West Newton Healthcare

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #2 and Resident #3), who were at risk for developing Diabetes-related foot complications, the Facility failed to ensure they received proper care and treatment to maintain good foot health.

Inspectors wroteBased on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who was readmitted to the facility from the hospital with a new diagnosis of seizures, the facility failed to ensure they developed and implemented a comprehensive individualized care plan specific to his/her associated risk of seizure activity, that included interventions, goals and outcomes.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Residents (Resident #1) who was experiencing an emergent change in condition, the facility failed to ensure quality of care was provided when multiple facility staff members did not know the access code to the elevator and Emergency Medical Services (EMS) were delayed in transporting him/her to the Hospital Emergency Department (ED) for evaluation and treatment.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at increased risk for elopement, had cognitive impairment, and required supervision for ambulation, the Facility failed to ensure that they provided adequate staff supervision to maintain Resident #1's safety, when on 04/09/26, Resident was transported to the hospital for an out-patient medical appointment without an escort, he/she eloped from the hospital, and was later found at the police station approximately four miles away from the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure four Residents (#5, #62, #98 and #9), out of a total sample of 27 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically: 1. For Resident #5 who had a stage 4 pressure ulcer (full Thickness and tissue loss appears as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) the facility failed to consistently implement a physician's ordered air mattress.2. For Resident #62, who had a stage 3 pressure ulcer, the facility failed to ensure that the wound doctor's treatment orders were being followed as recommended.3. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure dental services were provided for four Residents (#51, #81, #73, #72) out of a total sample of 27 Residents. Specifically, the facility failed to:1. Ensure Resident #51 was provided with consent to be seen by dental services resulting in the Resident not being seen by a dentist while residing in the facility for one year.2. Ensure Resident #81 was seen by dental services following a physician's order.3. Ensure Resident #73 had follow up as required following a dental visit.4. Ensure Resident #72 was seen by dental services following a physician's order.

Inspectors wroteBased on record review and interviews, the facility failed to have an effective immunization program in place for 11 Residents out of a total sample of 27 residents. Specifically, the facility failed to ensure the influenza vaccine was administered as soon as in became available.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that Residents on the third-floor unit were provided with a dignified existence. Specifically, the facility failed to ensure that staff members were not using their personal cellphones in the Resident Dining Room while Residents were occupying it.

Inspectors wroteBased on record review, and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one Resident (#2), out of 27 sampled residents. Specifically, for Resident #2 the facility failed to code a fall with major injury (subacute L1 fracture, a bone in the lumbar spine).

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that Activities of Daily Living were provided for dependent Residents for three Residents (#57, #88, #13) out of a total sample of 27 Residents. Specifically, the facility failed to:1. Ensure incontinent care was provided in a timely manner for Resident #57, who is assessed as incontinent of bladder and bowel, resulting in Resident #57 sitting in a soiled brief for an extended period. 2. Ensure that incontinent care was provided within a timely manner for Resident #88 who is assessed as incontinent of bowel and bladder resulting in Resident #88 sitting in a soiled brief for an extended period.3. Ensure that Resident #13 was supervised during mealtimes as indicated by the plan of care.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide and implement an ongoing activities program for one Resident (#88) to meet his/her needs for engagement in meaningful activities, out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure professional standards in quality of care for one Resident (#87), out of a total sample of 27 residents. Specifically, for Resident #87, the facility failed to identify skin injuries on the soles of Resident #87's feet.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#43), out of a total sample of 27 residents, received proper treatment to maintain vision ability. Specifically, the facility failed to implement Resident #43's ophthalmologist's recommendations for a prednisolone eye drop taper (medication used to treat non-infectious eye inflammations, including those caused by surgery) and to discontinue Cosopt (eye drop used to lower raised pressure in the eye and treat glaucoma, a disease that is caused by increased pressure inside the eye, resulting in vision loss if untreated) after eye surgery.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#11) out of a total sample of 27 Residents. Specifically, the facility failed to obtain a re-weigh in a reasonable amount of time after a significant weight loss was identified.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#56) out of sample of 27 residents. Specifically, for Resident #56, the facility failed to obtain physician's orders for oxygen use.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Resident #85 out of a total sample of 27 residents. For Resident #85, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) while providing direct care for the Resident on enhanced barrier precautions due to a suprapubic catheter (a flexible tube that drains urine directly from the bladder through a small opening in the lower abdomen).

