White Oak Post Acute Care

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 2 (#57 and #58) of 34 residents reviewed during the initial pool.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1 (#57) of 25 residents reviewed in the final sample. The facility failed to ensure Resident #57's urinary catheter securement device was in place at all times.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality by nursing staff failing to observe and ensure a resident consumed medications for 2 (#34 and #59) of 32 residents reviewed in the initial pool.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident with a Pressure Ulcer received care based on the comprehensive assessment and professional standards of practice to promote healing by failing to ensure the air mattress was properly functioning for 1 (#21) of 2 residents reviewed with pressure ulcers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received proper treatment and care to maintain good foot health by failing to maintain proper toenail length for 1 (#34) of 3 residents observed for foot care.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure tube feeding formula was administered as prescribed for 1 (#77) of 3 residents reviewed for tube feedings. Review of the Clinical Record for Resident #77 revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status. Review of the current Physician Orders for Resident #77 revealed, in part, the following:Enteral: continuous feed: Isosource 1.5 at 70 milliliters an hour. An observation was made on 06/01/2026 at 8:55 a.m. of Resident #77. Observed Resident #77's feeding tube attached to a feeding pump which read an error of Notice pump inactive. An observation was made on 06/01/2026 at 10:46 a.m. of Resident #77. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to properly label respiratory care equipment for 1 (#74) of 2 residents investigated for respiratory care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure temperatures were documented for the medication refrigerator in 1 of 1 (Med Room A) medication storage rooms observed.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene, proper glove usage, and utilized proper Personal Protective Equipment (PPE) while providing care for 2 (#57 and #77) of 7 sampled residents who were on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure an effective system was in place for staff to identify unsafe smokers and implement interventions including supervision to prevent accident hazards for 2 (#1, #5) of 3 residents reviewed for unsafe smoking. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 04/15/2026 when he was observed smoking in another resident's room while oxygen was in use. Resident #1 was a moderately cognitively impaired resident who was deemed an unsafe smoker upon admission to the facility on [DATE]. After 04/15/2026, not all staff were educated. On 05/03/2026, Resident #1 was noted smoking cigarettes in his room with smoking paraphernalia in his possession. Interviews revealed multiple staff members were unaware Resident #1 was assessed as an unsafe smoker. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place for staff to identify unsafe smokers and implement safety interventions for 2 (#1 and #5) of 3 residents assessed as unsafe smokers.

Inspectors wroteBased on observations and interviews, the facility failed to provide drinks consistent with resident preferences for 1 (#R7) of 1 resident observed for drinking preferences. The facility failed to provide Resident #R7 coffee when he requested it.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the physician was immediately notified when there was a significant change in the resident's skin condition for 1 (#3) of 3 sampled residents with pressure ulcers. This deficient practice resulted in an actual physical harm for Resident #3 when S3CNA observed and reported to S4LPN three dime size blisters on the resident's sacrum on 02/14/2026, and S4LPN failed to notify the physician. The physician was notified on 02/18/2026 when the wound was noted as a stage 3 pressure ulcer by S6TxNurse. On 02/18/2026, Resident # 3 was diagnosed with a stage 3 pressure ulcer measuring length 8.1 centimeters (cm) x width 9.2 cm x depth 0.1 cm. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement 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. The facility failed to ensure staff properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care for 2 (#5 & R1) of 4 residents reviewed for infection control. Review of the facility's titled Enhanced Barrier Precautions dated January 2025 revealed the following, in part: It is the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's MDS Assessment accurately reflected their status for 5 (#4, #7, #13, #21, and #43) of 19 residents in the sample. The facility failed to ensure: 1. Resident #7 was coded correctly for antipsychotics; 2. Resident #43 was coded correctly for insulin; 3. Resident #13 was coded correctly for their Level II PASRR status; and 4. Resident #4 and #21 were coded correctly for restraint status. This deficient practice had the potential to affect a current census of 92 residents. 1. Review of Resident #7's Clinical Record revealed an admission date of 02/20/2024 with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Schizophrenia, Delusional Disorders, and Unspecified Dementia. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly labeled, dated, and sealed. This had the potential to affect 92 residents who were served from the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 (#10, #79, and #95) of 19 sampled residents. The facility failed to ensure:1. Medication administration was accurately documented on the MAR for Residents #10 and #95; and2. Colostomy changes were documented for Resident #79.1. Review of the facility's undated policy titled, Medication-Documentation of Administration revealed the following, in part: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). [...]

