Winding Trails Post Acute

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#2, #11 and #12) of twelve residents were kept free from physical abuse out of twelve sample residents. Specifically, the facility failed to:-Protect Resident #2 from physical abuse by Resident #3;-Protect Resident #11 from physical abuse by Resident #3;-Protect Resident #12 from verbal abuse by Resident #3; and, -Protect Resident #12 from physical abuse by Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#7) of five residents reviewed for quality of care out of 12 sample residents. Specifically, the facility failed to change a wound care dressing daily for Resident #7, per the physician's order.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a surety bond or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility. Specifically the facility failed to ensure the surety bond had the correct amount to cover the entire balance for the residents' personal needs account at the facility.

Inspectors wroteBased on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to provide a response, action and rationale for food concerns brought up in the resident council meetings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure resident food was palatable in taste and texture.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for two (#4 and #60) of two out of 35 sample residents. Specifically, the facility failed to appropriately assess Resident #4 and Resident #60 for self-administration of medications.

Inspectors wroteBased on record review and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#63) of three residents out of 35 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in Resident #63's PASRR Level II report; and, -Ensure the PASRR Level II recommendations were included in Resident #63's care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#278) of three residents reviewed for activities out of 35 sample residents received individualized activities in accordance with standards of care. Specifically, the facility failed to provide person centered comforting activities for Resident #278 who was at end of life.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#39) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion out of 35 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #39 did not have a potential decline in activities of daily living (ADL).

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#60 and #63) of three residents out of 35 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #60 and Resident #63 understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #60 and Resident #63 had knowledge and skills to assess cognitive ability of residents to ensure residents understood the components of the agreement at the time it was presented to them.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents out of three sample residents reviewed for discharge planning. Specifically, the facility failed to: -Provide an appropriate discharge process for Resident #3; and, -Notify the family that Resident #3 was transferred to another skilled nursing facility until after the resident had already been transferred.

Inspectors wroteOTHER ACCIDENT HAZARDS I. Smoking A. Facility policy and admission Agreement 1. The DON provided the facility's smoking policy on 3/6/24 at 10:32 a.m. It read in pertinent part: Resident smoking status is evaluated upon admission. The evaluation includes [the] ability to smoke safely with or without supervision. The staff consults with the attending physician and the DON to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 2. The facility admission Agreement was provided by the marketing director (MKD) on 3/7/24 at 2:32 p.m. It read in pertinent part: Each resident who wishes to smoke will be assessed for safety during smoking. B. Facility failure to ensure safe smoking through smoking apron use (Resident #33 and #34) and timely smoking assessment (Resident #34 and #38). 1. Resident #33 Resident status: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#18, #7, #3 and #15) out of four residents reviewed out of 38 sample residents were protected from resident to resident physical abuse by Resident #6 and Resident #14. Resident #6 admitted on [DATE] with a history of aggression. Between 1/17/24 and 1/18/24, Resident #6 was involved in at least three altercations with Residents #18, #7 and #3. The altercation with Resident #3 resulted in Resident #3 being transferred to the hospital for head trauma where he received twelve staples to his head. The facility was aware Resident #6 was wandering into other residents' rooms but failed to implement a plan to monitor the resident and redirect her from other residents. Additionally, the facility failed to implement a plan to prevent physical abuse to Resident #15, by Resident #14 who had known aggressive behavior.

Inspectors wroteBased on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#17 and #8) of three residents reviewed for pain management out of 38 sample residents. The facility failed to ensure Resident #17 and Resident #8, both with a diagnosis of chronic pain, were assessed for pain accurately and administered pain medications as ordered. Both residents reported increased levels of pain. Resident #17's 2/19/24 pain assessment documented the resident had pain which affected her day to day activity. On 2/29/24, the resident reported she did not always get her pain medication as ordered. She said her pain affected her sleep and her ability to get around. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared.

Inspectors wroteBased on observation and interviews, the facility failed to effectively administer its resources to attain the highest practicable wellbeing for each resident. Specifically, the facility failed to: -Implement and maintain safety measures to prevent elopements with significant injury; -Prevent, report and investigate allegations of resident to resident abuse; and, -Provide sufficient leadership to address and/or avoid multiple significant concerns.

Inspectors wroteBased on record review and interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to ensure all direct and non-direct care staff received training in dementia care, substance abuse and behavior management.

Inspectors wroteBased on observation, record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility failed to: -Post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse; and, -Include protection for employees against retaliation for reporting in its abuse policy.