Inspectors wroteBased on observation and interviews, the facility failed to post nursing staff data daily, at the start of each shift, as required. Specifically, the facility failed to ensure they consistently posted the staffing as required.

Inspectors wroteBased on observations and interviews the facility failed to ensure a dignified dining experience for two Residents (#23, #50) out of a total sample of 24 residents and on 2 of 3 nursing units. Specifically: 1. For Resident #23, who is dependent on staff for feeding, the staff failed to ensure the resident was positioned properly to eat and was provided with the assist he/she needed, resulting in the resident eating with his/her hands and staring at meals without assistance. 2. For Resident #50, who is dependent on staff for feeding, the staff failed to ensure assistance with feeding was promptly provided when meals were served, resulting in the Resident watching others eat while he/she waited for long periods for assistance. 3a. In the 3rd floor unit dining room staff failed to provide a dignified dining experience and referred to residents as feeders, rather than by their name. 3b. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of practice for three Residents (#14, #35 and #74) out of a total of sample of 24 residents. Specifically: 1. For Resident #14 the facility failed to follow-up on rising abnormal PSA (prostate surface antigen). A potential indicator of cancer levels. 2. For Resident #35 the facility failed to ensure nursing clarified a physician's order for medications that were ordered orally and Resident #35 received medications via g-tube (tube inserted into the stomach). 3. For Resident #74 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different frequencies in one order).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Living (ADLs) were provided to three Residents (#23, #5, and #7) out of a total sample of 24 residents. Specifically: 1. For Resident #23 the facility failed to ensure assistance with bed mobility and dining was provided as needed. 2. For Resident #5 the facility failed to ensure assistance with positioning and feeding was provided as needed. 3. For Resident #7 the facility failed to ensure assistance with grooming was provided as needed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure laboratory services were provided for one Resident (#7) out of a sample of 24 Residents. Specifically, the facility failed to ensure routine labs were obtained according to the physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to discarding food that was spoiled and labeling/dating guidelines.

Inspectors wroteBased on observation, record review and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Resident (#16, #88) out of a total sample of 24 residents and on 1 of 3 resident units. Specifically: 1. For Resident #16, the facility failed to implement Enhanced Barrier Precautions (EBP) due to a peripherally inserted central catheter (PICC) line. 2. For Resident #88, the facility failed to implement EBP due to an external dialysis catheter 3. The facility failed to ensure that during meal pass, soiled dishware was not put back in the carts with meals awaiting delivery to residents. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed identify and minimize areas of possible entrapment in resident beds. Specifically for Resident #74, out of a total of 24 sampled residents, the facility failed to conduct routine inspections on his/her bed frame and mattress to identify possible areas of entrapment. The facility failed also failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 94 resident beds.

