Watertown Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a clean, comfortable, homelike environment for 3 residents of 19 sampled Residents (R14, R10, & R13). R14's room walls and privacy curtains had visible stains/marks on them. R10 was observed with a gown saturated with colostomy leakage, flies were on R10's blankets. R13's room was not clean. Findings Include: The facility 's Homelike Environment Policy, effective date July 2026, states: The facility is committed to maintaining a home-like environment that supports resident dignity, privacy, independence, choice, and quality of life. *Keep resident rooms and common areas clean, safe, comfortable, and welcoming. Example 1: On 7/7/26 at 11:20 AM, Surveyor observed numerous dark brown colored marks scattered on the wall along the side of R14's bed between bed and wall light. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure written bed holds were completed for 1 of 1 resident (R5) reviewed for bed holds out of a sample of 19. R5 was transferred to the hospital. The facility did not provide a written bed hold notice to R5 and/or R5's resident representative. This is evidenced by:The facility's policy, titled Bedhold Notice Upon Transfer, implemented 3/1/26, states in part: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Policy Explanation and Compliance Guidelines: .1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the comprehensive care plan was being followed for 1 (R9) of 19 care plans reviewed out of a total sample of 19 residents. R9's care plan indicates staff assistance of 2 for all cares. Staff are consistently assisting R9 using only one staff member. Evidenced by:The facility policy, titled, Care Planning - Interdisciplinary Team, dated March 2026, states, in part, Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation: 1. Resident care plans are developed according to the timeframes and criteria established . 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide elimination (incontinence) care and repositioning for 1 of 3 Residents (R18) reviewed for ADL care for dependent residents out of 19 sampled residents. R18 was not provided with incontinence care or repositioning for 3 hours and 40 minutes.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide appropriate colostomy care for 1 of 1 Residents out of a total sample of 19 Residents (R10). R10 has an open abdominal wound leaking bowel contents. This was a recognized complication after intestinal fistula repair with anticipated future surgical repair. R10's leaking colostomy was not care planned or identified on the Kardex treatment record resulting in staff not providing timely colostomy cares.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 1 of 1 resident (R12) reviewed for snacks out of a sample of 19. R12 did not receive a snack at 2:00 PM as ordered. This is evidenced by: The facility's policy, titled Therapeutic Diets, undated, states the following, in part: Policy Statement: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation: 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they maintained complete medical records on each resident in accordance with professional standards of practice. This has the potential to affect 2 residents (R6 and R12) out of 19 residents reviewed for medical records out of a total sample of 19 residents. R6's medical record was incomplete. R12's medical record was incomplete.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 1 of 19 sampled Residents (R15). LPN BB (Licensed Practical Nurse) did not follow Enhanced Barrier Precautions (EBP) or complete hand hygiene between glove changes while providing tracheostomy care for R15.

Inspectors wroteBased on interview and record review, facility personnel failed to provide basic life support to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 7 residents (R) reviewed (R4.)R4's chosen code status was full code. R4 was found pulseless and nonbreathing; facility staff delayed notifying 911 and delayed initiating cardio pulmonary resuscitation (CPR.) Facility staff failed to utilize life support equipment such as an AED (Automatic External Defibrillator) while providing CPR to R4. The facility's failure to provide proper basic life support to a resident who wished to be a full code, including immediately starting CPR, utilizing the AED, and promptly calling 911, created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 resident (R) of 3 residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing (R7.) R7 was admitted to the facility on [DATE] with a Stage 3 pressure injury (PI) to his sacrum and inability to turn and reposition himself. The facility failed to implement a turning and repositioning schedule until 5/5/26 (8 days later.) On 5/5/26, R7 was discovered with an avoidable Stage 2 PI to his left buttock. Subsequently, on 5/12/26, the PI to R7's left buttock worsened to an Unstageable PI. On 5/12/26, Physician T (a wound physician) documented Bed rest please following a PI assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident received food and drinks that are safe and appetizing temperature. This has the potential to affect all 92 residents who reside at the facility. Surveyor received a test tray with cold foods that were not cold enough. Surveyor received a test tray with hot foods that were not hot enough. R2 voiced concerns about food quality and temperature. This is evidenced by: The facility policy, titled Preventing Foodborne Illness - Food Handling, reviewed 1/25, states in part: Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Policy Interpretation and Implementation: 1. The facility recognizes that the critical factors implicated in foodborne illness are: .b. Inadequate cooking and improper holding temperatures. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure each resident has the right to privacy and confidentiality for 1 of 7 residents (R) reviewed (R7). During the survey, a camera (an electronic monitoring and recording device) was observed to be used in R7's room. Two of R7's family members have saved recordings with video and voice footage including all cares performed in the room (e.g., pericare, tube feedings, transfers, trach care, dressing, bathing, etc.). The facility does not turn off the camera or cover it up at any time to respect R7's privacy. Evidenced by:R7 was admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 2 of 3 residents (R1 & R2) reviewed for grievances. R1 reported finding a paperclip in her cereal to CNA O (Certified Nursing Assistant), who did not follow up appropriately to address this concern. R2 voiced a concern and the facility did not follow its grievance policy. This is evidenced by: The facility policy, titled Grievance Policy, dated 9/15/25, states in part: Policy Statement: The facility ensures that all residents have the right to voice grievances without discrimination, reprisal, or fear of retaliation. Residents and representatives will be informed throughout the process, and grievances will be promptly investigated and resolved. Policy Interpretation and Implementation: .Investigation and Resolution: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs for 1 of 1 resident (R5) receiving a psychotropic medication. R5 was prescribed Quetiapine, an anti-psychotic medication, scheduled twice daily and PRN (as needed), Cymbalta, an anti-depressant, scheduled daily, Lorazepam, an anti-anxiety medication PRN, Haldol, an anti-psychotic medication PRN, and Remeron, an anti-depressant, scheduled daily. R5's care plan does not address the use of anti-psychotic medications. This is evidenced by: Please note: the survey team requested a psychotropic medication policy but did not receive one from the facility. Per the SOM (State operations manual) An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision for 1 of 3 residents (R5) reviewed for elopement. On 5/18/26, R5 attempted to exit the building, setting off the door alarm. There was a 3-minute delay in the door alarm resetting. During this delay, the staff failed to adequately supervise R5, who was then able to exit the building and was found in the ER (Emergency Room) waiting room next door to the facility. This is evidenced by: Facility policy titled Elopement, undated, states in part: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care. Policy Explanation and Compliance Guidelines: . 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status and consult with the residents' Physician on this for 1 of 3 residents (R7) reviewed for nutrition. R7 did not have a nutrition care plan. R7 experienced a significant weight loss of 4.29% in one week (13.5# loss) and the facility did not notify the physician. Evidenced by: Facility policy: Weight Monitoring states in part: . Process. Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating and analyzing the assessment information. c. [...]

