Williamsport Health and Rehabilitation Center

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure a resident with pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #1) of 1 resident reviewed during the complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility discharged their residents inappropriately. This was evident for 1 (#3) of 4 residents reviewed for discharge.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to document a resident's discharge as required. This was evident for 2 (#3 and #4) of 4 residents reviewed for discharge.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to provide quality of care to their residents. This was evident for 1 (#1) of 1 resident reviewed for falls.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that their residents were free of accidents/hazards. This was evident for 1 (#1) of 1 resident reviewed for falls.

Inspectors wroteBased on record review and interview it was determined that the facility failed to have a process in place to ensure that residents' choice to not have cardiopulmonary resuscitation (CPR) was honored. This was evident for 2 (#8 and #7) of 2 residents reviewed for advanced directives. As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:20 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on [DATE] at 4:43 PM and it was not accepted. The facility submitted a second draft at 5:35 PM, and it was not accepted. The third draft was submitted on [DATE] at 6:16 PM and the facility's written plan to remove the immediacy was accepted on [DATE] at 6:31 PM with an alleged date of compliance of [DATE]. [...]

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to provide residents with their right to privacy of personal information by holding care plan meetings in their rooms with roommates present. This was evident for 1 (#3) of 1 resident reviewed for privacy concerns.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to maintain a clean and homelike environment for their residents. This was evident for 1 (Unit A) of 2 units observed for cleanliness.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide incontinent care for a resident in need of these services. This was evident for 1 (#5) of 2 residents reviewed for incontinent care.

Inspectors wroteBased on observations, record review, and interview, it was determined that the facility failed to have adequate staff to ensure that residents were bathed, dressed, and out of bed in a timely manner. This was evident for 1 of 2 units observed.

Inspectors wroteBased on record review and interview it was determined that the facility failed to implement corrective action when they determined that staff had inaccurate and inconsistent code status information on residents' medical records which resulted in residents receiving unwanted Cardiopulmonary Resuscitation (CPR). This failure led to another resident receiving unwanted CPR for the same reason. This was evident for 11 of 11 months of QAPI meeting minutes reviewed.

Inspectors wroteBased on interviews and a review of pertinent documents, the facility failed to follow the required procedure for addressing residents' grievances. This was evident for 1 (Resident #6) out of 3 residents reviewed for personal property during a survey.

Inspectors wroteBased on interviews with facility staff and review of the dietary supervisor credentials, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and comfortable homelike environment. This was evident for eight of eight days of environmental observations.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the proper storage of medications. This was evident for 1) three of five medication storage areas reviewed, 2) one unsecured storage room (C-Wing), 3) inappropriate temperature control and ice buildup in two refrigerators (C-Wing and A-Wing), and 4) the presence of food items in a medication refrigerator (West View Heights).

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to honor the resident's/resident representative's right to access personal and medical records. This was evident for 1 (Resident #133) of 2 residents reviewed for neglect.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to protect residents from verbal and psychosocial abuse. This was evident for two (Resident's #13 and #52) out of six residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to report an injury of unknown origin. This was evident for one (Resident #33) out of six reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to investigate an injury of unknown origin. This was evident for one (Resident #33) out of six reviewed for abuse.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to accurately reflect residents skin assessment on the MDS assessment. This was evident for one (Resident #11) out of two reviewed for pressure ulcer care.

Inspectors wroteBased on interview, observation and record review it was determined that the facility failed to ensure that residents received proper treatment and assistive devices to maintain their hearing abilities. This was evident for 1 resident (Resident #13) out of 2 residents reviewed for sensory/communication during a survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide pressure ulcer wound care as ordered by a physician. This was evident in two (Resident's #11 and #33) of two reviewed for pressure ulcer care.

Inspectors wroteBased on record reviews, interviews and observations, it was determined that the facility failed to ensure a urine collection bag was secured below the bladder. This was evident for 1 (Resident #73) of 3 residents reviewed for urinary catheters.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide proper monitoring of a resident receiving nutrition through a gastrostomy tube. This was evident for 1 (Resident #6) of 1 resident reviewed for tube feeding during the survey.

