Waters Edge Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility did not ensure a resident-to-resident altercation was thoroughly investigated for 1 (R2) of 1 resident-to-resident altercation reviewed. On 5/21/2026, R2 was involved in a resident-to-resident altercation. The Facility did not interview all staff that were present on the unit at the time of the incident.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R2) of 4 sampled residents. On 5/21/2026, R2 was involved in a resident-to-resident altercation. The facility did not provide adequate supervision to prevent the resident-to-resident altercation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from verbal, physical, and sexual abuse between residents residing on the facility's dementia unit. This deficient practice had the potential to affect all 30 residents residing on the facility's dementia unit.12 different allegations/incident of resident to resident abuse were identified during the survey. Facility records indicate R89 has a history of inappropriate sexual behavior. Additionally, a care plan indicated R89 has behavior problems of yelling, grabbing, displaying loving affection towards females, refusing cares, and combative. The facility had an awareness of R89's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring. [...]

Inspectors wroteBased on interview and record review, the facility did not timely report and thoroughly investigate allegations of abuse (sexual, physical, and verbal) and did not take proactive steps to prevent further potential abuse. This has the potential to affect all 30 residents on the dementia unit. The facility did not ensure that residents on the unit were protected while the investigation should have been in progress. R89 has a history at the facility of resident-to-resident incidents including punching residents and yelling and swearing at other residents. In addition, R89 has grabbed arms, kicking and punched and hit staff in the face during cares. Supervision for R89 was only increased at time of incidents but then was not continued to prevent further incidents. [...]

Inspectors wroteBased on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administration was not promoting the highest practicable mental and psychosocial well-being of residents by failing to implement procedures based on the facility Abuse, Neglect, and Exploitation policy and procedure last revised 7/12/25. Multiple staff were aware R89 and R106 were unpredictable. R89 had multiple resident-to-resident altercations, as well as punching staff in the face and was sexually inappropriate to staff and residents. Staff informed administration of R89's physical aggression and sexual behaviors to administration. Staff warned administration that R106 was escalating in behaviors towards R121. [...]

Inspectors wroteBased on interview and record review the Facility did not provide appropriate treatment and services for 1 (R89) of 1 resident with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R89 has a diagnosis of Unspecified Dementia, Unspecified Severity with Agitation, Depression, Anxiety Disorder and Visual Hallucinations. On 6/4/25, R89 triggered on the trauma assessment as having experienced physical assault, however, there is no care plan with person centered interventions for staff to work with R89. There was no comprehensive assessment with individualized interventions of R89's behaviors, the facility did not assess the behavior change to identify the root/cause of R89's behavior. The facility did not complete a dementia assessment. [...]

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 1 (R106) of 1 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.*R106 was not provided medically related social services to address the emotional distress R106 was expressing that affected R106's mental and psychosocial well-being, resulting in R106 left the facility Against Medical Advice(AMA) without medically needed medications. Findings Include:The facility's Facility assessment dated [DATE] documents that the facility can provide person-centered/directed care: psycho/social/spiritual support including mental health and behavior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an effective pest control program to address the flies in the facility.*) R13 informed Surveyor that the facility has a problem with flies and has a fly swatter by the bed to keep flies away. Surveyor observed flies by R13's bedroom window.*) R26 had flies in R26's room during an interview with Surveyor and were landing on R26's hat.*) R75 informed that the flies in the facility are bad, especially when food is out.*) R107 informed Surveyor that flies are around in the room and hallways especially when food is not picked up right away or garbage's are not emptied.*) Surveyors observed flies in resident rooms, resident unit hallways, and hallway by the facility kitchen. This deficient practice has the potential to affect all 103 of 103 resident residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure privacy and confidentiality for 12 of 20 residents. On 9/24/25, at 12:46 PM, R112's person health information was observed unprotected on an unattended medication cart computer screen, in the hall in view of anyone walking in the hallway. On 9/23/25, at 1:30 PM, Surveyor observed, from the hallway, Licensed Practical Nurse (LPN)-KK move R45's gown up, check R45's enteral feeding tube's placement, flush the tube and administer medication via the enteral tube. R45's room door was not closed. On 9/25/25, at 11:19 AM, Surveyor observed on top of the 2 South medication cart is a 2 South sheet with approximately eleven resident's names with personal information such as their blood pressure, vital signs, types of liquids received, seizure monitoring, fall risk, no male care givers, etc. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. This had the potential to affect all 103 Residents residing in the facility at the time of the survey.*) R13 informed Surveyor that R13's room does not get cleaned daily and that the garbage is not always emptied causing odors in the bedroom.*) R107 informed Surveyor that R107's room does not get cleaned every day per policy and that the garbage do not get emptied. R107 had a dry yellow spot on the top sheet of R107's bed and a urine odor was noted and R107's garbage was full.*) Surveyor reviewed grievances from May 2025 - August 2025 and noted 11 total grievances regarding bedrooms not being cleaned.

