Wonder City Rehabilitation and Nursing Center

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility document review, the facility failed to store hazardous chemicals in a manner to minimize accidents and hazards on two of two units, which had the potential to affect residents on both units. The deficient practice resulted in the identification if immediate jeopardy (IJ) and substandard quality of care. Following the verification and removal of IJ, the scope and severity was lowered to level two, pattern.

Inspectors wroteBased on observation, resident and staff interview, facility document review, and resident record review, the facility failed to provide sufficient nurse staffing to meet the needs of residents on two of two units.

Inspectors wroteBased on observation, resident and staff interview and facility document review, the facility failed to provide sufficient dietary support personnel resulting in meals being served late to residents on two of two units.

Inspectors wroteBased on observation, resident and staff interview, clinical record review, and facility document review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature affecting residents on two of two units.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and serve food in accordance with professional standards for food service safety in the main kitchen, which had the potential to affect residents on two of two units.

Inspectors wroteBased on staff interview and record review, the facility failed provide a full-time, qualified social services worker meeting requirement of S483.70(p). Specifically, the facility employed an individual with a Bachelor of Science degree as the facility social worker; and the facility was unable to provide credible evidence demonstrating the individual had completed at least one year of supervised social work experience under the supervision of a qualified bachelor's degree-level social worker. This deficient practice had the potential to affect residents requiring psychosocial assessment, discharge planning, behavioral support services, and coordination of resident rights and social service needs.

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain essential equipment in a functional manner in the main kitchen, which affected residents on two of two units.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program affecting the main kitchen, which had the potential to affect residents on two of two units, as all food for the facility is stored and prepared in the main kitchen.

Inspectors wroteBased on observation and resident interview, the facility failed to maintain a clean, comfortable and homelike environment for one of two units.

Inspectors wroteBased on observation and clinical record review, the facility failed to implement the comprehensive person-centered care plan for (4) four of (13) thirteen residents in the survey sample. (Resident #8, #6, #2 and #3).

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to revise and update the residents' person-centered care plan for (2) two of (13) thirteen residents in the sample (Resident #5 and Resident #2).

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to follow physician orders for administration of insulin with specific parameters for (1) one of (13) thirteen residents in the survey sample (Resident #8).

Inspectors wroteBased on observation, interview and record review, the facility staff failed to have credible evidence of a hospice plan of care, services provided by hospice and documentation of hospice provider visits for (1) one resident in a survey sample of (13) thirteen residents receiving hospice care (Resident #5).

Inspectors wroteBased on observation, resident interview, and clinical record review, the facility failed to ensure a resident was treated with respect and dignity for one (1) of seventeen (17) residents, Resident #3.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility failed to notify a provider of two falls for one (1) of seventeen (17) residents, Resident #2.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).

Inspectors wroteBased on interview, record review, and policy review, the facility failed to thoroughly investigate and prevent further potential abuse by ensuring protective measures were implemented after an allegation of sexual abuse was reported for 1 of 3 sampled residents reviewed for abuse investigations (Resident # 9).

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).

Inspectors wroteBased on observation, staff interviews, clinical record review and facility document review, the facility staff failed to deliver the prescribed oxygen flow rate according to the physician's order for (1) one of (13) thirteen residents in the survey sample (Resident #6)

Inspectors wroteBased on staff interview, facility document review, and review of nursing schedules, the facility failed to ensure the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week, as required by S483.35(b), for a facility census of 123 residents. This deficient practice had the potential to affect all residents residing in the facility requiring ongoing nursing assessment, clinical oversight, care planning, change in condition evaluation, medication management, and supervision of licensed nursing staff.

Inspectors wroteBased on observation, resident interview, clinical record review and facility document review, the facility staff failed to honor resident's food preferences for (1) one of (13) thirteen residents in the survey sample (Resident #8).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care consistent with standards of practice to promote the healing of and prevent infection of pressure ulcers for one Resident (Resident #214) in a survey sample of four Residents reviewed for pressure ulcers, resulting in harm for Resident #214. Immediate Jeopardy (IJ) was identified on 10/31/23 at 3:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated the IJ on 11/3/23 at 3:15 PM. The scope and severity was lowered to a level 3, isolated.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accident hazards for one Resident (#223) in a survey sample of 32 Residents. Immediate Jeopardy (IJ) was identified on 11/2/23 at 12:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 11/3/23 at 4:15 PM. The scope and severity were lowered to a level 2, pattern.

Inspectors wroteBased on observation, interviews, clinical record reviews and facility documentation reviews, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to issue a notice in writing, at the time of transfer indicating the reason of transfer and appeal rights, for two Residents (Resident #208 and 213) in a sample of 3 Residents reviewed.