Inspectors wroteBased on record review, interviews and observation, it was determined that the facility failed to ensure oxygen therapy was provided according to the physician's order. This was evident for 1 (Resident #5) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to the resident based on professional standards of practice. This was evident for 1 (Resident #139) of 1 resident reviewed for pain management.

Inspectors wroteBased on record review and staff interviews it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received an annual performance review and 12 hours/year of in-service training for 2 (GNA #20 and GNA #21) out of 2 employee records reviewed during the survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure the accurate documentation of controlled substances in the narcotics daily count logs. This was evident for two of two narcotic record books reviewed (A-wing and C-wing) during the medication administration observation task.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure the provider responded to a recommendation made by a consulting pharmacist. This was evident for 1 (Resident #21) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on pertinent document review and interview it was determined that the facility failed to provide the residents with medications as ordered by the physician. This was evident for 1 Resident (resident #135) out of 4 residents reviewed for neglect during a survey.

Inspectors wroteBased on record review, interviews and observations, it was determined that the facility failed to provide routine dental services to a Medicaid funded resident. This was evident for 1 (Resident #21) of 3 residents reviewed for dental care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective process to ensure that residents received their preferred beverages. This was evident for 4 (Resident #108, # 17, 90, #91) out of 6 residents observed for Dinning during a survey. The findingsOn 7/17/25 at 12:26 PM an observation was made of lunch trays delivered on the terrace unit. On 7/17/25 at 12:30 PM an observation of Resident #108's meal ticket indicated that milk was listed as part of the meal. However, observation of the food tray revealed that milk was not present. GNA (Staff # 11) confirmed that the milk was missing from the tray. On 7/17/25 at 12:30 PM an observation of Resident #17s meal ticket indicated that milk was listed as part of the meal. However, observation of the food tray revealed that milk was not present. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure resident care equipment was in good working order. This was evident for 1 (R#94) of 34 residents screened on the A Wing unit during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure residents had access to call bells and failed to ensure that call bells were maintained in working condition. This was evident for four of thirty-five residents reviewed (Residents #37, #92, and #112, #5) who did not have call bells within reach, and for two of twenty-seven residents (Residents #25 and #42) whose call bells were present but not functioning.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to post nursing staffing data on a daily basis and failed to ensure 18 months of posted nursing data were retained. This was evident for 5 of 5 nursing units.

Inspectors wroteBased on interview and record review it was determined that the facility failed to have a process to ensure that all grievances were investigated and received a response in a timely manner. This was evident for 2 (#87 and #95) of 2 residents reviewed for the grievances.

Inspectors wroteBased on record review and staff interview; it was determined that the facility failed to protect a resident (resident #59) from misappropriation of personal funds from a facility staff member. This was evident for 1 of 94 residents reviewed during an complaint survey.

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #61) This was evident for 1 of 94 residents reviewed during a complaint survey.

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that there were enough staff on duty to answer call lights in a timely manner for the residents. This was evident for 2 of 3 complaints for call bell response times.

Inspectors wroteBased on the review of a complaint, medical record review and interview with residents and staff, it was determined that the facility staff failed to administer medications to residents without any significant medication errors by inappropriately administering insulin to 2 residents that were not diabetic. This was evident during the review of a complaint that affected 2 of 2 residents during a medication pass.

Inspectors wroteBased on surveyor observation, record review, and interviews with residents and staff, it was determined that the facility staff failed to ensure that care and services were provided to assist all residents in achieving their highest practicable level of wellbeing. This was evidenced by: [...]

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident during the survey and has the potential to affect all residents.

Inspectors wroteBased on a review of medical records, policies, and other pertinent documentation, observations, and interviews, it was determined that the facility failed 1) to ensure that staff completed the controlled drug count at the change of shift as evidenced by missing/inaccurate documentation by nursing staff that the count had been completed prior to the end of the shift, and 2) to ensure that nursing staff routinely signed that the count was correct at the change of shifts. This was evident for 6 (Rehab units 1 & 2, long-term care units A, B, and C) out of 6 medication carts reviewed for the controlled drug count verification sheet.

