the three compartment sink. This failure had the potential to affect all residents. The census was 65. 1. Review of the facility's Dish machine Temperature policy dated April 2011 showed: -Actual wash and rinse temperatures must be observed and logged at the beginning of the dishwashing period by the dish machine operator; -Report temperatures that are below the required levels to the Dietary Services manager immediately. Review of the dishwasher general operating instructions wall poster in the dishwashing area showed: -It is recommended that 140 degree water be used; -Report to your supervisor if it is lower than 120 degrees F or higher than 160 degrees. Review of the dishwasher daily start up procedures showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed to maintain the lids to cover the outdoor dumpster in good repair. The facility census was 65. 1. Observation on 12/29/22 at 8:00 A.M., showed trash bags stacked inside the outdoor dumpster high above the top of the dumpster. Further observation showed the two lids to cover the dumpster pushed inside of the dumpster and the bottom half of each lid missing due to breakage. During an interview on 12/29/22 at 8:00 A.M., the maintenance director said the dumpster lids had been broken for a while. The Maintenance Director said he/she called the trash company about two weeks ago and asked them for a new dumpster and they said they would not provide one. [...]

Inspectors wroteBased on interview and record review facility staff failed to ensure the Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) (CMS-10055) was completed for three residents (Resident #265, #41, and #269). The facility census was 65. 1. Review of the facility policies showed the facility did not provide a policy addressing Advanced Beneficiary Notices. 2. Review of Resident #265's SNFABN review form completed by the facility showed the facility documented: - Medicare part A skilled services started 10/26/22; - Last covered day of part A service was 11/17/22; - The resident did not document a payment option before the CMS-10055 was signed. 3. Review of Resident #41's SNFABN review form completed by the facility showed the facility documented: - Medicare part A skilled services started 9/6/22; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to ensure four residents (Residents #4, #50, #264 and #269) who required staff assistance were provided with adequate assistance to maintain good grooming and hygiene. The facility census was 65. 1. Review of the Facility's shower policy, dated March 2015, showed staff were directed as follows: -Purpose is to maintain skin integrity, comfort and cleanliness; -Encourage the resident to do as much as possible; -Wash face and entire body, shampoo hair and rinse well; -Dry the resident well; -Dress the resident and dry hair well, comb and style hair. 2. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/04/2022 showed staff assessed the resident as follows: -Moderate cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide safe mechanical lift transfers for three residents (Residents #7, #12 and #47) in a manner to prevent accidents. The facility staff also failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents. The facility census was 65. 1. Review of the Invacare Reliant 600 Heavy-Duty Power Lift instruction guide, dated 2018, showed the guide instructed operators of the lift that the legs must be kept in the maximum open position for stability and safety. Review showed if it is necessary to close the legs of the lift to maneuver the lift under a bed, the guide instructed operators to close the legs only as long as it takes to position the lift over the patient, then return the legs to the maximum open position. [...]

Inspectors wroteBased on interview, and record review the facility staff failed to communicate pharmacy recommendations to the physicians for four residents (Resident #3, #11, #37, and #41) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 65. 1. Review of the facility's Drug Review policy, dated March 2015, showed: -All medications given to each resident will be reviewed on a monthly basis in order to insure adherence to stop orders; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with physician; -Determine the most acceptable time frame to attempt reduction of drug dosage from behavior evaluation. Review of the facility's Physician Services policy, dated March 2015, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure that as needed (PRN) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) orders were limited to 14 days unless a specific duration and clinical rationale were provided for one resident (Resident #37) and failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for two residents (Resident #11 and #57). The facility census was 28. 1. Review of the facility's Drug Review policy, dated March 2015, showed: -All medications given to each resident will be reviewed on a monthly basis in order to insure adherence to stop orders; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage carts. The facility census was 65. 1. Review of the facility's Medication Storage Policy, dated March 2015, showed staff are directed as follows: -No discontinued, outdated, or deteriorated drugs and biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. Observation on 12/29/22 at 9:00 A.M., showed the 100 hall medication cart contained: -One Meclizine 25 mg tablet pack with 26 tablets remaining with an expiration date of 8/5/22; -One loose white tablet with 66/422 stamped on it; -One Zinc 50 mg bottle with and expiration date of 6/22; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per policy for five out of ten sampled employees (Dietary Aide S, Registered Nurse T, Licensed Practical Nurse U, Housekeeper V, and Certified Nurse Assistant P). The facility census was 65. 1. Review of the facility's Tuberculosis Control Policy, undated, showed: -Recommendations for employees: --Initial examination: provide a tuberculin skin test (Mantoux, five tuberculin units (TU) of PPD to all employees during pre-employment procedures, unless a previous reaction greater than 10 millimeters (mm) is documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed upon discharge for one sampled resident (Resident #61) out of three sampled closed records. The facility census was 65. 1. Record review of the facility's Discharge Planning policy dated April 2006 showed: -The Social Service Department will have primary responsibility for discharge planning within the facility; -The discharge summary will include the events leading to admission, the diagnosis, prognosis, treatment and adjustment of the resident, and plans at discharge. Review of Resident #61's Face Sheet showed the resident was admitted to the facility on [DATE] with a diagnosis of profound intellectual disabilities and was discharged on 10/03/2022. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 65. 1. Review of the facility policies showed staff did not provide a policy for nurse staff posting. Review of the facility's records showed the record did not contain nurse staff posting for the required 18 months. Observation on 12/27/22 at 10:48 A.M., showed the nurse staff posting was not visible in the facility. Observation on 12/28/22 at 9:19 A.M., showed the nurse staff posting was not visible in the facility. [...]