Inspectors wroteBased on record reviews and interview, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate PASRR Level II determinations and recommendations into a resident's transitions of care for 1 (#98) of 4 (#3, #13, #66, and #98) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality by nursing staff failing to observe and ensure a resident consumed medication for 1 (#10) of 7 residents reviewed for medication administration.

Inspectors wroteBased on interviews and record review, the facility failed to obtain informed consent prior to the installation of bed rails/grab bars for 1 (#13) of 19 residents in the sample. This deficient practice had the potential to affect a current census of 92 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure Insulin pens were labeled with an opened date on 2 (MCa and MCb) of 2 medication carts reviewed. This deficient practice had the potential to affect all residents who received insulin in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for pressure ulcers. The facility failed to ensure nursing staff accurately documented Resident #2's pressure ulcer interventions.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure medications were administered safely and timely by leaving medications at bed side for 1 (#3) of 3(#1, #2, and #3) residents observed during the survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide adequate supervision for 1 (#5) of 3 (#5, #6, and #7) residents reviewed for wandering. The facility failed to ensure staff appropriately supervised Resident #5 who was assessed to be a wanderer, unsafe smoker, and a high fall risk. This deficient practice resulted in an immediate jeopardy situation on the weekend of 02/15/2025 through 02/16/2025, when Resident #5, a severely cognitively impaired resident identified as a wanderer, unsafe smoker and high fall risk, entered the smoking patio while no staff were present to provide supervision. Resident #5 self-propel himself in his wheelchair through the gate of the smokers' patio onto the sidewalk along the resident patio exterior doors. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure nursing staff notified the NP of a residents fall outside, which required a care plan update, for 1 (#5) of 3(#3, #4 and #5) residents reviewed for falls.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that each resident's comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 1 (R1) of 8 (#1, #2, #3, #4, #5, #6, #7 and R1) resident records reviewed for comprehensive assessments. The facility failed to ensure that the resident admission assessment was completed within the 14-day requirement.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1 (#3) of 3 (#3, #5, and #7) residents reviewed for falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's comprehensive plan of care was developed within 7 days after completion of the comprehensive assessment for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6, #7) residents reviewed for care plans.

Inspectors wroteBased on record review and interviews, the facility failed to ensure census checks were accurately documented for 2 (#5 and #6) of 3 (#5, #6, and #7) residents reviewed for elopement and wandering.

Inspectors wroteBased on record review and interviews, the facility failed to have sufficient certified nursing assistant staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. The deficiency had the potential to affect the facility's total census of 76 residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the Ombudsman of facility-initiated resident transfers for 2 (#5 and #6) of 3 (#4, #5, and #6) residents reviewed for emergency transfers. This deficient practice had the potential to affect a current census of 76 residents.