Inspectors wroteBased on observation, interview and review of relevant documentation, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food safety as evidenced by the facility's failure to 1) have a cleaning schedule for the ice machine; 2) seal and label open containers of food; and 3) ensure that elevated temperatures in the nursing unit food refrigerators were reported to maintenance. This has the potential to affect all residents.

Inspectors wroteBased on observation, resident and staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that the facility had the resources and that those resources were used effectively in order to meet the health and safety needs of each resident and failed to identify and correct inappropriate care processes/standards, as evidenced by 1) failing to revise and update the facility's Resident Abuse Reporting Policy and Procedure, 2) failing to ensure that facility staff protected residents from abuse and neglect, 3) failing to ensure the facility reported investigations to the State Agency within the required time frame, 4) failing to ensure that all allegations of abuse were thoroughly investigated so that the necessary actions could be taken to prevent further abuse. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 19 out of 22 staff (Geriatric Nurse Aide #9, #18, #24, #27, #31, #39, #46, #47, #48, #49, #50, #51, #55, Licensed Practical Nurse #1, #19, #32, Registered Nurse #34, #35, and Social Worker #21) not up to date staff reviewed for COVID-19 testing during the survey This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on interviews with facility staff, a review of the facility's policies and procedures, and a review of the facility's testing documentation, it was determined that the facility failed to implement their policies and procedures for testing staff who were granted an exception for COVID-19 vaccinations. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to ensure that 2 physicians' certificates of incapacity were obtained, and Advance Directives were completed as per the Health Care Decisions Act prior to allowing resident representatives to make informed health care decisions on the resident's behalf. This was evident for 7 (#97, #71, #83, #70, #35, #78 and #26) of 26 residents reviewed for advance directives during the survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that restorative nursing services were incorporated into residents' care plans and provided by staff as recommended upon discharge from therapy. This was found to be evident for 3 (#28, #7, #33) of 6 residents reviewed for decline in activities of daily living and positioning.

Inspectors wroteBased on medical record review, observation, and interview, it was determined that the facility failed to maintain complete and accurately documented medical records for each resident as evidenced by: A) Failing to have an effective system in place to ensure that both paper and electronic versions of the MOLST forms were voided when a new MOLST was established for 6 (#97, #7, #71, #26, #35, and #70) of 13 residents reviewed for advance directives. B) Falsely documenting completion of treatment interventions that were not actually provided for 1 (#35) of 13 residents reviewed for abuse. C) Failing to document resident behaviors as per the physician order for 1 (#201) of 13 residents reviewed for abuse.

Inspectors wroteBased on observations, review of facility records, and resident and staff interview, it was determined that the facility failed to implement an effective Quality Assessment and Assurance (QAA) based on repeat deficiencies related to 1) resident abuse, 2) abuse policies and procedures, 3) timely reporting of allegations of abuse to the state agency, 4) conducting a thorough investigation of allegations of abuse, 5) physician notification for a resident's change in condition, 6) notice of bed hold policy, 7) respiratory care services, 8) residents unnecessary medications, 9) improper storage of medications, 10) inaccurate/incomplete medical records, and 11) posting of nursing staff for all units. This was evident for 1 recertification survey reviewed and 1 complaint survey reviewed. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document that education was provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff. This was evident for 2 (#21 and #71) of 5 residents and 4 (#28, #35, #46, and #47) of 4 facility staff members reviewed for COVID-19 vaccinations during the survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to allow residents to exercise their rights as evidenced by staff throwing away old newspapers that belonged to a resident who had asked staff not to throw them away. This was evident for 1 (#63) of 61 residents reviewed.

Inspectors wroteBased on medical record review, staff interview, and resident interview, it was determined that the facility failed to fully inform the resident in a manner that they could understand of the reason for their special contact isolation isolation secondary to a possible C-Diff infection. This was evident for 1 (#513) of 15 residents reviewed.

Inspectors wroteBased on medical record review and family and staff interview, it was determined that the facility staff failed to notify the physician when a resident's blood pressure was high. This was evident for 1 (#251) of 4 residents reviewed for complaints.