Inspectors wroteBased on interview and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 3 residents (R2) reviewed for transfer referrals. R2 had been requesting for 6 weeks for social services to make the necessary referrals for her to move to a facility closer to family. The facility failed to make the requested referrals. Evidenced by:The facility policy, titled Social Services, dated 11/2025, indicates the following, in part: . Policy Explanation and Compliance Guidelines: . 2. The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, or psychosocial well-being. 3. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment in accordance with professional standards of practice for 4 residents (R) (R4, R5, R16, and R8) of 4 sampled residents. R4 was admitted to the facility with a surgical wound to the sternum that increased in size and became infected. Registered Nurse (RN) assessments were not completed timely and staff did not document changes in the wound or notify the physician of the changes. (This example is being cited at a level G (actual harm/isolated.) R5 went 4 days without a documented bowel movement (BM). The physician was not notified and R5 was not provided with prescribed as needed (PRN) medication. Staff did not consistently document whether or not R5 had a BM. In addition, R5's Treatment Administration Record (TAR) for colostomy care and surgical wound care was not thoroughly completed. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R9 and R13) of 23 sampled residents were treated with dignity and respect that promoted maintenance or enhancement of quality of life. R9 was observed being assisted by staff in the hallway and to an activity. R9's entire back and side were exposed. R13 was observed sitting in the common area wearing only a t-shirt and an incontinence brief.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R11 and R12) of 23 sampled who need assistance with activities of daily living (ADLs) received the necessary care and services. R11 was observed to have whiskers on the chin and chin area. R11 stated R11 did not like having whiskers and preferred to be shaved. R12 was observed to have a bowel movement while laying in bed. Despite reporting the bowel movement to staff, R12 was not assisted for 35 minutes.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R10) of 5 sampled residents. R10 developed an unstageable deep tissue injury on the sacrum and bilateral buttocks. Repositioning was not documented in accordance with the facility's policy. In addition, air mattress function was not documented on R10's Treatment Administration Record (TAR) for multiple shifts from 4/10/26 through 4/19/26.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R8) of 1 sampled resident. R8 had a physician order for bronchial hygiene using Cough Assist (a device that clears secretions from the lungs by gradually applying positive air pressure to the airway and then rapidly shifting to negative air pressure, stimulating a deep natural cough to assist with clearing mucus and secretions) treatments twice daily. The treatments were not consistently completed.

Inspectors wroteBased on staff and resident interview and record review, the facility did not assist in making transportation arrangements to and from the source of service for 1 resident (R) (R2) of 1 sampled resident. R2 missed a dentist appointment due to transportation issues on 4/16/26. R2 stated R2 missed other appointments in the past.

