Welcome Nursing Home

Inspectors wroteBased on observation, medical record review, staff interview, review of the pharmacy refrigerated medication list, review of manufacturer guidelines, and review of facility policy, the facility failed to ensure safe medication handling and proper labeling of multi-use vials. Additionally, the facility failed to ensure medications were not left unattended, affecting one (#71) resident with the potential to affect the direct safety risk of 14 residents (#09, #10, #15, #16, #25, #28, #29, #39, #41, #70, #77, #81, #89, #91) who were identified by the facility as being cognitively impaired, independently ambulatory, and residing on the 200 hall. The facility census was 91.

Inspectors wroteBased on observation, staff interview, product label review, and facility policy review, the facility failed to ensure the resident environment was free from improperly stored hazardous chemicals. This had the potential to affect 14 residents (#9, #10, #15, #16, #25, #28, #29, #39, #41, #70, #71, #81, #89, and #91) identified by the facility as cognitively impaired and independently mobile. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure an advance directive was in the medical record for Resident #80 and further failed to ensure the advance directive forms for Residents #28 and #97 were signed by the physician. This affected three (#28, #80, and #97) of 91 residents reviewed for advance directive. The facility census was 91.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure physician notification when a significant change in condition occurred for one resident (#66) when a lumen of the resident's peripherally inserted central catheter (PICC) line (a central venous catheter that provides access to the large veins near the heart through a peripheral vein in the arm) was occluded, preventing administration of a physician-ordered intravenous antibiotic (Meropenem). This affected one (#66) of three residents (#14, #53, and #66) receiving intravenous therapy. The facility census was 91.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure a homelike environment. This affected three (#52, #64 and #66) of three residents reviewed for a homelike environment. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, review of a facility self-reported incident, and review of facility policy the facility failed to protect residents from abuse. This affected two (#100 and #41) of two residents reviewed for abuse with the ability to affect all residents. The facility census was 91.

Inspectors wroteBased on medical record review, review of the self-reported incident (SRI), staff interview, and policy review, the facility failed to timely report an allegation of abuse to the state agency. This affected one (#41) of two residents reviewed for abuse. The facility census was 91.

Inspectors wroteBased on record review, staff interview, review of facility self-reported incidents (SRIs), and review of facility policy, the facility failed to ensure thorough investigations were conducted for allegations of abuse and injuries of unknown origin. Specifically, the facility failed to complete all required investigative steps to determine the cause of the incidents and whether abuse, neglect, or mistreatment occurred. This affected three (#41, #43, and #100) of five residents reviewed for SRI's. The facility census was 91.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to have the focus interventions in place within the care plan for one (#100) resident who was identified at risk for fractures. This affected one (#100) of two residents reviewed for care planning. The facility census was 91.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure access to hand hygiene supplies for a resident utilizing a bedside commode (BSC). This affected one (#64) of three residents reviewed for hand hygiene. The facility census was 91.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to ensure a resident had skin breakdown protection in place as ordered. This affected one (#72) of two residents reviewed for non-pressure skin issues. The facility identified two (#44, #72) residents requiring skin protection related to contractures. The facility census was 91.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure incontinence care was completed in a timely manner. This affected one (#11) resident reviewed for incontinence care. The facility census was 91. Review of the medical record for Resident #11 revealed this resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, with psychotic disturbance, Neuromuscular dysfunction of bladder, and pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition. This resident was dependent on staff for activities of daily living (ADLs), and incontinence care. Review of the care plan dated 01/29/26 revealed Resident #11 was always incontinent of bowel and had a foley catheter in place. [...]

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure oxygen was administered per the physician's order. This affected two (#17 and #86) of two residents reviewed for oxygen therapy. The facility census was 91.

Inspectors wroteBased on review of the medical record, and review of facility policy, the facility failed to ensure medications and treatments were administered as ordered. This affected one (#66) of three residents reviewed for medication and treatment administration. The facility census was 91.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions were followed. This affected one (#11) resident reviewed for Enhanced Barrier Precautions. The facility census was 91. FIndings include:Record review for Resident #11 revealed this resident was admitted to the facility on [DATE] . Diagnoses included unspecified dementia, with psychotic disturbance, Neuromuscular dysfunction of bladder, and pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition, was dependent on staff for activities of daily living (ADLs), and incontinence care. Review of the care plan for Resident #11 revealed Resident #11 required Enhanced Barrier Precautions (EBP) related to an indwelling medical device. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of a self reported incident (SRI) and subsequent investigation, review of a transcribed interview, policy review, and review of corrective action documentation, the facility failed to ensure residents were free from misappropriation. This affected two (#1 and #2) of three residents reviewed for misappropriation. The facility census was 83. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and major depressive disorder. [...]

Inspectors wroteBased on observations and staff interview the facility failed to maintain a sanitary ice machine. This affected all residents except Residents (#3, #4, #27, #34, #75, #77 and #80) who received nectar like fluids and Residents (#40 and #42) who received no nourishment by mouth. The census was 84 residents. Findings Include: Observations on 10/25/22 at 2:50 P.M. revealed black fuzzy substance located on the upper inside frame of the ice machine. This ice machine was in the hall on the unit. Staff used the machine to provide fresh drinks to the residents. Interview on 10/25/22 at 2:56 P.M., the Administrator and Director of Nursing verified that black fuzzy substance identified on the upper frame above the available ice. Interview on 10/25/22 at 3:23 P.M., the Maintenance Director stated he completed general cleaning every Monday and completed deep cleaning once a month. [...]

Inspectors wroteBased on observation, staff interview, record review and review of facility policy, the facility failed to provide wound care treatment as ordered for a resident with wounds. This affected one Resident (#78) out of two Residents (#78 and #7) observed for wound care. The facility identified four Residents (#7, #30, #32 and #78) with wounds and who required interventions for wound care. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility policy, the facility failed to treat a resident with respect and dignity while providing care. This affected one resident (#37) of four residents observed for medication administration. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and review of the Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessments was accurate. This affected one resident (#37) of 18 residents reviewed for accuracy of assessments. The facility census was 85.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure medications were administered according to ordered parameters. This affected two residents (#70 and #60) of four residents reviewed for medications. The facility census was 85.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents received medications as ordered. Observations of 31 medications being administered to four residents with two errors resulted in a medication error rate of 6.4%. This affected on resident (#37) of four residents observed for medication administration. The facility census was 85.