Inspectors wroteBased on staff interviews and record review, the facility failed to report alleged violations of potential abuse to the proper authority in accordance with State law for alleged violations involving eight (#4, #17, #6, #7, #3, #18, #14 and #15) of eight residents reviewed for allegations of abuse out of 38 sample residents. Specifically, the facility failed to: -Report an allegation of verbal abuse by Resident #4 to Resident #17 to the nursing home administrator (NHA), director of nursing (DON), local police or the State Agency; -Report an allegation of physical abuse by Resident #6 to Resident #7 and Resident #3; -Report an allegation of physical abuse between Resident #6 and Resident #18; and, -Report an allegation of physical abuse by Resident #14 to Resident #15.

Inspectors wroteBased on record review and interviews, the facility failed to ensure incidents of potential abuse were thoroughly investigated for three (#6, #18 and #7) of four residents out of 38 sample residents. Specifically, the facility failed to: -Ensure a known physical abuse incident between Resident #6 and Resident #18 was thoroughly investigated; and, -Ensure reports of physical abuse by Resident #6 to Resident #7 were followed up on and investigated.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for five (#8, #9, #3, #17 and #21) of five residents reviewed out of 38 sample residents. Specifically, the facility failed to ensure Residents #8, #9, #3, #17 and #21 received all prescribed medications, which resulted in significant medication errors of omission.

Inspectors wroteBased on record review and interviews, the facility failed to ensure nurse aides received 12 hours of training based on annual performance evaluations and facility assessment. Specifically, the facility failed to ensure certified nurse aides (CNAs) #2, #3, #4, #5 and #6 received at least 12 hours of training.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the right to refuse treatment for one (#14) of three residents reviewed out of 25 sample residents. Specifically, the facility failed to ensure Resident #14 was not treated and administered medications against his wishes.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on two of two units out of four units. Specifically, the facility failed to: -Ensure staff had access to and wore PPE in COVID-19 positive resident rooms; -Provide education to staff on use of PPE and disinfection of multi use equipment; and, -Test and document results of staff who had been potentially exposed to COVID-19.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain mobility for two (#1 and #2) of three residents out of six sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2, who required assistance with bathing, were showered or bathed per the resident's preference.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for one (#1) of one resident out of six sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances expressed by Resident #1 regarding missing and late meals, missed showers, being left alone in the shower, wound dressing changes and lack of bed linen changes.

Inspectors wroteBased on record review and interviews the facility failed to ensure two (#3 and #1) of three residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Specifically, the facility failed to ensure: -Resident #3 received immediate interventions including increased supervision during a change of condition to prevent falls; -Resident #3 was assessed for injury, including neurological checks, after witnessed falls with head injury and unwitnessed falls; and, -Resident #1 had a resident centered care plan to prevent falls. I. Facility policy and procedure The Fall Risk policy, revised March 2018, was received from the nursing home administrator (NHA) on 11/20/23 at 10:16 a.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, quality of life, quality of care and infection control.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure three (#9, #33 and #44) of six residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #9 was provided consistent bed baths according to the plan of care; -Ensure Resident #33 was provided timely meal assistance, consistent nail care and frequent toothbrushing; and, -Provide eating assistance for Resident #44, who required extensive assistance with eating.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the resident's environment was free from accident hazards for four (#15, #28, #29, #39 and #47) of six out of 36 sample residents. Specifically, the facility failed to: -Conduct a post fall investigation after Resident #29 had fallen and consistently implement fall measures; -Resident #15 and #39 had effective fall interventions in place; -Resident #28 fall interventions in place and the care plan was updated with appropriate post fall interventions; and, -Resident #47 fall interventions were consistently implemented.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for three (#2, #303 and #24) of three residents reviewed for pain out of 36 sample residents. Specifically, the facility failed to complete a thorough pain assessment for Resident #2, #24 and #303 which included, recognizing the onset, presence of and characteristics of pain.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#2 and #49) out of 36 sample residents. Specifically, the facility failed to: -Ensure resident refrigerator temperatures were monitored for refrigerated food storage; and, -Provide the resident and/or resident representative with information on their right to store food and the process for doing so. I. Facility policy The Refrigerators: Patient In-Room policy, dated 9/1/22, was provided by the NHA on 6/15/23 at 1:00 p.m. It read in pertinent part, Food supplied by the patient/responsible party that required refrigeration must be labeled with the date the food was placed in the refrigerator. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to ensure that toiletry items were marked in the shared bathroom.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure resident bathrooms ventilation fans were functioning on three of four resident bathrooms. Specifically, the facility failed to ensure vents were properly working in residents bathrooms.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to promote and maintain resident's dignity for one (#302) of three residents reviewed for meal assistance out of 36 sample residents. Specifically, the facility failed to ensure Resident #302 was offered his breakfast and lunch in a timely manner.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide services for two (#8 and #29) out of 36 sample residents according to professional standards of practice Specifically, the failed to: -Ensure Resident #8's vital signs, specifically the resident's blood pressure, was monitored prior to the administration of a blood pressure medication; and, -Notify the physician when Resident #29's blood sugars were out of parameters and follow physician's orders for insulin.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#27) of five out of 36 sample residents with a pressure ulcer had preventative measures and received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to: -Have consistent skin assessments documented in Resident #27's electronic medical record; and, -When Resident #27 developed a stage 2 pressure ulcer to his right ankle, interventions for his feet and ankles were not implemented until nine days after the wound developed.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to ensure one (#50) of reviewed for hydration out of 36 sample residents was provided sufficient fluids to maintain hydration health. Specifically, the facility failed to provide and offer fluids to Resident #50, who had a history of dementia and was dependent resident, outside of mealtimes.