Inspectors wroteBased on staff interview and record review, the facility did not ensure therapy services were provided for 1 resident (R) (R10) of 2 sampled residents. R10 had an order for Speech Therapy evaluation and treatment (dated 4/10/26). R10 was not seen by Speech Therapy while residing in the facility from 4/10/26 through 4/29/26.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 77 residents residing in the facility. The facility did not have an RN on duty for 8 consecutive hours per day 7 days per week on 5 of 10 days reviewed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 71 of 77 residents residing in the facility. (Six residents received nutrition via tube feeding.)Kitchen equipment and food services areas were not in a clean and sanitary condition. The facility did not follow safe food cooling protocols. The facility did not ensure food was kept and served at a safe temperature. The facility did not ensure time/temperature control foods were labeled appropriately with open and use-by dates.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the minimum required members of the facility's Quality Assessment and Assurance (QAA) committee met at least quarterly. This practice had the potential to affect all 77 residents in the facility. The facility did not have documentation that the minimum required members of the QAA committee met for quality assessment and assurance purposes on a quarterly basis.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 6 residents (R) (R66, R14, R35, R7, R56, and R32) of 34 sampled residents. R66 reported concerns about the laundry process and missing items. R66 stated R66 was missing a sweater and a pair of pajama pants. R14 reported that laundry is frequently lost. R14 stated R14 was missing a nightgown with red cardinals that was reported to staff. R35, R7, and R56 reported concerns about the laundry process and missing items. R32 arrived at the facility in a wheelchair that was borrowed from a friend. R32 reported to staff that the wheelchair went missing approximately 4 days after R32 was admitted . The grievance was not thoroughly investigated or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 6 (Certified Nursing Assistant (CNA)-DD, CNA-EE, CNA-FF, Activity Aide (AA)-GG, Maintenance Staff (MS)-HH, and CNA-II) of 10 staff reviewed for caregiver background checks. The facility did not ensure timely completion of CNA-DD's caregiver background check. The facility did not ensure a caregiver background check was completed for CNA-EE. The facility did not ensure timely completion of CNA-FF's caregiver background check. The facility did not ensure a caregiver background check was completed before allowing AA-GG to work with residents. The facility did not ensure a caregiver background check was completed before allowing MS-HH to work in resident care areas. The facility did not ensure timely completion of CNA-II's caregiver background check.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure written bed hold, transfer, and Ombudsman notification was completed for 7 residents (R) (R6, R13, R79, R56, R11, R9, and R21) of 26 sampled residents. R6 was transferred to the hospital on [DATE], 12/2/25, and 1/22/26. The facility did not provide written bed hold or transfer notices and did not notify the Ombudsman of the transfers. R13 was transferred to the hospital on 1/19/26. The facility did not provide a written bed hold or transfer notice and did not notify the Ombudsman of the transfer. R79 was transferred to the hospital on [DATE] and did not return to the facility. The facility did not provide a written bed hold or transfer notice and did not notify the Ombudsman of the transfer. R56 was transferred to the hospital on 1/30/26. [...]

Inspectors wroteBased on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 6 residents (R) (R21, R62, R22, R29, R7, and R36) of 26 sampled residents. R21 was admitted to the facility on [DATE] with a tracheostomy. R21's MDS assessment, dated 2/12/26, did not indicate R21 had a tracheostomy. In addition, R21's MDS assessments, dated 11/12/26 and 2/12/26, inaccurately indicated that R21 was comatose. R62's MDS assessment, dated 2/6/26, inaccurately indicated that R62 was comatose. R22 signed onto Hospice services on 1/14/26. R22's MDS assessment, dated 2/18/26, did not indicate R22 received Hospice services. R29 was prescribed levetiracetam (an anticonvulsant medication). R29's MDS assessment, dated 1/2/26, did not indicate R29 received anticonvulsant medication. R7's MDS assessment, dated 1/2/26, indicated R7 received insulin. [...]

Inspectors wroteBased on staff interview and record review, the facility did not develop and/or implement an individualized comprehensive care plan for 3 residents (R) (R82, R74, and R72) of 26 sampled residents. R82 reported an allegation of misappropriation. The facility's investigation indicated a safe keeping of valuables care plan would be implemented. The facility did not implement a safe keeping of valuables care plan for R82. R74 received dialysis services. The facility did not implement a dialysis care plan for R74. R72 had a diagnosis of Alzheimer's disease. The facility did not implement an Alzheimer's disease/dementia care plan for R72.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 9 residents (R) (R71, R13, R66, R67, R14, R15, R23, R58, and R63) of 9 sampled residents. R71 had an order for acetic acid that was unclear regarding application and use. R71 was not administered 11 of 44 doses. R13's methenamine hippurate for frequent urinary tract infections (UTIs) was not restarted timely after a hospital stay. Medications for R66, R67, R14, R15, R23, R58, and R63 were not administered timely or in accordance with physician orders. n 3/9/26.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 77 residents residing in the facility. Certified Nursing Assistant (CNA)-NN did not complete appropriate hand hygiene during cares for R72. R13 was on contact precautions. Assistant Administrator (AA)-M entered R13's room without completing hand hygiene or donning appropriate personal protective equipment (PPE). Registered Nurse (RN)-Y did not complete appropriate hand hygiene during medication preparation and administration for R14, R15, R23, and R58. Hand hygiene was not offered to multiple residents prior to dining, including R73 and R66.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R20, R3, and R72) of 5 sampled residents had documentation that indicated the residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R20 was prescribed Seroquel (an antipsychotic medication) for anxiety/depression and buspirone (an antipsychotic medication) for anxiety. The facility did not ensure informed consent for medication forms were thoroughly reviewed and completed with R20. R3 was prescribed risperidone (an antipsychotic medication) for agitation, sertraline (an antidepressant medication) for depression, and trazodone (an antidepressant medication) for insomnia. [...]

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure care conferences were held regularly for 1 resident (R) (R3) of 1 sampled resident. R3 did not have regularly scheduled care conferences.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) document was completed or offered for 2 residents (R) (R7 and R74) of 26 sampled residents. R7 and R74's medical records did not contain a POAHC document or documentation that indicated the facility offered to assist with one.