Inspectors wroteBased on observation, record review and interview, the facility failed file a grievance for one Resident (#7), out of a total sample of 24 residents. Specifically, the facility staff failed to ensure the Social Worker (SW) filed a grievance on behalf of Resident #7's Guardian who expressed care concerns.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to identify and assess the use of an abdominal binder as a potential restraint for one Resident (#74) out of a total sample of 24 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for one Resident (#26) out of a total sample of 24 Residents. Specifically, for Resident #26 the facility failed to code oxygen use on the MDS assessment.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure they developed and implemented a comprehensive person-centered care plan for four Residents (#90, #73, #24, #74) out of a total sample of 24 residents. Specifically: 1. For Resident #90 the facility failed to ensure the bed was in the lowest position and floor mats were in place when the resident was in bed, as ordered by the physician. 2. For Resident #73 the facility failed to develop a person-centered comprehensive care plan for a diagnosis of history of suicidal ideation. 3. For Resident #24 the facility failed to develop a care plan for the use of psychotropic medications. 4. For Resident #74 the facility failed to implement padded side rails.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for two Residents (#35 and #61) out of a total sample of 24 residents. Specifically, 1. For Resident #35 the facility failed to review and revise the care plan related to the oxygen flow rate for a tracheostomy (surgical incision in the neck to the windpipe to create an airway). 2. For Resident #61 the facility failed to review and revise the care plan related to protective equipment used for smoking (smoking apron).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure vision services were provided for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to ensure arrangements were made to repair eyeglasses for Resident #6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing implemented interventions for pressure ulcer care for one Resident (#61) out of a total sample of 24 Residents. Specifically for Resident #61 the facility failed to ensure that nursing implemented physician's ordered Prevalon boots and failed to consistently elevate his/her heels off the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#35) out of a total sample of 24 residents. Specifically, the facility failed to ensure staff obtained physician's orders for bilateral hand splints (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#88) out of a total sample of 24 residents. Specifically, for Resident #88 the facility failed to obtain weights as ordered and identify and address potential significant weight changes by not reviewing post dialysis weights and reweighing the resident in a timely manner to confirm a significant weight change. Findings Include: Review of facility policy titled Weight Management, dated as revised 4/4/19 indicated the following: -Weights will be obtained weekly x 4 after admission. Subsequent weights will be monthly unless physician's orders or the resident's condition warrants more frequent as determined by the Interdisciplinary Team (IDT). [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for one Resident (#26), out of a total sample of 24 Residents. Specifically for Resident #26 the facility failed to ensure nursing a.) consistently set his/her oxygen flow rate as ordered by the physician and b.) nursing changed nebulizer machine tubing as ordered by the physician.

Inspectors wroteBased on record review and interview the facility failed to ensure a care plan was developed for Trauma Informed Care, with resident specific triggers and interventions, for three Residents (#2, #73, and #78) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that bilateral side rails were implemented in accordance with the care plan, for one Resident (#74) out of a total sample of 24 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of four nurses observed made 10 errors out of 43 opportunities, resulting in a medication error rate of 20.93%. Those errors impacted two Residents (#34 and #77).

Inspectors wroteBased on observation and interview the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically: 1. A medication nurse gave the keys, including narcotic keys to an unassigned staff nurse, providing that nurse access to their medication cart; and 2. Nursing failed to secure the medication cart on 1 of 3 nursing units.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide dental services for one Resident (#85) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure accuracy of the medical record for two Residents (#90 and #88) out of a total sample of 24 residents. Specifically: 1. For Resident #90 nursing documented in the Treatment Administration Record (TAR) that a bed was in the lowest position and that fall mats were in place when they were not; and 2. for Resident #88 the facility failed to accurately document in the Medication Administration Record (MAR) when medications were administered.

Inspectors wroteBased on observations and interviews, the facility failed to post nursing staff data daily, at the start of each shift, as required.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure physician's orders were followed for prevention of pressure ulcer development for one Resident (#91) out of a total sample of 40 residents. Specifically, the facility failed to implement heel booties as ordered resulting in a reddened area on the Resident's left heel and a deep tissue pressure injury on the right heel and failed to implement the correct setting for an air mattress.

Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental and psychosocial well-being for Residents on three of three nursing units.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide a choice of smoking was honored for two Resident's (#15) and (#79), out of a total sample of 40 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement care plans for three Residents, (#20, #70 and #255). Specifically: 1. For Resident #20, the facility failed to implement supervision during meals as part of a nutritional care plan 2. For Resident #70, the facility failed to implement a scoop mattress as part of a fall care plan, and 3. For Resident #255, the facility failed to develop a care plan related to suicidal ideation, out of a total of 40 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure four Residents (#404, #68, #255 and #90), out of a total sample of 40 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed 1. for Resident (#404), to take a baseline measurement of a peripherally inserted central catheter (PICC) on admission and monitor the condition of the insertion site as well as the length of the catheter exiting the body, 2. For Resident #68 the facility failed to follow a physician recommendation for a hand surgeon consult, 3. For Resident #255 the facility failed to review and implement hospice recommendations, and 4. For Resident #90 the facility failed to ensure that a diabetic resident received the correct supplement during a medication pass.