Inspectors wroteBased on record review and staff interviews, the facility did not report allegations of abuse to the State Survey Agency. Residents (R110, R89, R26, R106, R121, R122, R39, R69, and R116) were identified in 8 allegations of abuse and/or resident-to-resident altercations. Although reported to NHA-A (Nursing Home Administrator), the incidents were not reported immediately to the State Survey Agency. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure last reviewed/revised 7/12/25 documents: .Definitions: 'Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 7 (R11, R1, R3, R9, R120, R41, and R90) of 7 residents reviewed were notified of the reason for transfer/discharge and bed hold policy in writing to the resident and/or their representative. Residents were not notified of the rate to reserve the resident's bed because it was not documented in the transfer and bed hold notice. The transfer and bed hold notice did not document the email address for the The State Survey Agency and for the Long Term Care Ombudsman. The transfer and bed hold notice also did not contain documentation of the name , address(mail and email) and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders. The ombudsman was not notified of the transfer/discharge. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 12 (R60, R11, R41 and R90) residents reviewed for falls. R60 had a fall from bed while staff was providing cares which resulted in a laceration requiring sutures. The care plan was not revised with recommended interventions and staff were not educated following the fall. R11 had multiple falls. Observations found fall precaution interventions were not implemented and the facility did not complete thorough investigations of his falls. Following the falls, there was no evidence of an RN assessment. R41 had 6 falls while residing in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 4 of 4 medication carts observed effecting a pattern of residents residing in the facility. *On [DATE] at 12:01 p.m. during the medication administration task Surveyor observed R129's Novolin R insulin pen was not dated when opened. *On [DATE], at 11:33 a.m., Surveyor observed in the front 2 South medication cart in the top drawer a bottle of artificial tears lubricant eye drops for R2 not dated when opened. *On [DATE], at 11:49 a.m., in the top drawer left section of the 1 North back medication cart Surveyor observed approximately 33 small pink pills laying in the drawer. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 6 (R80, R71, R45, R129, R11, & R90) of 6 Residents. *Appropriate hand hygiene was not observed during medication administration for R80 & R71. *Staff did not wear appropriate Personal Protective Equipment (PPE) when administering medication via a G (gastrostomy) tube to R80 & R45 who are on Enhanced Barrier Precautions (EBP). *The glucometer was not disinfected after R129's blood sugar was obtained. *Staff did not wear appropriate PPE during personal cares and tube feeding procedures for R11 who is on enhanced barrier precautions. *R90's Foley catheter drainage bag was observed on the floor and without any barrier to prevent contamination.

Inspectors wroteBased on interview and record review the facility failed to ensure staff did not engage in misappropriation of 1 (R9) of 1 resident's reviewed for misappropriation of property.*R9's cell phone was reported to be missing on 9/15/2025. Through investigation it was determined there was a misappropriation of property when housekeeper-PP took R9's personal cell phone on 8/21/2025 while R9 was hospitalized without R9's consent.

Inspectors wroteBased on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R11) of 1 Resident reviewed with PASARR level 2 recommendations. *R11's PASARR dated 7/28/25 determination states R11 requires intensive, continuous treatment program called specialized services to address R11's intellectual/developmental disability or mental illness. Findings Include:The facility's Specialized Rehabilitative Services revised 11/11/24 documents:.The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. [...]

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure 2 of 20 sampled residents' plan of care contained accurate information to implement interventions. * R90 was observed with an air mattress on their bed and a blue mat on their floor. R90 plan of car for a pressure injury did not include an air mattress. R90 plan of care for falls did not indicate when, and where, to use a blue mat. *R11 Guardian directed them to have pleasure feedings. This intervention was not documented on R11 comprehensive plan of cares. The facility's policy and procedure titled Care Plan Revisions Upon Status Change dated 5/12/2025. The purpose of this policy is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and assistance with repositioning for 1 of 2 (R60) residents reviewed for ADL's (Activity of Daily Living). R60 was not provided assistance to reposition as she requested until Surveyor intervened and asked staff to assist the resident.