Inspectors wroteBased on interview and observation, it was determined that facility staff failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. This was evidenced by the facility's failure to ensure that the resident's bathroom walls were clean and sanitary for 1 (#18) of 7 residents reviewed for general concerns.

Inspectors wroteBased on review of medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that grievances were thoroughly investigated and failed to ensure documentation of investigation follow up. This was found to be evident for 1 (#28) of 13 residents reviewed for abuse during the survey and 1 (#38) of 3 resident's reviewed for Personal Property.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that their residents were free of abuse as evidenced by staff to resident abuse that was substantiated. This was evident for 1 (#61) of 11 residents reviewed for abuse. The findings Include: A medical record review for Resident #61 on 6/14/22 at 7:40 AM revealed an annual MDS, with an Assessment Reference Date of 4/22/22, which documented in section C that resident had scored a 13 out of 15 on a Brief Interview for Mental Status (BIMS - a standardized test to determine a resident's level of cognitive functioning) which indicated an intact cognition. Section E documented that Resident #61 had physically agressive behaviors directed towards others such as hitting and kicking. Also, it was noted that these behaviors occurred 1-3 days during the 7 days reviewed, and that it interfered with care. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an environment free of physical restraints. This was evident for 1 (#509) of 11 residents reviewed for abuse.

Inspectors wroteBased on review of medical records, facility investigation documentation and other pertinent documents, and interviews, it was determined that the facility failed to develop and implement abuse policies and procedures to ensure that facility staff appropriately identified and reported allegations of abuse to the Administrator immediately and to ensure that once the facility had been aware of an allegation of abuse that they reported it to the state agency within the required timeframes. This was evident for 4 (#28, #71, #61, and #35) of 13 residents reviewed for abuse during the survey.

Inspectors wroteBased on review of medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that abuse allegations were thoroughly investigated to determine if abuse occurred and take appropriate action. This was found to be evident for 4 (#28, #35, #63, and #83) out of 13 residents reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status as evidenced by failure to accurately identify a resident's range of motion status. This was found to be evident for 2 (#74, #33) of 4 residents reviewed for position and mobility.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility 1) failed to have an effective system in place to ensure that restorative nursing services were incorporated into resident care plans, 2) failed to develop and implement a comprehensive person-centered care plan for a resident with limited range of motion and contractures and a resident with hypomagnesemia, 3) and failed to follow the care plan. This was evident for 3 (#74, #28, #7) of 4 residents reviewed for a decline in activities of daily living, 1(#88) of 4 residents reviewed for hospitalization, 1 (#33) of 4 residents reviewed for position/mobility, and 1 (#251) of 4 residents reviewed for complaints.

Inspectors wroteBased on review of the medical record, it was determined the facility staff failed to ensure that the resident's plan of care was reviewed and revised by the interdisciplinary team after a quarterly review assessment. This was evident for 1 (#5) of 3 residents reviewed for skin assessments.

Inspectors wroteBased on observation, review medical records and facility policy, and interview with staff, it was determined that the facility failed to ensure that each resident received necessary respiratory care and services. This was evidenced by the facility staff's failure to properly date and label oxygen tubing when changed for 2 (#78 and #26) of 6 residents reviewed for Respiratory Care, and failed to ensure that care was provided in accordance with facility policy and the resident's plan of care for 1(#26) of 6 residents reviewed for Respiratory Care.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that physician's progress notes accurately reflected the medications that the resident was currently receiving. This was found to be evident for 2 (#74 and #1) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on surveyor observation and interview with facility staff, it was determined that the facility staff failed to post the required staffing information in a prominent place easily accessible to residents and visitors. This was evident for 1 (Canal Side Skylight) of 6 resident care areas observed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that the residents were free from unnecessary medications as evidenced by 1) failing to follow a physician's order to monitor a resident's blood sugar four times a day for a resident receiving insulin; and failure to follow the physician's order to hold the insulin injection when the blood sugar level was below 120 and 2) failing to discontinue a duplicate medication as ordered by the attending physician. This was found to be evident for 2 (#59 and #34) of 7 residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the residents were free from unnecessary psychotropic medications as evidenced by 1) the administration of as needed antianxiety medication in the absence of documentation of the need for or request of the medication. This was found to be evident for 1 (#1) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview, and facility policies review, it was determined that facility staff 1) failed to ensure documentation of a multi-use medication's expiration date when opened, 2) failed to discard medication bottles and medical supplies when expired, and 3) failed to develop policy and procedures for multi-use medication containers and follow the directions. This was evident in 2 of 5 rehab nursing units observed during random observations made during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure lab results of COVID tests were kept in the resident's medical record. This was found to be evident for 3 (#74, #1 and #59) of 3 residents whose COVID testing results were reviewed during the survey.