Inspectors wroteBased on Resident interview, facility staff interview, clinical record review and facility documentation review, the facility staff failed to provide assistance with activities of daily living (ADL) for three Residents (Resident #205, #207, and #214) to maintain good personal hygiene, in a survey sample of 3 Residents reviewed for ADL care.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the kitchen and on one of two nursing units, which had the ability to affect many Residents.

Inspectors wrote2. For Resident #208, the facility staff failed to notify the Resident's Representative, of the Resident's transfer to the hospital. On 10/30/23, a clinical record review was conducted of Resident #208's chart. This review revealed that Resident #208, was transferred to the hospital on [DATE]. Review of Resident #208's progress notes revealed an entry from the medical provider on 10/18/23 at 1 PM, that read, Resident is a (age/gender) who is seen today in follow-up for 2 episodes of black vomit. Per nursing resident had 2 episodes this morning of black coffee-ground emesis. Upon examination resident is in no acute distress but complains of nausea and epigastric discomfort . Resident to be sent to the emergency room for evaluation for hematemesis. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to obtain and/or complete a Preadmission screening (PASRR) timely for one Resident, (Resident #204) in a survey sample of 3 Resident's reviewed.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for two Residents, (#214 & #223) in a survey sample of 32 Residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation review, the facility staff failed to provide services that meet professional standards of care for one Resident (#214), in a survey sample of 32 Residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one Resident (#214) in a survey sample of 32 Residents.

Inspectors wrote2. For Resident #214, the facility staff failed to utilize alternatives and failed to assess for the risk of entrapment, prior to installing bed side rails. On 10/31/23, Surveyors C and D visited Resident #214 in the room, facility staff (RN B and LPN B) were present. It was noted that Resident #214 was non-verbal, severely contracted, and unable to assist with her care, to include turning and repositioning. Facility staff were observed to provide total care of the Resident to turn and move her in bed, the Resident was able to offer no assistance. It was also noted that Resident #214's bed had bilateral 1/2 side rails. Review of Resident #214's clinical record revealed the following: a. [...]

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to provide food and drinks in accordance with residents preferences for two residents, Residents #210 and #211, in a sample of 4 residents reviewed for food preferences.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one Resident (Resident #214) in a survey sample of 32 Residents.

Inspectors wroteBased on observation, interview, and facility documentation review, the facility staff failed to maintain all patient care equipment in safe operating condition for one Resident (#214) in a survey sample of 32 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to prevent the development and worsening of pressure ulcers for 2 Residents (Resident #18 and #21), resulting in harm for both Residents, in a survey sample of 61 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Residents received adequate supervision and assistance prevent accidents for 1 Residents (#331) in a survey sample of 61 Residents. Resident #331 who was supposed to be on one-to-one (1:1), went out a second story window and sustained injuries. Immediate Jeopardy was called for Resident #331 on 7/13/23 at 9:10 am. The Immediate Jeopardy began on 6/17/23 and was removed on 7/14/23 at 12:40 PM.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive care and services in accordance with professional standards and the comprehensive care plan and Resident choices for 1 Resident (#123) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation the facility staff failed to provide appropriate treatment to prevent a urinary tract infection for 1 Resident (Resident #21) in a survey sample of 61 Residents resulting in harm.

Inspectors wroteBased on observation, interview, record review, and facility menu review, the facility failed to coordinate services and provide meals and snacks for one of two sampled residents (Resident (R) 7) reviewed for dialysis and received dialysis treatments at an outside dialysis center.

Inspectors wroteBased on observation, interview, review of the facility's meal schedule, and facility policy review, the facility failed to have sufficient dietary staff to assure food was prepared, served, and stored in a sanitary and safe manner. Kitchen food preparation, service equipment and floors were not kept cleaned and sanitized. Dietary staff failed to cover stored food, discard hot dog buns with mold growth and serve milk from the kitchen tray line at a temperature of 41 degrees Fahrenheit or below. Additionally, there were not sufficient dietary staff to ensure resident meals were served as scheduled. The lack of dietary staff had the potential to affect 115 residents who consumed meals that were prepared from the kitchen.

Inspectors wroteBased on observation, interview, tasting of food served on a requested test tray, record review, and facility policy review, the facility failed to serve food that was palatable and hot to 10 of 12 sampled residents (Resident (R)7, R42, R47, R82, R85, R95, R98, R102, R123 and R126) reviewed for food palatability.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to cover stored food, discard hot dog buns with mold growth, keep kitchen equipment and areas clean including the dry storage can rack, food preparation pans, and floors, and serve milk from the tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below. This failure had the potential to affect all 115 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on staff interview and facility record review, the facility staff failed to maintain a written transfer agreement with a hospital, which has the potential to affect all 123 Residents residing in the facility.