Inspectors wroteBased on interview and record review the facility did not ensure its procedures for indicating a residents' code status was followed for 1 (R11) of 20 residents sampled. R11 did not have a current physician order for R11's code status. Findings Include:The facility's policy and procedure Communication of Code Status revised 4/1/25 documents: .Explanation and Compliance Guidelines:2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record.4. The designated sections of the medical record are: physician orders obtained per election form and uploaded signed election form. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R101, R131 and R50) of 3 resident received necessary care and treatment. On 8/25/25, R101 had signs and symptoms of a urinary tract infection (UTI) and an order for a urinalysis with culture and sensitivity was obtained. The urine sample was not processed. On 9/4/25, R101 had an order for a wound culture and the specimen was obtained and not stored properly. Another specimen was not obtained until 9/9/25 delaying treatment to an infected wound R131 was admitted to the facility on [DATE] with surgical wounds to the left leg. A comprehensive wound assessment was not completed until 8/13/2025. R131 did not have monitoring or treatments to the left leg surgical wounds until 8/12/2025. On 9/24/25 R50 was observed to have pericare performed and 2 incontinent briefs were placed on R50.

Inspectors wroteBased on interview and record review, the facility did not ensure that resident with pressure injury received necessary treatment and services consistent with professional standards of practice for 3 (R7, R50, and R131) of 8 residents reviewed for pressure injuries. R7 developed a blister to the thumb that declined to a stage 3 pressure injury from R7's palm guard. There were no interventions in place prior to R7 developing the stage 3 pressure injury and the interventions put in place after development were not clear as to what needed to be in place for R7. R50's pressure injury was not staged correctly on admission; a treatment was not put in place for 3 days after admission. On 7/2/25, R50's pressure injury doubled in size. R50's treatment and care plan were not revised after R7's pressure injury worsened. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R49) of 1 resident receiving oxygen had the prescribed oxygen setting. On 9/22/25 and 9/23/25, Surveyor observed R49 with a nasal cannula and oxygen flowing at 4 liters per minute. The physician orders document oxygen 2 liters per minute.

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 (R3) of 1 resident reviewed for Dialysis received Dialysis care in accordance with professional standards of practice.*R3 did not have a MD (Medical Doctor) order for dialysis and for monitoring R57's Arterio-Venous (AV) Fistula for bruit (the regular, whooshing sound made by blood flowing through a dialysis fistula or graft) or thrill (the vibration felt over an arteriovenous fistula or graft) from 5/21/25 through 9/24/25.

Inspectors wroteBased on interview and record review the facility did not ensure that irregularities noted by the pharmacist during the Medication Regimen Review (MRR) were sent to the attending physician to include at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified for 2 of 5 (R11 and R60) residents reviewed for unnecessary medications. R11's pharmacy MRR recommendations for July and September 2025 were not acted upon by the facility or physician. R60's pharmacy MRR recommendations for August 2025 were not acted upon by the facility or physician.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 25 opportunities which resulted in a medication error rate of 8%. Two medication errors were identified for R71. R71 Pantoprazole Sodium 20 mg was not available to be administered and after receiving Advair inhaler, LPN-MM did not have R71 rinse & spit.