Inspectors wroteBased on surveyor observation and interview with the resident and staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to 1) ensure staff were performing hand hygiene between changing gloves, and 2) provide a safe and sanitary environment as evidenced by staff failure to store a resident's toothbrush in a sanitary manner. This was evident for 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and this was evident for 1 (#18) of 61 resident's reviewed during the survey.

Inspectors wroteBased on medical record review, policy and procedure review, and staff interviews, it was determined that the facility staff 1) failed to document that the residents and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent, 2) failed to develop the policies and procedures to ensure that residents or RPs receives education regarding the benefits and potential side effects of Influenza and pneumococcal immunizations. This was evident for 5 (#21, #22, #57, #59, and #71) of 5 residents reviewed for Immunization during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the walk in freezer was functioning in a manner that prevented ice build up, which included ice frozen to the floor; and failed to ensure unit refrigerators were maintained in a manner to keep items at safe temperatures. This was found to be evident for the one walk in freezer in the kitchen; and one of the six unit refrigerators used for storing food items.

Inspectors wroteBased on a review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure that the written transfer notice included all the required information including the right to appeal. This was found to be evident for 3 (#78, #88, and #102) out of the 4 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility 1) failed to notify the resident and/or resident's Representative Party (RPs) in writing of the bed hold policy upon transfer of a resident to an acute care facility (Resident #88, 78 and 102) and 2) and failed to ensure that the policy included the required information. This was evident for 4 (Resident #7, #78, #88, and #102) of 4 residents reviewed for transfers out of the facility.

Inspectors wroteBased on resident and staff interviews, surveyor observation and record reviews, it was determined that the facility failed to have sufficient nursing staff to assist residents in the dining room at mealtime, to provide restorative services to residents and failed to provide geriatric nursing assistant with yearly evaluations.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months, for 6 out of 6 personnel files reviewed.

Inspectors wroteBased on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor was responsible for oversight of food preparation and daily kitchen operation.

Inspectors wroteBased on staff interview, surveyor observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance program. This was evident during the survey process and review of the Quality Assurance Program.

Inspectors wroteBased on observation and resident interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by 1) failing to serve all residents at the same table at the same time during dining observations, and 2) failing to cover a urinary drainage bag. The observations were noted during 2 of 2 lunch time dining in the Canal Heights dining room.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to develop comprehensive and implement comprehensive, resident-centered care plans to meet the residents medical, nursing, mental and psychosocial needs. This was evident for 7 (#97, #63, #103, #102, #72, #78, #16) of 38 residents reviewed during the investigation phase of the survey.

Inspectors wroteBased on observation, record review and interview with facility staff it was determined that facility staff failed to revise resident plans of care to reflect residents' current status. This was evident but not limited to 7 (#60, #34, #41, #43, #100, #16, #73) of 38 residents residents reviewed during the investigative phase of the survey.

Inspectors wroteBased on resident family and staff interview and medical record review, it was determined the facility failed to provide the necessary care and follow-up to ensure that residents received the appropriate treatment and services to maintain, and/or improve ambulatory status. This was evident but not limited for 2 (#9, #30) of 2 residents reviewed for restorative.