Inspectors wroteBased on staff interview and record review, the facility did not provide written notification of coverage change and the financial liability for continued stay at the facility when Mediare Part A benefits were ending for 1 resident (R) (R77) of 3 sampled residents. The facility did not provide R77 with Notice of Medicare Non-Coverage (NOMNC) (which details appeals rights) or Advanced Beneficiary Notice (ABN) forms for a Medicare Part A stay scheduled to end on 1/30/26.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R22) of 26 sampled residents. The facility did not complete a Comprehensive Significant Change MDS assessment when R22 started Hospice services.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 2 residents (R) (R55 and R64) of 37 sampled and supplemental sampled residents. The facility did not timely transmit RAI/MDS assessments for R55 and R64.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) was completed appropriately for 2 residents (R) (R2 and R9) of 6 sampled residents. R2 had diagnoses of schizoaffective disorder, anxiety, and depression. The facility did not complete a PASRR Level II Screen for R2. R9 had diagnoses of epilepsy, major depressive disorder, and anxiety disorder. R9's PASRR Level I Screen was completed inaccurately, therefore, a Level II Screen was not completed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R3 and R20) of 3 sampled residents. R3's plan of care contained interventions for anti-roll back bars on R3's wheelchair and a fall mat in R3's room. The interventions were not consistently implemented. In addition, the facility did not complete neuro checks and a root cause analysis for R3's falls on 11/1/25 and 1/1/26. The facility did not complete a smoking assessment for R20 to determine if R20 was able to smoke independently. In addition, R20's care plan did not address smoking.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R71 and R7) of 26 sampled residents received the necessary care and services to prevent or monitor weight loss or gain. R71 received nutrition though enteral feeding and had significant weight loss. Staff did not monitor R71's weight as ordered. Staff did not monitor R7's weight as ordered or notifiy the physician of weight changes.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for high-risk medications was in place for 3 residents (R) (R3, R7, and R29) of 5 sampled residents. R3 was prescribed levetiracetam (an anticonvulsant medication). R3 was not monitored for adverse reactions or side effects of the high-risk medication. R7 was prescribed oxycodone hydrochloride (an opioid medication) and oxycodone (an opioid medication) as needed (PRN) for pain. R7 was not monitored for adverse reactions or side effects of the high-risk medications. R29 was prescribed morphine sulfate (an opioid medication) PRN for pain. R29 was not monitored for adverse reactions or side effects of the high-risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R71 and R84) of 26 sampled residents were free of significant medication errors. R71 was admitted to the facility with a diagnosis of osteomyelitis. R71 did not receive three doses of intravenous (IV) antibiotics as ordered. R84 was admitted to the facility with sepsis from a soft tissue infection and right calf cellulitis and abscess. R84 did not receive two scheduled doses of IV antibiotics. R84 requested to go to the hospital so R84 would not miss another dose.

Inspectors wroteBased on staff and resident interview and record review, the facility did not have reliable transportation to and from the source of service for 1 resident (R) (R13) of 2 sampled residents. R13 had a baclofen pump that needed to be changed. R13 had multiple missed appointments due to transportation issues prior to getting the pump changed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R72) of 5 sampled residents was offered the influenza vaccine. R72 was admitted to the facility on [DATE]. The facility did not offer or obtain R72's consent or declination for the influenza vaccine. In addition, R72 did not receive education about the vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R2 and R72) of 5 sampled residents were offered a COVID-19 vaccine. R2 was admitted to the facility on [DATE]. The facility did not offer R2 a COVID-19 vaccine or obtain R2's consent or declination for the vaccine. In addition, the facility did not provide education regarding the vaccine. R72 was admitted to the facility on [DATE]. The facility did not offer R72 a COVID-19 vaccine or obtain R72's consent or declination for the vaccine. In addition, the facility did not provide education regarding the vaccine.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy, the facility failed to ensure the results of an abuse investigation were submitted to the State Agency (SA) within five working days for 1 resident (R) (R4) of 2 sampled residents reviewed for allegations of abuse. The facility submitted an initial report to the SA on 11/22/25 for an allegation of abuse involving R4. The final investigative report report was due on 12/1/25. The facility did not submit the final investigative report until 12/3/25.

Inspectors wroteBased on staff and resident interview, the facility did not ensure there were sufficient supplies for 1 of 4 Residents (R2). R2 indicated the facility ran out of the brief size R2 needed and R2 had to wear two briefs instead of one. Staff interviews verified the facility frequently ran out of wipes, briefs, and wash cloths used for resident care.

Inspectors wroteBased on observation and staff and resident interview, the facility did not provide adequate privacy during cares in a double occupancy room for 1 of 4 Residents (R2). R2 reported a concern with a male visitor in the room while staff provided care for R2.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 1 residents (R6) reviewed for tracheostomy (an opening surgically created through the neck into the trachea in which a tube is inserted to provide an airway to allow air to fill the lungs) care. During R6's tracheostomy care, facility staff did not maintain sterile technique. This is evidenced by:The facility's policy Tracheostomy Care, dated 10/23, includes: The purpose of this procedure is to guide tracheostomy care. General Guidelines 1. Aseptic (the practice of using methods to prevent contamination) technique must be used; c. during tracheostomy tube changes. Sterile gloves must be used during aseptic procedures. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 of 1 Residents (R2). During the provision of peri-care for R2, staff did not properly change gloves and complete hand hygiene.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident, with a personal fund deposited with the facility, had conveyance of the resident's funds within 30 days of discharge and a final accounting of those funds to the individual or probate administering the resident's estate, in accordance with State law for 1 of 1 resident reviewed (R1) for trust accounts. R1 discharged from the facility on 3/25/24. R1's account was still active at facility with a balance of $2520.00. There was no conveyance of R1's account after resident discharged and no final accounting of those funds to R1's Health Care Power of Attorney (HCPOA). This is evidenced by: Facility's admission packet, dated 3/2020, includes: . Payment Policy- Payment is required one month in advance and the Facility's Business Office can provide information as to when payment is due each month. [...]