Inspectors wroteBased on interview and record review, the facility did not ensure therapy services were provided in a timely manner for 2 (R11 and R50) of 2 residents reviewed for therapy services. *R11 has a MD order to start therapy services initiated on 9/11/25. R11 did not have a therapy evaluation until 9/22/25. *R50 was admitted to the facility on [DATE]. On 6/20/25, R50's MD documented that R50 should have a Physical (PT) and Occupational therapy (OT) evaluation and treatment. R50 was not evaluated and treated by PT and OT until 7/11/25.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R12) of 5 residents were offered/administered the pneumonia vaccine and/or influenza vaccine. R12 was admitted to the facility on [DATE] and was not offered or administered the influenza vaccine.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R9, R11, R12) of 5 residents reviewed for immunizations. R9's Electronic Medical Record (EMR) does not contain any documentation as to whether R9 was offered, received, or declined the COVID-19 immunization. R11's EMR does not contain any documentation as to whether R11 was offered, received, or declined the COVID-19 immunization. R12's EMR does not contain any documentation as to whether R12 was offered, received, or declined the COVID-19 immunization.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to have sufficient nursing staff with the competencies and skills sets to ensure one (Resident (R)7) out of a total sample of 15 residents, had the correct ordered amount of insulin administered. This had the potential for the resident to have a decreased blood glucose level and potential complications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a significant medication error did not occur when the physician's orders were not followed during administration of insulin for one (Resident (R)7) of three sampled residents related to insulin administration out of a total sample of 15 residents. This had the potential for the resident to have an adverse reaction to the incorrect amount of insulin administered.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to wear a gown for a resident on Enhanced Barrier Precautions (EBP) for one of two residents (Resident (R) 3) observed for wound care in the sample of six residents. The deficient practice increased the risk for cross contamination and infections.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sufficient supply of clean linen was readily available for resident care for three of four linen closets on two of two floors observed. This had the potential for the residents to have unmet personal care needs.

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to ensure a safe environment for one of nine residents (Resident (R) 1) reviewed for accidents. R1 fell from his bed and onto the floor while a staff member (Certified Nursing Assistant (CNA1) was providing his routine care. This failure caused R1 to experience significant injuries related to the fall, including a broken hip and a large laceration to his forehead requiring nine staples.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R2) of 2 Facility Self Report investigations was reported to the State Agency as required. On 7/21/24 R2's family member expressed concerns related to incontinence care on 7/19/24. On 8/5/24 R2's family member expressed additional concerns related to all cares for the same date of 7/19/24. The facility did not submit the facility investigation within 5 days of the initial report to the state agency. The 5 day investigation was submitted on 8/21/24 instead of within 5 working days after the allegation.

Inspectors wroteThe facility did not ensure a charge nurse was assigned for each shift. This had the potential to affect all 95 residents that reside in the building.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 13 (R37, R67, R29, R86, R18, R59, R73, R88, R71, R36, R24, R547, and R548) of 13 residents on a pureed diet. The [NAME] did not follow a recipe for preparing texture and modified consistency diet for pureed food.

Inspectors wroteBased on observation and interview, the facility did not ensure residents had bed linens in good condition that properly fit the bed for 1 (R23) of 19 residents reviewed in the sample. *R23 did not have a bottom sheet on the bed that covered the whole bed with 2 observations.

Inspectors wroteBased on interview and record review the facility did not complete a significant change in status assessment MDS (Minimum Data Set) for 1 (R59) of 2 residents reviewed for significant change. R59 elected to receive hospice services on 06/28/2024. The facility did not complete a Significant Change MDS when R59 was enrolled into hospice care.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure 1 (R84) of 1 Resident reviewed for having received proper treatment and assistive device to maintain R84's hearing abilities. Findings Include: R84 was admitted to the facility on [DATE] with a primary diagnosis of Dementia. R84's admission Minimum Data Set (MDS), dated [DATE], documents R84 has adequate hearing and does not use hearing aids. R84 has an active guardian in place. On 07/29/24, at 11:03 AM, Surveyor interviewed R84. Surveyor had a very difficult time speaking with R84 due to R84's hearing difficulties. Surveyor noted R84 did not have hearing aids. Surveyor reviewed R84's Electronic Health Record and noted an order for R84 to have an Audiology consult regarding hearing aids dated 01/17/2024. Surveyor noted the order was not documented as completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 1 (R61) of 9 residents reviewed with pressure injuries. R61 was noted to have developed two blisters on R61's left hand after staff removed R61's hand splint. R61's comprehensive care plan did not include interventions for the use of hand splints and R61's treatment administration record (TAR) was not revised after R61 developed blisters to left hand to include documentation of when the hand splint and/or palm guard should be applied.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure 1(R36) out of 1 residents reviewed with limited range of motion received appropriate treatment and equipment to increase range of motion and/or to prevent further decrease in range of motion. *R36 was observed not wearing a splint used to improve range of motion per R36's plan of care.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a resident was supervised with meals to prevent choking. This was observed with 1 (R37) of 1 residents requiring supervision with eating meals. R37 requires supervision with eating to prevent choking. R37 was observed eating on their own without supervision.