Inspectors wroteBased on record reviews, observation, and interviews the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 3 (#3, #4 and #5) of 5 (#3, #4, #5, #6 and #8) residents reviewed. The facility failed to: 1. Ensure Resident #3's PT evaluation was completed as ordered; and 2. Ensure Resident #4's care plan was comprehensive and individualized for wandering behaviors; and 3. Ensure Resident # 5's every 30 minute checks were completed as ordered. This deficient practice had the potential to affect a current census of 76 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 (RR1) of 4 (#1, #8, #9 and RR1) residents reviewed for ADL care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Activities of Daily Living (ADL) care was accurately documented for 2 (#8 and #9) of 3 (#1, #8 and #9) Residents reviewed for ADL care. Findings Review of the facility policy titled, Documentation, revealed the following, in part: The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., for continuity of care, treatment decision and to support services provided for payment. 2. A legal record that protects the resident, physician, nurse and the facility that may be traditional paper record, electronic record or combination of both. Review of Resident #8's clinical record revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to provide pharmaceutical services to meet the needs of 1 (#1) of 3 (#1, #2, and #4) sampled residents reviewed for behavioral health services. The facility failed to ensure S2RN administered Resident #1's Ativan per the Physician's Order.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The facility failed to ensure: 1. An effective system was in place for nursing staff to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place for staff to implement safe smoking interventions for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure licensed nurses and nurse aids were trained and competent to update, implement, and identify a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; 2. Ensure licensed nurses and nurse aids were trained and competent to implement and identify safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 9 of 9 (Room A, Room B, Room C, Room D, Hall E, Hall F, Room G, Room H, and Room I) areas observed for environmental concerns. This deficient practice had the potential to affect a census of 88 residents currently residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 4 (#13, #18, #26, and #46) of 6 (#13, #18, #26, #38, #46, and #48) sampled resident records reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to provide the ordered therapeutic diet for 1 (#21) of 4 (#21, #22, #42, and #66) residents reviewed for nutrition.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Medication carts were free of loose pills for 2 (Med Cart A and Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts reviewed. 2. Medication carts were free of expired drugs or biologicals for 1 (Med Cart B) of 2 (Med Cart A and Med Cart B) medication carts reviewed. 3. Medications were stored at proper temperatures in 1 (Med Frig D) of 1 (Med Frig D) medication refrigerators reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 5 out of 5 dietary staff hired were trained on how to test the chemical dishwasher for chlorine.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 81 residents who were served from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents understood the binding arbitration signed on admission for 2 (#143 and #192) of 3 (#44, #143, and #192) residents reviewed for arbitration.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement appropriate plans of action to correct and ensure ongoing compliance with identified quality deficiencies. This deficient practice had the potential to affect a census of 88 residents currently residing in the facility. Cross Reference: F558, F609, F656, F677, F689, F802, F812, F835, and F880

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. Proper Personal Protective Equipment (PPE) was worn by staff for 2 (#5 and #49) of 2 residents on Enhanced Barrier Precautions (EBP); and 2. Urine soiled laundry was removed from a resident's room for 1 (#87) of 27 (#4, #8, #13, #16, #18, #21, #22, #25, #26, #27, #32, #38, #42, #43, #46, #48, #49, #53, #54, #56, #58, #64, #65, #66, #85, #87, #192) residents observed during initial pool.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences by failing to respond to call lights in an appropriate time frame for 1(#192) of 5 (#27, #53, #54, #66 and #192) residents reviewed for call light response.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure allegations of physical abuse and misappropriation of resident property were reported to the facility administrator and the state survey agency timely for 1 (#54) of 27 residents reviewed for abuse in the initial pool.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status. The facility failed to ensure: 1. A resident's annual Minimum Data Set (MDS) assessment was accurately coded in regards to PASRR Level II for 1 (#48) of 6 (#13, #18, #26, #38, #46, and #48) residents reviewed for PASRR; and 2. A resident's quarterly MDS assessment was accurately coded in regards to hospice status for 1 (#4) of 28 residents reviewed in the final sample.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to develop and/or implement a comprehensive person-centered care plan for 5 (#4, #14 #32, #54 and #75) of 28 residents reviewed in the sample. The facility failed to ensure: 1. Resident #4's hospice status was reflected in the care plan; 2. Resident #14's ostomy care was provided per physician's orders; 3. Resident #32 attended her scheduled physician's appointment as per physician's orders; 4. Resident #54's transfer status was reflected in the care plan; and 5. Resident #75's smoking status was reflected in the care plan.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that a resident who was unable to carry out Activities of Daily Living (ADL's) without assistance received the necessary services to maintain good grooming and personal hygiene for 1 (#32) of 3 (#16, #87, and #32) reviewed for ADL's.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 of 1 (#43) residents reviewed for tube feeding.