Inspectors wroteBased on observation, record review and interview, the facility failed to: 1. assess and treat one Resident (#68) after a decline in functional status, 2. provide appropriate communication services for one Resident (#255) resulting in agitation and frustration with his/her ongoing inability to communicate with staff, 3. provide assistance with meals for two Residents (#28 and #81), out of a total sample of 40 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to 1. change oxygen tubing according to a physician's order for three Residents (#31, #20 and #48), and 2. failed to change an oxygen concentrator filter for one Resident (#48), out of a total sample of 40 residents.

Inspectors wroteBased on interview, facility assessment review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for six out of six certified nursing assistants (CNAs), and six out of six licensed nurses whose education records were reviewed.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for six of six sampled Certified Nurses Assistants (CNAs).

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure it provided a physician ordered medication for one Resident (#64) out of a total sample of 40 residents. Specifically, on 1/31/24 Nurse #1 did not have Resident #64's physician ordered Trazadone (medication used to treat depression) and Nurse #1 failed to obtain the medication from the emergency medication supply. Findings Include: Review of the facility policy titled 'Administering Medications', dated February 2020, indicated the following and is not limited to: *Medications are administered in a safe and timely manner and as prescribed. Resident #64 was admitted to the facility in October 2022 with diagnoses including anxiety and depression. [...]

Inspectors wroteBased on observations, record reviews, policy reviews and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of four nurses observed made four errors in 38 opportunities on two of three units resulting in a medication error rate of 10.53%. These errors impacted three Residents (#90, #27 and #64), out of five residents observed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that a resident was free from significant medication error. Specifically, the facility failed to ensure blood pressure increasing medication was held per physician orders parameters for one Resident (#64) out of a total sample of 40 residents.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to ensure medications with short expiration dates were dated when opened, failed to ensure medication carts were securely locked when unattended and medications were securely locked.

Inspectors wroteBased on interviews and review of the facility assessment, the facility failed to accurately evaluate their resident population and identify the resources needed to provide the necessary care and services of the resident population related to activities programming.

Inspectors wroteBased on record review and interview the facility failed to accurately document in the medical record for three Residents (#404, #97 and #91) out of a total sample of 40 residents. Specifically for 1. For Resident #404 the doctor's orders indicated that dialysis was on hold when the Resident was receiving dialysis. 2. For Resident #97 nursing was documenting the Resident was receiving Glucerna when it was not available. 3. For Resident #91 nursing documented the Resident was wearing booties when they were not available.

Inspectors wroteBased on observation and policy review, the facility failed to ensure staff followed infection control standards on one of three nursing units. Specifically: 1. The facility failed to ensure staff followed isolation precautions while providing care and housekeeping services during a Covid-19 outbreak. Additionally, 2. the facility failed to ensure that professional standards of practice were upheld during a medication pass to prevent the spread of infection.

Inspectors wroteBased on record review, policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for six of six Certified Nurse Aides (CNAs).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a dignified existence for four Residents (#30, #49, #74 and #35) out of a total sample of 40 residents. Specifically for 1. Residents #30 and #49 the facility failed to assist with the removal of unwanted chin hair, 2. For Resident #74 the facility removed the Resident's socks in the dining room to cut his/her toenails and 3. For Resident # 35 the facility failed to provide clean sheets.

Inspectors wroteBased on record review and interview, the facility failed to 1. complete admission consents and 2. invoke the health care proxy for 1 Resident (#255) out of a total sample of 40 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one Resident (#2C) had a physician order in place and was assessed for the ability to self-administer medications independently, out of a total sample of 32 Residents.

Inspectors wroteBased on observation, record review and interview the facility failed to 1. Ensure resident wheelchairs were maintained in a safe, clean condition on two out of three units observed and specifically for two Residents (#30 and #63) out of a total of 40 residents. 2. Ensure residents were provided with a homelike dining experience.