Inspectors wroteBased on observation and record review the facility did not ensure that residents with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for 1 (R63) of 5 residents reviewed for catheter care. Surveyor observed staff perform catheter cares for R63 that were not consistent with standards of practice for indwelling catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who were fed by enteral means received the appropriate services to prevent complications of enteral feeding for 2 (R23 and R36) of 4 residents reviewed for enteral feeding. *R23 had enteral feeding orders for seven times a day that were transcribed as five times a day in the medical record resulting in weight loss. R23 had multiple formulas on one order with each formula having a different number of administration times affecting the amount of free water that would be administered with no documentation as to which formula was provided and no communication with the Registered Dietician (RD) as to what formula and free water was provided to R23. *R36 had orders for enteral feeding and free water flushes. The orders did not correlate with the RD's documentation of what R36 was being provided.

Inspectors wroteBased on record review and interview, the facility did not ensure assessments accurately reflected residents' status for 5 (R37, R7, R60, R48, and R41) of 5 reviewed for Preadmission Screening and Resident Review (PASRR). *R37, R7, R60, R48, and R41 had PASRR Level I and Level II completed, and that information was not entered correctly into the Minimum Data Set (MDS) comprehensive assessment.

Inspectors wrote2.) R9 was admitted to the facility on [DATE] and has diagnoses that include open wound of lower back and pelvis, Type 2 diabetes mellitus, chronic obstructive pulmonary disease, neuropathy, anemia, chronic kidney disease stage 3, major depressive disorder, muscle weakness, and squamous cell carcinoma of the skin with removal of masses in sacral area. R9's admission minimum data set (MDS) dated [DATE] indicated R9 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R9 needing moderate assist with 1 staff member for toileting and personal hygiene. R9 was assessed to have a surgical wound and stage 2 pressure injury on admission and was at mild risk for pressure injuries with a Braden score of 17 on 12/14/2023. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 1 (R9) of 3 residents reviewed received appropriate services related to catheter care and/or fecal incontinence with constipation to prevent urinary tract infections and to restore normal bowel function as possible. R9 had a Foley catheter placed and did not have a comprehensive care plan or orders for care or monitoring of the Foley catheter. R9 developed 2 urinary tract infections. R9 was assessed as being incontinent of bowel on admission and had concerns with constipation and loose stools. R9 did not have a comprehensive care plan for bowels and did not have monitoring or a toileting program to maintain continence and R9 became incontinent of bowel.

Inspectors wroteBased on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly and did not to demonstrate their response and rationale for such requests. The grievance log generated from Resident Council Meetings does not identify the name of the resident filing the grievance, grievance details, how the grievances were investigated, or the outcome of each grievance investigation. This has the potential to affect all 98 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility did not provide notice of resident rights and services prior to or upon admission for 40 (R2, R18, R19, R20, R21, R12, R22, R23, R24, R25, R11, R26, R27, R28, R29, R30, R16, R31, R32, R33, R34, R35, R10, R36, R37, R38, R39, R40, R41, R5, R42, R43, R44, R45, R46, R47, R48, R49, R50, R1) of 40 residents reviewed. *R2 was admitted to the facility on [DATE] and was handed a facility admission agreement packet to sign on [DATE]. R2 does not currently have a signed admission agreement on file for the facility. *R18, R19, R20, R21, R12, R22, R23, R24, R25, R11, R26, R27, R28, R29, R30, R16, R31, R32,R33, R34, R35, R10, R36, R37, R38, R39, R40, R41, R5, R42, R43, R44, R45, R46, R47, R48, R49, and R50 did not have signed admission agreements when they were admitted to the facility. *R1 was admitted to the facility [DATE]. [...]

Inspectors wroteBased on interview and record review the facility did not report 3 of 4 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. This has the potential to affect R6, R12, R13, R14, R15, R10, & R11. R6's sexual abuse allegation was not reported to Nursing Home Administrator-A & State agency immediately but not later than 2 hours after the allegation is made. The allegation of possible drug diversion was not reported to the Nursing Home Administrator and State agency within 24 hours for R12, R13, R14, R15, & R11. R11's allegation of misappropriation was not reported to the State agency within 24 hours.

Inspectors wroteBased on observation and staff interview, this facility did not ensure that confidential medical records were safeguarded against loss, destruction, or unauthorized use. This has the potential to affect up to 30 current residents at this facility. The confidential medical records are not stored in a secure manner to prevent unauthorized access.