Inspectors wroteBased on observation, interview, and record review, the facility does not have an effective infection control program to control the spread of infectious disease, in this case COVID-19; this has the potential to affect all 71 residents residing at the facility. Staff were observed going in and out of COVID positive rooms without appropriate PPE (Personal Protective Equipment). Staff were observed exiting COVID positive room with PPE on and doffing PPE in the hallway. Staff were observed not using source control. Staff were working with COVID symptoms and not tested. Facility is not utilizing dedicated equipment in COVID positive resident rooms. Privacy curtains are not being pulled between COVID positive and COVID negative residents. Staff were observed working with a COVID positive resident and then with same PPE about to work with a resident who was COVID negative. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 resident (R29) reviewed for parenteral medications. R29 was readmitted to the facility on [DATE] with a midline for IV (intravenous) antibiotic treatment following a diagnosis of sepsis secondary to urinary tract infection with E. coli bacteremia (bacteria in the blood). On 7/27/24, LPN P (Licensed Practical Nurse) attempted to flush the midline and was unable to, noting that some of the normal saline ran down R29's arm. LPN P reported this to RN O (Registered Nurse) around 2:20 PM on 7/27/24. RN O did not complete an immediate assessment and when he did complete an assessment, he found the line to appear infiltrated (catheter delivering fluid into tissues instead of the vein). [...]

Inspectors wroteBased on interview and record review, the facility did not implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for residents; and did not ensure the staff responsible for the arbitration agreement had complete understanding of an arbitration agreement and was able to thoroughly explain the agreement for complete resident/reasonable party understanding. This deficient practice had the potential to affect all 71 residents who resided in the facility and went through the admission process as arbitration agreements is part of the facility's admission process. R25, R12, R128, R129 and R72's resident representative voiced concerns regarding not fully understanding the arbitration agreement they signed upon admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents (R) received adequate supervision to prevent accidents for 2 of 2 sampled residents (R57 and R56) and 3 supplemental residents (R36, R63, and R35) reviewed for the charging of their electric wheelchairs. R57's electric wheelchair was plugged in and charging in his room. R35's electric wheelchair was in her room along with her charging cord for her electric wheelchair. Surveyor observed R56's power wheelchair charger plugged into the wall in room. Surveyor observed R36's power wheelchair charger plugged into the wall in room. Surveyor observed R63's power wheelchair charger plugged into the wall in room. This is evidenced by: The facility policy Electric Wheelchair Policy, implements 3/8/20, states, in part: [...]

Inspectors wroteBased on observation, interview, and policy review, the facility did not ensure that all residents receive food at a palatable temperature for 1 of 4 hallways and 1 of 1 test trays. Residents voiced concerns with receiving hot foods cold. Surveyor requested test tray. Hot foods temped cold and cold foods temped warm. R39 and R32 stated the food is cold. Evidenced by: The facility policy, Record of Food Temperatures, with no date, states, in part; .2. Hot foods will be held at 135 degrees or greater .11. No food will be served that does not meet the food code standard temperatures . Example 1 On 11/5/24 at 11:40AM, Surveyor requested a meal tray down the 100 hallway. Pork with gravy temped at 114.2 F, potatoes 124.7 F, and red juice temped at 50.1 F. Hot foods were cold and drink was warm. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were treated with respect and dignity and cared for in a manner to enhance their quality of life for 1 (R5) of 3 residents reviewed for resident rights. R5 voiced concern with staff not assisting her out of bed after using the bed pan. R5 indicated the interactions with staff make her feel like a child. R5 was admitted to the facility on [DATE] with a diagnoses including stroke, anxiety disorder, major depressive disorder, pain, adult psychological abuse, kidney failure, muscle wasting, vascular disease, and need for assistance with personal cares. R5 most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/8/24, indicates R5 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R5 is cognitively intact. R5 is own person. R5's Comprehensive Care Plan, states, in part; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 supplemental residents (R1) investigated for self administration of medication. Surveyor observed R1 to have medication at bedside. R1 did not have a self-administration of medication assessment completed. Evidenced by: The facility policy, entitled, Resident Self Administration Medication, dated 3/1/20, states, in part: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure grievances were documented and thoroughly resolved for 2 of 23 sampled residents (R5 and R29.) R5 voiced concern regarding staff not assisting her in getting back up after she uses the bed pan. R5 indicated this makes her feel like a child and staff will say, We aren't playing the up and down game. R29 voiced a concern regarding being left on the commode and filed a grievance. Staff did not follow-up with R29 regarding the resolution of the grievance. Evidenced by: The facility policy Grievances dated 3/1/19, states in part: .The facility will ensure prompt resolution to all grievances, keeping the resident and the resident representative informed throughout the investigation and resolution process .G. [...]

Inspectors wroteExample 2 R10 admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, dementia with psychotic disturbance, and anxiety disorder. R10's quarterly MDS (Minimum Data Set) dated [DATE], question section N0450 B: Has a gradual dose reduction been attempted is marked NO, indicating a GDR (Gradual Dose Reduction) has not been attempted. Section N0450 C: Date of last attempted GDR: was not answered. On [DATE], R10's Risperdal oral tablet 0.5 mg was reduced from four times a day to three times a day. R10's physician orders dated [DATE] include Risperdal oral tablet 0.5mg three times a day. On [DATE] at 3:21 PM, Surveyor interviewed DON B (Director of Nursing) regarding the MDS process. DON B indicated the facility follows the Resident Assessment Instrument (RAI) Manual for completing the MDS. [...]