Inspectors wroteBased on observation and interviews, the facility failed to ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 88 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary treatment and services, consistent with professional standards, to promote healing and prevent the development of new pressure ulcers by failing to ensure a resident's heels were floated as ordered for 1(#2) of 3 (#2, #R1 and #R4) residents reviewed for facility acquired pressure ulcers. This deficient practice resulted in an actual harm for Resident #2, a paraplegic with no sensation to the lower extremities, on 07/16/2024 at 8:58 a.m. when the resident was observed lying in bed with his feet resting directly on the foot board and heels not floated off the surface of the mattress. Further observations were made at 10:39 a.m., 11:51 a.m., and 1:00 p.m. when S6TN confirmed there were new areas of discoloration on both the resident's right and left heel. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection 2 (#2 and #R1) of 5 (#1, #2, #3, #R1, and #R4) residents reviewed for repositioning. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment while providing care to Resident #2 and #R1, residents on Enhanced Barrier Precautions; 2. Staff did not hang a urinary drainage bag above the level of Resident #2's bladder during a transfer; and 3. Staff performed proper hand hygiene during the care of Resident #R1.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#3) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure Resident #3's request to get out of bed was honored in a timely fashion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 1 (#3) of 3 (#1, #2, and #3) sampled residents reviewed for ADLs. The facility failed to ensure Resident #3 received incontinence care timely.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#R3) of 3 (#3, #R2, and #R3) residents reviewed for diabetes.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained and clarified for 2 (#1 and #3) of 5 (#1, #2, #3, #5, and #6) residents reviewed for indwelling devices. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2024. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#7) of 2 (#7 and #8) residents reviewed with wander guards. This deficient practice resulted in an immediate jeopardy situation for Resident #7, a severely cognitively impaired resident with exit seeking behaviors, on the morning of 05/20/2024. At approximately 9:05 a.m., a Good Samaritan alerted the facility that Resident #7 was in a parking lot. After being alerted to Resident #7's elopement from the facility, staff located the resident in a parking lot, 1.1 miles away from the facility, across a high trafficked four-lane divided highway next to the interstate. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure all admission orders were obtained, clarified, and entered into the resident's electronic medical record. The facility failed to ensure Resident #1 had physician orders for PEG and nephrostomy site care. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2023. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the administrator reported to and was accountable to the governing body. S1ADM failed to ensure the facility's QAPI program was maintained. This deficient practice had the potential to affect a census of 87 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. This deficient practice had the potential to affect a census of 87 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop, implement and maintain an effective, comprehensive, data-driven QAPI (Quality Assurance and Performance Improvement) program focused on indicators of the outcomes of care and quality of life. This deficient practice had the potential to affect a census of 84 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure it was free of significant medication errors for 1 (#1) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for medications. The deficient practice had the potential to effect the 84 residents residing in the facility receiving medications.

Inspectors wroteBased on an observation, interviews and record review, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines by failing to: 1) Follow the approved menu in regard to meals served; 2) Record and archive deviations/substitutions of menu. This deficient practice had the potential to affect the 77 Residents who receive meals prepared by the facility kitchen.

Inspectors wroteBased on record review, observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 77 residents who were served meals from the kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure effective communication was performed as mandatory training for all direct care staff for 3 (S7CNA, S8CNA, S9CNA) of 5 (S5LPN, S6LPN, S7CNA, S8CNA, S9CNA) personnel files reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident elopement was reported to the State Survey Agency as required within the specified timeframes for 1 (#7) of 2 (#7 and #8) residents reviewed for elopement.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1(#4) of 8( #1, #2, #3, #4, #5, #6, #7 and #8) residents reviewed in the sample. The facility failed to ensure Resident #4 received the correct diet as ordered by the physician.

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#2 and #5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for wound care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed in final sample. The facility failed to ensure Resident #1's care plan reflected his frequent bath refusals.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment while providing care for 1 (#2) of 2 (#2 and #3) sampled residents who were on Enhanced Barrier Precautions.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to protect the resident's right to be free from physical abuse by Resident #2 for 1 (#1) of 6 (#1, #2, #3, #4, #5 and #6) residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed provide, at minimum, abuse, neglect and exploitation training for 1 (S6CNA) of 6 (S2CNA, S3CNA, S4LPN, S5CNA, S6CNA and S7CNA) personnel records reviewed for the completion of abuse, neglect, and exploitation training.