Inspectors wroteBased on interview and record review the facility did not ensure that R7 & R16, a married couple, have the right to share a room together after both consented. R7 & R16 informed Surveyor they wanted to live in the same room but this was not being allowed by the facility.

Inspectors wroteBased on interview and record review the Facility did not notify the state mental health authority promptly after a significant change in 1 (R6) of 1 Residents mental illness. R6 was diagnosed with bipolar disorder on 2/22/24 and started receiving Depakote Delayed Release Sprinkles 250 mg (milligrams) twice a day on 2/23/24. The Facility did not submit a level 1 PASARR (Preadmission Screening and Resident Review) until 5/13/24 and the level 1 did not include the bipolar disease diagnosis or Depakote.

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary ADL (Activities of Daily Living) services for 1 (R4) of 4 residents who were dependent on staff to provide ADL care. R4 was observed with long nails pressing into the palms of her hands due to bilateral hand contractures. R4's care plan indicated her nails should be kept short to prevent injury.

Inspectors wroteBased on interview and record review the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices was provided for 2 (R3 & R9) of 9 Residents. R3 was admitted to the facility on [DATE] with a right diabetic foot ulcer and a left below knee amputation surgical incision. Treatments for these areas were not started until 1/19/24, 3 days later. R3's blood pressure, heart rate, and fluids were not monitored according to physician orders. R9's sacrum surgical wound with a wound vac was not comprehensively assessed until 5 days after admission on [DATE] when the wound doctor assessed R9's sacrum surgical wound.

Inspectors wroteBased on observation, interview, and record review the facility did not have identified safety devices/supervision in place for preventing falls/accidents or incidents requiring increased supervision for 2 (R4 and R6) of 2 residents reviewed for safety/supervision. * R4 was observed to be left unattended in bed, with the floor mats not in place to both sides of her bed per her plan of care. * R6 exhibited agitated and sexually inappropriate behavior and was not supervised closely enough to prevent future inappropriate behaviors.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R10 & R3) of 2 residents reviewed for nutrition maintained acceptable parameters of nutritional status. *R10's weights were not obtained per facility guidelines. No weights were obtained in November 2023 or April 2024. *R3 should have been weighed on 1/16/24, 1/17/24, 1/18/24 and one time during the week of 1/21/24 to 1/27/24. Upon return to the facility on 2/13/24, R3 should have been weighed on 2/13/24, 2/14/24, 2/15/24 and during the week of 2/18/24 to 2/24/24. No weights were obtained on those dates. Findings Include: Surveyor reviewed the Weight Monitoring policy and procedure dated 4/10/24 documents: Policy: [...]

Inspectors wroteBased on observation, record review, interview, the facility did not ensure 1 (R4) of 2 residents reviewed had their oxygen administered according to physician's orders. * R4 was observed to have her oxygen administered at 6 liters per minute and her orders were to have her oxygen at 1-5 liters per minute according to her oxygen saturation levels.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the physician was notified with a need to alter treatment of a pressure ulcer for one of two residents (Resident (R9) reviewed for pressure injuries. The facility's failure to notify the physician with a need to alter treatment had the potential to impede healing of a pressure ulcer.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 8) reviewed for abuse were free from physical abuse. The failure to ensure a resident was free from resident-to-resident abuse could have resulted in the potential for harm when R7 struck R8 in the back of the head and left chest.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the discharge planning process was following which included notifying the resident's Physician or Nurse Practitioner (NP) and APS (Adult Protective Services) when residents left Against Medical Advice (AMA) per the facility's policy for three of three residents (Residents (R) 6, R1, and R10) reviewed for discharge out of 16 sampled residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the ordered non-pressure wound treatment was provided to one of three residents (Resident (R) 2) reviewed for non-pressure wounds of 16 sample residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the ordered pressure ulcer treatment was provided to one of two residents (Resident (R9) reviewed for pressure injuries of 16 sampled residents.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure call lights were within reach for 2 Residents (R) (R1 and R4) of 17 residents reviewed. R1 and R4 were observed on multiple occasions without a call light within reach.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure specialized services were incorporated into the plan of care for 1 Resident (R) (R1) of 1 sampled resident. The facility identified R1's intellectual disability through a diagnosis of cerebral palsy and submitted a Pre-admission Screening and Resident Review (PASRR) Level II. After specialized services were obtained, R1's plan of care was not assessed and specialized services were not incorporated into R1's transition of care.