Inspectors wroteBased on observation, interview, and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 2 of 22 sampled residents (R56 and R68). Surveyor observed R56's Medtronic to be unplugged rendering it unable to transmit data timely to the cardiac clinic that monitors R56's pacemaker. R68 was not weighed daily per physician order. Evidenced by: The facility policy, Weight Monitoring, no date, states, in part; .Based on resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range .5. A weight monitoring schedule will be developed upon admission for all residents: .d. If clinically indicated- monitor weight daily . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for 1 of 5 residents (R10) reviewed for unnecessary medications. R10 does not have a timely Abnormal Involuntary Movement Scale (AIMS) test. This is evidenced by: The facility policy Use of Psychotropic Med implemented 4/24/24, states, in part: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . Psychotropic drugs include, but are not limited to the following categories: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 31 opportunities that affected 1 out of 3 residents (R1) included in the medication pass task, which resulted in an error rate of 6.45%. LPN N (Licensed Practical Nurse) did not prime R1's insulin pens before administration. (Of note, if insulin pens are not primed the resident may not receive the correct dose of insulin.) This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/19, states, in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 resident's (R329). R329 had an order for Novolin 70/30 FlexPen (Insulin) and Metoprolol Tartrate 25 MG (Lowers blood pressure), that was not administered on 10/12/24 and 10/13/24, missing a total of two doses of his daily insulin and four doses of his blood pressure medication. This is evidenced by: The facility policy titled, Medication Administration, dated 3/1/19, states in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders . 10. [...]

Inspectors wroteExample 3 R32 admitted to the facility on [DATE], with diagnoses that include, in part: other chronic pancreatitis, pseudocyst of pancreas, personal history of other diseases of the digestive system. R32's MDS (Minimum Data Set), dated [DATE], indicates BIMS (Brief Interview of Mental Status) score of 15, indicating R32 is cognitively intact. On [DATE] at 8:34 AM, Surveyor observed resident taking Creon (a prescription medication used to treat pancreatic insufficiency) out of her bedside cabinet, top drawer. LPN N (Licensed Practical Nurse) indicated that the medication was supposed to be locked in a lock box/bag and would need to be removed from R32's room. R32 indicated that staff had never discussed the need to keep medication locked up. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 2 supplemental residents (R64 and R35). R64 was treated with an antibiotic when she didn't meet the facility's standard of practice (McGeer). R35 was treated with an antibiotic when she didn't meet the facility's standard of practice. This is evidenced by: The Facility's Policy and Procedure entitled Antibiotic Stewardship Program undated, documents in part: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR (Situation, Background, Assessment, and Recommendation) form prior to notifying the physician. ii. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP) to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 4 sampled residents (R1). R1 admitted with no pressure injuries and was identified to be at risk for PI development. R1 developed an unstageable pressure injury. The facility failed to put aggressive measures in place to promote healing, prevent infection, and to prevent new PI from developing. Evidenced by: Facility policy, titled Pressure Injury Prevention Guide, dated 2016, includes: . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change of condition for 1 of 3 sampled residents (R1). On [DATE], R1 experienced a change in condition exhibiting as shortness of breath and critically low oxygenation. The facility failed to recognize the change of condition as a medical emergency, complete a comprehensive cardiorespiratory data collection, and consult with the RN which resulted in a delay of treatment. LPN E's (Licensed Practical Nurse) failure to recognize a change of condition, complete a comprehensive cardiorespiratory data collection, and consult with the RN resulted in a delay of treatment and created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 2:15 PM, NHA A (Nursing Home Administrator) was informed of the IJ. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident's environment remains as free of accident hazards as is possible and did not ensure resident's care plans are up to date for 1 of 3 residents (R3) reviewed for accidents. R3 fell on 8/3/24, sustaining a laceration under his left eye that required stitches. This is evidenced by: The facility's Policy and Procedure entitled Falls Management Process dated 1/10/24 documents the following in part: .12. The nurse will determine the most appropriate intervention, implement, and update care plan . The facility's Policy and Procedure entitled Comprehensive Care Plan dated 3/1/23 documents the following in part: .3. The comprehensive care plan will describe, at a minimum, the following .f. Resident specific interventions that reflect the resident's needs and preferences .8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide appropriate treatment and services to achieve and maintain as much normal bowel and bladder function as possible for 2 of 4 sampled residents (R) (R4 and R2) reviewed with a bladder and bowel decline. R4 is being cited at severity level 3 (actual harm). R2 is being cited at severity level 2 (potential for more than minimal harm). R4 was continent of bowel and bladder prior to admission. R4 had a decline in bowel and bladder continence from 7/15/24 to present. R4 was assessed by the facility as continent on admission on [DATE] and currently is frequently incontinent of bladder and bowel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 4 of 4 halls and has the potential to affect all 72 residents (R) residing at the facility. R5, R7, R9, R4, and R2 voiced concerns regarding not having enough staff to meet their basic needs. Residents also voiced long call light wait times. Facility staff stated there are tasks that they are not able to get done due to not having enough staff per shift. Evidenced by: The Facility Assessment Tool, dated, 8/18/17, states, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a dignified existence and self-determination in choices which affected 1 of 9 resident (R4) out of a total sample of 9 residents. R4 voiced concerns that she was forced to wear a nightgown because she had no clean clothes. As evidenced by: R4 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Kidney Disease, Type II Diabetes with Diabetic Neuropathy, Dehydration, Major Depressive Disorder, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Unsteadiness on feet, Weakness. R4's admission Minimum Data Set (MDS) with a target date of 7/18/24, indicates, in part: Brief Interview of Mental Status (BIMS) of 14, indicating cognitively intact. On 8/6/24 at 9:34 AM, Surveyor observed R4 sitting in a wheelchair in her room, dressed in a nightgown. [...]