Inspectors wroteBased on record review and interviews the facility failed to ensure that residents were free of unnecessary psychotropic medications for two (#33 and #50) of five residents reviewed for psychotropic medications out of 36 sample residents. Specifically, the facility failed to: -Ensure that Resident #50 had behavior monitoring for target behaviors in place while on an antipsychotic and failing to conduct a gradual dose reduction (GDR); and, -Ensure that Resident #33 had behavior monitoring for target behaviors and followed through on recommendation for GDR for a psychotropic medication.

Inspectors wroteBased on observation, record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for one (#24) of two residents reviewed for hospicare care out of 36 sample residents. Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #24.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Record review revealed the facility has been in outbreak status since late December 2021. Specifically, the facility was in outbreak status as of 12/23/21 when a staff member tested positive for COVID-19. On 12/27/21, another staff member tested positive for COVID-19. Thereafter, the following staff tested positive for COVID: [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to test staff, including individuals providing services under arrangement for Coronavirus (COVID-19). Specifically, the facility had been in a COVID-19 outbreak status since 12/23/21 that included positive cases for both residents and staff. The facility failed to conduct bi weekly PCR testing for all staff per the CDC and CMS guidance due to outbreak status since 12/23/21, to ensure the virus did not spread to residents within the facility. The facility failed to protect individuals, equipment and supplies, allowing individual and testing items within six feet of the testing area and each other. Observations showed staff performing testing in front of the testing supplies, therefore not protecting the testing equipment from being contaminated. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. [...]

Inspectors wroteIII. Resident #282-Failure to prevent two stage 3 pressure injuries A. Resident #282 status Resident #282, age [AGE], was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), the diagnoses included generalized muscle weakness, unspecified dementia, and long term use of anticoagulant medication. The 1/3/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment; the brief interview for mental status (BIMS) was not conducted. She had no behavioral problems, psychosis, or rejection of care. She required extensive assistance from one person with bed mobility, transfers, dressing, toileting and personal hygiene. She was at risk of developing pressure injuries as of 7/4/21 and had pressure reducing devices for her bed. B. Wound care observation Wound care observations were conducted on 4/12/22 at 11:09 a.m. [...]

Inspectors wroteBased on interviews, record review and observations, the facility failed to ensure the resident had the right to be free from involuntary seclusion not required to treat the resident's medical symptoms for one (#59) of three out of 33 sample residents. Specifically, the facility failed to ensure Resident #59 was kept free from involuntary seclusion which resulted in psychosocial harm. Resident #59, who had a documented history of anxiety, claustrophobia and was totally dependent upon staff, activated her call light on 3/19/22 to get staff assistance. The resident had a history of yelling out, after activating her call light, because of past experiences of staff not answering her call light timely. [...]

Inspectors wroteBased on observations, interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part: -The facility failed to protect residents from COVID-19 as evidenced by not having an effective infection control program. Cross-reference F880 -The facility failed to monitor each contracted staff member' vaccination status to ensure proper advanced personal protective equipment (PPE) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. [...]

Inspectors wroteBased on record review and interviews, the governing body failed to implement policies regarding the management and operations of the facility. Specifically, the facility failed to ensure the governing body was providing effective oversight to the facility to ensure the facility was in compliance with state and federal regulations.

Inspectors wroteBased on staff, medical director interviews and record review, the facility failed to ensure all responsibilities of the medical director were effectively performed, which had the potential to affect all residents of the facility. Specifically the facility failed to ensure: -The medical director fulfilled his responsibility for providing the implementation of resident care policies or the coordination of medical care in the facility; and, -Facility wide training in infection control. Cross- reference: F686-Treatment and services to prevent/heal pressure ulcers, F880-Infection control, F886-Testing resident and staff, and F888-COVID-19 vaccination.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, quality of care and infection control.