Inspectors wroteBased on staff interview, and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R1) of 6 sampled residents. R1 was admitted to the facility with skin damage and was not provided treatment according to physician orders.

Inspectors wroteBased on observation and interview the facility did not ensure 4 (R15, R66, R50 and R46) of 4 residents that receive insulin had open vials dated and 1 (R32) of 1 residents that receive eye drop medication had the open container dated. During the medication storage task, Surveyor observed R15, R66, R50 and R46 insulin vials, from the medication cart on the 1 north unit, were opened and not dated as to when they were opened. During the medication pass, Surveyor observed R32's eye drop medication was opened and not dated as to when it was opened.

Inspectors wroteBased on observation, interview, and policy review, the facility did not store or prepare food in accordance with professional standards for food safety. This deficient practice had the potential to effect 78 of 98 residents who receive food from the facility kitchen. Facility kitchen observations include: - Food in unsealed bags in which the food item was exposed to the air - Food in containers that were unlabeled and without an open on or use by label on the container. - Equipment not appropriately cleaned between food items when pureed. - Food in unit refrigerators without an open on or use by date label, and not labeled with individual's name.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R12) of 3 residents reviewed for grievances had their grievances fully investigated or followed up on by the facility to ensure resolution of the concern. R12 submitted grievances to the facility that were not followed up on to ensure R12 was satisfied with the outcome.

Inspectors wroteBased on observation, interview and, record review the facility did not ensure residents who were unable to carry out personal hygiene received incontinence care and oral hygiene for 2 (R88 and R12) of 5 residents who are dependent on staff for activities of daily living. *R88 was repositioned in bed and an odor of stool was noted. The staff assisting with repositioning did not perform incontinence care at the time of repositioning R88. *R12 was not provided oral hygiene twice daily with physician ordered toothpaste.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R34) of 20 residents reviewed for quality of care received treatments and care based on the comprehensive assessment of a resident and in accordance to professional standards of practice. R34 was observed having a peripherally inserted central catheter (PICC) for medication administration. The PICC was observed to be dirty with dried blood underneath and rolled up on the edges but reinforced with tape. The facility did not have adequate monitoring of the site including: no as needed changes to the dressing, no flush orders and no care plan to address changing the dressing or monitoring the site. MD (Medical Doctor) wrote an order to discontinue the PICC and then canceled the order but it was not updated in R34's Electronic Medical Record (EMR). This had the potential to cause an infection.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 (R75) of 3 residents reviewed for weight loss and nutrition had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. R75 was admitted to the facility with a G-Tube (Gastrostomy Tube) and Protein Calorie Malnutrition. R75 was not weighed or assessed by the RD (Registered Dietitian) in December 2022. R75 was not weighed in January 2023. In January 2023, R75 was assessed by the RD who based the assessment off a November 2022 weight. In February 2023 R75 is documented to have had a significant weight loss that was identified by the Registered Dietician who ordered a reweigh to confirm weight loss and then would increase to tube feedings if it was confirmed a true weight loss. The reweigh was not done and subsequently the tube feeding increase was not done. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R27) of 1 resident with a G (gastrostomy) tube received the necessary services to ensure appropriate administration of medication. On 5/23/23 during morning medication pass, R27 received medication through a G tube and Licensed Practical Nurse (LPN) C did not flush the G tube prior to administration of the medication and after administration of the medication. LPN C also did not verify the G tube placement prior to administering of the medication.

Inspectors wroteBased on observation, interview and record review the facility did not ensure they were free of medication errors for 1 (R27) of 6 residents reviewed during medication pass. Two medication errors were observed out of twenty five opportunities with a medication error rate of 8%. On 5/23/23 Surveyor observed Licensed Practical Nurse (LPN) C administer R27's morning medication. R27 did not receive two medications, scheduled humalog 6 units and lacosamide 10 ml (milliliters).

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure an effective infection control program was being implemented for 2 (R87, R27) residents reviewed. *The facility did not ensure staff properly utilized PPE (Personal Protective Equipment) and conducted hand hygiene in accordance with standards of practice when providing care to R87. *The facility did not ensure staff properly provided medications to residents (R27) in a sanitary manner.