Inspectors wroteBased on interview and record review, the facility failed to file a grievance for one Resident (#72) out of a total sample of 40 residents. Findings Include: Review of the facility policy titled Grievances, dated as revised 12/18, indicated the following: Policy: The facility will support each resident's right to voice grievances and to ensure that after a grievance has been received, the Grievance Official (Administrator or designee) will collaboratively work with team members to resolve the issue and provide written grievance decisions to the resident and or resident's family. Guideline: The Administrator is identified as the Grievance Official responsible for oversight of the grievance process in the facility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure podiatry services were offered and toenails were kept trimmed and free of infection for 1 Resident (#74) out of a total sample of 40 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for two Residents (#44 and #404), out of a total sample of 40 residents.

Inspectors wroteBased on record record review and interview the facility failed to create a baseline plan of care within the required 48 hours of admission for one Resident (#404) out of a total sample of 40 residents.

Inspectors wroteBased on record review and interview, the facility failed to update the falls care plan with appropriate interventions to prevent further falls for one Resident (#97) out of a total of 40 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to identify and address a significant weight loss timely and implement interventions addressing his/her weight loss for one Resident (#97), out of a total sample of 40 residents, resulting in an 11.7% loss of his/her total body weight in three months.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff provided appropriate care and services for one Resident (#42) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 40 sampled residents. Specifically, the facility failed to: a. ensure staff labeled the enteral formula container and water flush bag with the Resident's name, date and time hung, the administration rate, duration, and initials of the staff member hanging them. b. [...]

Inspectors wroteBased on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#404) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 40 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident (#404) for emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings Include: Review of the facility policy titled 'End-Stage Renal Disease, Care of a Resident with (sic)' last revised July 2023, indicated the following but not limited to: Policy: [...]

Inspectors wroteBased on observation record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#91), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 40 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health services for 1 Resident (#255) out of a total sample of 40 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide medically related social services to attain the highest practicable physical, mental, and psychosocial well-being, for one Resident (#255) specifically, providing or arranging for needed mental and psychosocial counseling services after verbalizing suicidal ideation

Inspectors wroteBased on record review and interview, the facility failed to provide dental services to replace missing dentures for 1 Resident (#78) out of a total sample of 40 residents.

Inspectors wroteBased on observation and policy review the facility failed to maintain proper sanitation practices in the kitchen, specifically related to glove use when serving the tray line.

Inspectors wroteBased on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident and provide a homelike environment. Specifically, the facility administration failed to ensure the governance and leadership members sustained a sufficient activities program and a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in staffing and the serving of meals in a homelike manner.

Inspectors wroteBased on interview and record review, including review of the Quality Assurance and Performance Improvement program (QAPI) facility policy, the facility failed to ensure that the governing body provided oversight and accountability for: 1. The maintenance of an effective QAPI program. 2. The provision of a sufficient activity program.

Inspectors wroteBased on record review and interview the facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly.

Inspectors wroteBased on interview and review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 2023, the facility staff failed to ensure an effective QAPI plan was in place.

Inspectors wroteBased on observation and interview the facility failed to ensure that the Medical Director or an appropriate designee attended Quality Assurance and Performance Improvement Plan (QAPI) Committee meetings at least quarterly.

Inspectors wroteBased on record review and interview, the facility failed to offer and provide influenza immunization for one Resident (#64) out of five residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to offer and provide Covid-19 immunization for one Resident (#64) out of five residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of the transfer/discharge notice upon transfer to the hospital for four Residents (#3, #16, #42 and #48) out of a total of 40 sampled Residents.

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of the bed hold notice upon transfer to the hospital for four Residents (#3, #16, #42, and #48) out of a total of 40 sampled Residents.

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #1) the Facility failed to ensure they maintained a complete and accurate medical records when Certified Nurse Aide Activity of Daily Living (ADL) Flow Sheet documentation was not consistently completed for Resident #1 during the Months of July 2023, August 2023, and September 2023. Findings Include: Review of the Facility Policy titled Charting and Documentation, dated as last revised 09/2022, indicated services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. [...]