Inspectors wroteBased on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to address and include in the facility assessment an evaluation of the restorative nursing program.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide resolutions to food concerns voiced by residents in the food committee, resident council and reported directly to a staff member. I. Facility policy and procedure The Patient Protection policy, revised October 2021, was provided by the assistant nursing home administrator (ANHA) on 4/18/22 at 2:30 p.m. It revealed in pertinent part, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to revise and review comprehensive care plans for four (#51, #23, #68, and #22) of 18 residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #51's care plan was reviewed and revised to reflect the resident's range of motion needs; -Ensure Resident #23 care plan was integrated with hospice services; and, -Ensure Resident #68 and Resident #22 were invited and participated in their plan of care conference and care plan updated accordingly. Cross0reference F688 for range of motion

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for three (#44, #74 and #282) of four residents reviewed for activities out of 33 sample residents. Specifically, the facility failed to ensure Resident #44, #74, and #282 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure six (#6, #25, #27, #44, #59 and #282) residents reviewed of 10 residents received treatment and care in accordance with professional standards of practice out of 33 sample residents. Specifically, the facility failed to assess Resident #6 for change of condition. Resident developed severe edema on his left lower leg and was sent to the emergency room for evaluation. In addition, Resident #6's skin assessments were not consistently and accurately documented to reflect the development of several wounds on his legs that led to infection and cellulitis. Resident #25-Failure to perform treatments as ordered by the physician, failure to notify the physician of newly developed skin concerns; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for four (#22, #40, #51 and #59) of five residents reviewed for activities of daily living of 33 sample residents. Specifically, the facility failed to: -Provide restorative care services to Resident #40 on a regular basis, and consistently apply wrist splint as recommended by an occupational therapist (OT), -Provide range of motion (ROM) exercises for Resident #22, and, -Ensure Resident #51 and #59 received range of motion services for impaired mobility. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure certified nurse aides (CNA) are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to evaluate the competencies of certified nurse aides on restorative tasks such as brace/splint application, active and passive range of motion.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#27, #81, #25, #59, and #37) out of five residents reviewed out of 33 sample residents were free from unnecessary medications as possible. Specifically, the facility failed to: -Identify and monitor targeted behaviors for psychotropic medications for Resident #27; and, -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #27, #81, #25, #59, and #37.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, in three out of five medication carts. Specifically, the facility failed to: -Label insulin vials and pens with an open date and store them according to manufacturer's recommendation; -Label inhalers and eye drops with an open date; and, -Remove expired medication from the medication cart.

Inspectors wroteBased on observations and interviews, the facility failed to ensure one (#37) out of 33 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure Resident #37 was treated with dignity and respect by answering her call light timely and speaking to her in a respectful manner.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents had the right to formulate advance directives by not keeping advance directives updated and current for two (#27 and #44) of two residents reviewed for advance directives out of 33 sample residents. Specifically, the facility failed to ensure the medical orders for scope and treatment (MOST) forms matched Resident #27 and Resident #44's physician orders.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure services provided to three (#24, #32 and #13) of 33 sample residents met professional standards of practice. Specifically, the facility failed to ensure an assessment was completed and documented by a registered nurse (RN) following a fall sustained by Resident #24, Resident #32 and Resident #13.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#24, #46 and #44) of four residents reviewed out of 33 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure three female residents (Residents #24, #46 and #44) received grooming services to remove long facial hair from their chin.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide necessary care and services for residents who were unable to carry out activities of daily living for two (#40 and #51) of six residents reviewed for activities of daily living of 33 sample residents. Specifically, the facility failed to: -Provide showers and personal care such as washing face and brushing teeth for Residents #40; and, -Offer and encourage oral care for Resident #51, who required assistance with personal hygiene.

Inspectors wroteBased on observations, record review, and interviews the facility failed to assist one (#20) of two residents out of 33 sample residents with obtaining vision services. Specifically, the facility failed to ensure Resident #20 received her prescribed eye glasses timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#13) of three residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to conduct a root cause analysis and implement person-centered interventions after Resident #13, who had five falls in four months.

Inspectors wroteBased on resident and staff interviews and record review the facility failed to assist a resident to obtain routine or emergency dental services, as needed, for one (#51) of two out of 33 sample residents. Specifically, the facility failed to provide dental services for Resident #51.