Inspectors wroteBased on record review, and staff and vendor interview, the Bedrock Corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 72 residents in the facility. The Bedrock Corporate governing body failed to maintain current payment status with several service providers and vendors that resulted in vendors refusing to provide further service until payment is received, the facility is delinquent in their property taxes and utilities, the governing body has not paid State bed tax or federal Civil Money Penalties (CMPs), the facility pharmacy provider was abruptly terminated after a past due notice was issued including potential of disruption of service. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 (R1) resident observed for self-administration of medications out of a total sample of 3 residents. R1 was observed to have medications at her bedside and had not been assessed to self-administer medications. Evidenced by: The facility policy entitled, Resident Self Administration of Medication, dated 3/1/23, states in part, Policy Explanation and Compliance Guidelines: 1. Each resident has the opportunity to self-administer medications during the routine assessment. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 2 residents (R1 and R5) reviewed were able to choose their physician. R1 during an interview indicated that she has not been allowed to see her primary care physician and instead is only allowed to see the in-house physician and Nurse Practitioner (NP) R5 was not aware she is able to select her own physician instead of being followed by the Medical Director. Evidenced by: The facility's policy titled Resident Rights implemented 10/01/22, states in part: .Policy: The facility will inform the resident both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents from occurring for 1 of 3 residents reviewed for accidents/supervision (R1). R1 was admitted following hospitalization for an intentional overdose with Potassium (Electrolyte that affects heart rhythm) and Amlodipine (Calcium-channel blocker, decreases blood pressure by widening blood vessels) and staff failed to maintain adequate supervision of the resident while R1 was in possession of these medications. Evidenced by: The facility policy entitled, Accidents and Supervision Policy, dated 3/1/23 states, in part: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents. The facility was under a tornado warning and staff failed to follow the facility's policy and procedure to ensure resident safety for 4 or 4 residents (R1, R2, R3, and R4) interviewed. This has the potential to affect more than a limited number of residents residing in the home. R1, R2, R3, and R4 reported that facility staff did not move them into the hallway during a tornado warning. Evidenced by: The facility's policy Tornado dated 10/1/23, states in part, .7. Emergency procedures for tornado warning: a. Make announcement that the facility is under a tornado warning. b. Implement take cover procedures immediately. i. Relocate residents to designated safe areas. ii. Close doors. iii. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from verbal/mental abuse by a Certified Nursing Assistant (CNA). This affected 1 of 4 residents (R1) reviewed for abuse. R1 had a verbal altercation with CNA C (Certified Nursing Assistant) which led CNA C to become angry and perseverate on the altercation. CNA C then wrote a letter to R1 telling him that she was going to kill him. The facility's failure to keep residents safe from verbal/mental abuse created a finding of Immediate Jeopardy that began on 5/26/24. The Administrator was informed of Immediate Jeopardy on 6/11/24 at 1:26 PM. The immediate jeopardy was removed and corrected on 5/27/24. This is being cited as past noncompliance. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, 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 administrator of the facility and to other officials for 1 of 4 sampled residents (R1) reviewed for abuse. R1 received a life-threatening letter from a facility Certified Nursing Assistant (CNA), the facility failed to report the incident to the State Agency (SA) This is evidenced by: The facility's policy titled Abuse, Neglect, and Exploitation dated 10/1/22, states in part .Definitions: [...]

Inspectors wroteBased on observation, interview, and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 3 sampled residents (R1). The facility was aware of R1's history of having a small bowel obstruction and did not thoroughly assess R1 when he presented with symptoms of nausea and vomiting, did not provide continued monitoring every shift by obtaining vitals and observing/monitoring for continued emesis and describing appearance and amount. The facility failed to monitor R1's condition every shift by obtaining vitals and observing/recording the appearance of R1's urine when they suspected he had a Urinary Tract Infection and while waiting for the Urine Analysis results. The facility failed to monitor R1's intake every shift and failed to notify R1's Medical Doctor of his low fluid intakes. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not report 1 of 4 incidents to the State Survey Agency timely. R4 reported that R2 came in to R4's room on 4/8/24 and R2 touched R4 on the buttock and pulled his pants down. R4 reported this to facility staff on 4/8/24. The facility failed to report non-consensual sexual touching to state agency timely as the facility reported to state agency on 4/10/24. Evidenced by: The facility policy, Abuse, Neglect, And Exploitation, dated 10/01/22, states, in part; .Sexual Abuse is non-consensual sexual contact of any type with a resident .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (R1). R1 has known self-injurious behavior and the facility did not ensure measures were in place to protect him from further accidents and self-injurious behavior.