Inspectors wroteBased on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility failed to 1) ensure that a resident that was placed on oxygen had a physician's order for oxygen with the amount of oxygen to be administered, 2) failed to develop a respiratory, resident centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) who was placed on oxygen, 3) failed to label oxygen tubing when initiated and 4) failed to ensure that oxygen was administered at the rate ordered by the physician. This was evident for 1 (#103) of 3 residents reviewed for discharge and 1 (#78) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on review of the medical records, it was determined that the facility staff failed to ensure that each residents medication regimen was free from unnecessary drugs by failing to hold medications when the residents' vital signs were below the physician prescribed parameters. This was evident for 1 (#100) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and review of facility narcotic logs, it was determined the facility staff failed to ensure that narcotic counts were performed with dual signatures, that opened refrigeratable medication was labeled with its open date and that medication carts were not left unlocked and unattended. This was evident on 1 (Terrace [NAME] Wing) of 4 hallways observed.

Inspectors wroteBased on review of residents' medical records and interview with facility staff, it was determined that the facility failed to maintain accurate and complete medical records. This was true for 5 (#114, #103, #97, #216, #77) of 45 residents reviewed during the investigation phase of the survey.

Inspectors wrote4) Resident #49 was observed sitting in his/her wheelchair in the Canal Side Height's dining room during the lunch-time meal on 10/18/18 at 12:50 PM. The resident had a urinary catheter (a bag connected to a tube which drains urine from the bladder.). The catheter bag was lying on the floor underneath the wheel-chair. Additionally, the content of the drainage bag was not covered to maintain the resident's dignity. The director of nursing was notified of the findings on 10/19/18. Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to: [...]

Inspectors wroteBased on review of the medical record and interview with the resident and staff, it was determined that the facility failed to notify the Physician and Dietician when a resident had a significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.

Inspectors wroteBased on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff it was determined that the facility staff failed to provide 1 (#268) of 3 Medicare beneficiaries reviewed with a written notice of Medicare Provider Non-Coverage.

Inspectors wroteBased on observation, it was determined that facility staff 1) failed to protect a resident's medical record from public view and 2) failed to take steps to provide a resident privacy during an interview. This was evident for 1 of 3 medication carts observed during the survey and for 1 (#78) of 8 residents in Canal Side Terrace-B observed for the initial pool process of the survey.

Inspectors wroteBased on medical record review and staff interview it was determined that he facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 2 (#16, #78) of 10 residents reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#72) of 4 residents reviewed for dental.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to have a discharge summary written and available to go with a resident to another facility upon discharge. This was evident for 1 (#43) of 3 residents reviewed for discharge.

Inspectors wroteBased on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. This was evident for 1 (#8) of 1 residents reviewed for activities.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility failed to ensure that a resident who received dialysis services 1) had fluids monitored, 2) had the fistula site monitored and 3) had a resident centered care plan for dialysis. This was evident for 1 (#103) of 3 residents reviewed for discharge.

Inspectors wroteBased on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a physician, physician assistant, nurse practitioner or clinical nurse specialist supervised the immediate care and needs for a resident with significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.

Inspectors wroteBased on observations and staff interview, it was determined that facility failed to provide the correct consistency of a diet as prescribed by a physician. This was identified for 1 (#29) of 11 residents reviewed for nutrition and during 2 of 2 meal time observations.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to have the results of a recent complaint survey posted in the survey binders that were accessible to residents, family members and legal representatives of residents. This was evident in four of four survey binders.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to 1) notify the resident/resident representative in writing of a transfer/discharge of a resident, along with the reason for the transfer, and failed to notify the Ombudsman. This was evident for 8 (#11, #103, #97, #59, #16, #78, #92, #102) of 10 residents reviewed that were transferred to an acute care facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#11, #103) of 10 residents reviewed that were transferred to an acute care facility.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to develop baseline care plans that included instructions needed to provide effective and person-centered care and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 7 (#92, #97, #59, #63, #103, #78) of 38 residents reviewed during the investigative phase of the survey.

Inspectors wrote2) Based on daily observations of the daily shift posting of staff on the Canal Side Heights (A-wing), the posted staffing was not In a prominent place readily accessible to residents and visitors nor in a clear readable format which could be read by a wheel chair bound resident. The daily shift posting of staff was located on a clip board in the nursing station area of the unit. The clip board with the required staffing information was high up on the wall making it difficult to read from the height of a wheel chair bound resident. Based on surveyor observation and interview with staff, it was determined that he facility failed to ensure the required nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident on 3 of 6 resident care areas observed during the survey.