Inspectors wroteExample 4 R3 was admitted to the facility on [DATE], and has diagnoses that include alcohol abuse, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury). R3's admission Minimum Data Set (MDS) Assessment, dated 11/20/23, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R3 is cognitively intact. R3's Smoking and Safety Assessment, dated 11/10/23, states, in part: AS_1. Smoking Safety Interaction 1. Smoking and Safety. 1. Supervision, designated smoking location, and smoking times are determined by facility policy. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being for 6 residents (R7, R5, R3, R4, R6, and R8) of 10 sampled residents. R7 admitted to the facility with a history of substance abuse. The facility failed to offer R7 services related to this diagnosis and failed to create a care plan with how staff will monitor R7's visitor from bringing medications and alcohol into the facility. R5 admitted to the facility with a history of alcohol dependency with intoxication and alcohol abuse. The facility failed to offer R5 services related to these diagnoses and failed to create and implement a care plan that includes what staff should monitor R5 for, a goal related to R5's alcohol use, and interventions related to R5's alcohol use. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R5) of 10 sampled residents. The facility did not ensure R5's medications were given per Physician orders as he left the facility without his medications. The facility did not update R5's Medical Doctor (MD) when his medications were omitted. The facility did not hold all R5's medications and consult with R5's MD when he was found to have alcohol odor on his breath. Evidenced by: Facility policy, entitled Medication Administration, implemented 3/1/20, includes, in part: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Facility policy, entitles Medication Errors, undated, includes: [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy, the facility failed to assess the risk, advise of the risk and/or benefits, and obtain consent prior to use of bed rails with air mattresses for 8 residents (R23, R11, R16, R18, R19, R24, R25, and R28) on the skilled unit. R23's bed was equipped with an alternating air mattress as well as bed rails so she could assist with bed mobility. On 12/23/23, R23 was having a hard time breathing and wanted to get up. R23 was found entrapped between the bed rail and the air mattress. Facility staff were able to free her and began CPR (Cardio Pulmonary Resuscitation) which was unsuccessful. R11, R16, R18, R19, R24, R25, and R28 were also found to be using bed rails without a risk assessment, without being advised of the risks and benefits of the side rails, and without obtaining informed consent for their use. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a medication error rate of 5% or less. LPN H and LPN I (Licensed Practical Nurse) were late administering medications to R19, R20, R21, R1, and R22. This resulted in 29 errors out of 34 opportunities which calculates to an 85.2% error rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 residents (R16 and R17) and/or their representatives reviewed for facility initiated emergent hospital transfer, from a total sample of 33 residents, were provided with written transfer/discharge notice that included the reason for transfer, the place of transfer, and other information regarding the transfer.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 residents (R16 and R17) and/or their Resident Representative (RR) received written notification of the facility's bed-hold policy.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 62 residents residing in the facility. Dietary Manager (DM)-G did not wear a hairnet that fully covered DM-G's hair. The kitchen and food preparation areas were unclean. The facility did not ensure warewasher (dishwasher) surface temperatures reached an appropriate temperature to ensure sanitization. The facility did not have a practice to monitor and document cooling temperatures. Cook (CK)-H and CK-I did not obtain temperatures of microwave reheated food to ensure the food was heated evenly.

Inspectors wroteBased on observation, and staff and resident interview, the facility did not ensure dignity was maintained for 1 Resident (R) (R57) of 2 residents reviewed for indwelling urinary catheters. During multiple observations, R57's catheter drainage bag was uncovered and visible to others.

Inspectors wroteBased on observation, and resident and staff interview, the facility did not ensure a safe, clean, comfortable and homelike environment for 1 Resident (R) (R57) of 3 residents reviewed. On 7/31/23 at 11:35 AM, Surveyor observed R57 in a common area in a wheelchair. Surveyor noted R57's wheelchair had hardened white matter on the front left seat and a hole in the right armrest that measured 1 x 1 cm (centimeter). The seat cushion, metal bars and plastic parts of the wheelchair were soiled with dried hard matter. The left armrest was cracked and peeling. The right outer metal part of the side of the wheelchair contained brownish dried matter. R57 stated, I think this chair is a hundred years old and It really needs a good cleaning. R57 indicated R57 was unsure if the wheelchair was cleaned on a regular basis and indicated the wheelchair was in the current condition for a while. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R72) of 2 residents who received medication through a peripherally inserted central catheter (PICC) was monitored or assessed for complications. R72 was admitted to the facility with a PICC line (a soft, thin flexible tube inserted in a vein used to administer IV (intravenous) medication and fluid). R72's PICC line was not monitored or flushed for 25 days.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R46 and R77) of 5 sampled residents prescribed high-risk medications had a plan of care that addressed use of the medications and contained interventions to monitor for possible adverse reactions. R46 was prescribed antihistamine medication for anxiety and opioid (narcotic pain relief) medication for pain. The facility did not develop a plan of care that addressed the use of both medications and contained interventions to monitor for adverse reactions to the high risk medications. R77 was prescribed opioid medication for pain. The facility did not develop a plan of care that addressed the use of opioid medication and contained interventions to monitor for adverse reactions to the high risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not offer or administer Pneumococcal vaccines for 3 Residents (R) (R45, R53, and R57) of 5 residents reviewed for immunizations. R45 received the Pneumococcal 23 vaccine on 7/18/16. R45 was not offered or administered the Pneumococcal 15 or Pneumococcal 20 vaccine. R53 received the Pneumococcal 13 vaccine on 4/8/15 and the Pneumococcal 23 vaccine after the age of 65 on 11/16/17. A discussion with R53, R53's provider and the facility did not occur regarding R53's eligibility to receive the Pneumococcal 20 vaccine. R57 received the Pneumococcal 13 vaccine on 10/14/15 and the Pneumococcal 23 vaccine after the age of 65 on 5/2/18. A discussion with R57, R57's provider and the facility did not occur regarding R57's eligibility to receive the Pneumococcal 20 vaccine.