Inspectors wroteBased on observation, interviews, clinical record reviews and facility documentation reviews, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure two of three sampled residents (Resident (R) 38, and R91) and/or their Resident Representative (RR), reviewed for a facility-initiated emergent hospital transfer, were provided with a written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the resident and their Resident Representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 3 Residents (# 123, 63, & 65) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly dispose of garbage and refuse. One of two outside facility trash dumpsters contained uncovered and mounded garbage that was above the top of the dumpster because it did not have a lid to cover and contain the garbage placed inside by staff.

Inspectors wroteBased on observation, interview, review of Resident Council Meeting minutes, and facility policy review, the facility failed to maintain an effective pest control program so the facility was free of pests. This deficient practice had the potential for residents of the facility to be at risk for diseases caused by pest infestations.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to assess for appropriateness of self-administration of medications for 1 Resident (Resident #119) in a survey sample of 61 Residents.

Inspectors wroteBased on interview, clinical record review, and facility documentation the facility staff failed to immediately inform the resident representative(s) when there was a significant change in the Resident's condition for 2 Residents (#201, #208) in a survey sample of 32 Residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to issue appropriate notices when skilled services were ending for 1 Resident (Resident #10) in a survey sample of 3 Residents, reviewed for such notices.

Inspectors wroteBased on resident interview, staff interview and facility documentation review, the facility staff failed to provide privacy during care for 1 of 61 residents (Resident #123).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to promptly respond to resolve resident grievances about resident clothing being lost in the laundry and clothing not being returned from the laundry in a timely manner for seven of seven (Residents (R) R42, R59, R82, R85, R95, R98 and R119) sampled residents reviewed for grievances.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to report an injury of unknown origin involving one Resident (Resident #18) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to conduct an investigation with regards to an injury of unknown origin involving one Resident (Resident #18) in a survey sample of 61 Residents.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for antipsychotic use for two of five sampled residents (Residents (R) 47 and R91) reviewed for unnecessary medications. These failures placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on interview, record review, and policy review the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation after a resident experienced a significant change in mental health status which included being newly diagnosed with major depressive disorder, psychosis, and mood affect disorder, and experiencing hallucinations. The failure to ensure the required PASARR screening and review was completed affected one (Resident (R) 38) of three sampled residents reviewed for PASARR Level II evaluations.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure a PASARR (Pre-admission Screening and Resident Review) was completed for 1 Resident (#76) in a survey sample of 61 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for 2 Residents (#'s 13 & 123) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #65, of 61 sampled residents.

Inspectors wroteBased on Resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure pain management was provided to 1 Resident (Resident #21) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation review, the facility staff failed to review for risk and benefits and assess for entrapment, prior to installing bed rails for two Residents (#223, #214), in a survey sample of 32 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure Residents are free from unnecessary psychotropic medications for 1 Resident (#63) in a survey sample of 61 Residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to store medications in a secure location on 1 of 2 nursing units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the food preferences for three of six sampled residents (Resident (R) 42, R82, and R95) reviewed for choices.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one Resident (Resident #214) in a survey sample of 32 Residents.

Inspectors wroteBased on observation and staff interview, the facility staff failed to implement infection control standards to prevent the spread of infections within the facility on 1 of 2 nursing units.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to 1) provide influenza vaccines for 2 residents, Residents #13 and #98, out of 5 residents reviewed for influenza immunization and facility staff failed to 2) provide a pneumococcal vaccine for 1 resident, Resident #12, out of 5 residents reviewed for pneumococcal immunization.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 1 resident, Resident #98, out of 5 residents reviewed for COVID-19 bivalent immunization.

Inspectors wroteBased on Resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that Resident beds were maintained in a safe operating condition for 2 Residents (Resident #21 and #330) in a survey sample of 61 Residents.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure that the required 12 hours annual in-service training was completed for 2 certified nursing aides (CNAs), CNA C and CNA D, in a survey sample of 3 CNAs.

Inspectors wroteBased on observations and interview, the facility failed to post the current Nurse Staffing Information. This had the potential to affect all 123 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the kitchen was maintained and operating in a sanitary manner. This created the potential for the transmission of food borne illness to 100 of 109 residents who received meals prepared in the kitchen, (9 residents received nutrition via feeding tubes).

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure eight of 40 sampled residents (Resident (R) 6, R12, R51, R53, R54, R63, R78, and R84) were treated in a dignified manner and care and services provided as needed. Specifically, R53's clothing and bedding were soiled with vomit; staff failed to change her clothing and bedding in a timely manner, R6, R51, R54, R63, and R78, who required assistance with meals, were identified by nursing staff as, feeders. Staff failed to apply R12's hand splint so she could feed herself using silverware resulting in the resident putting her head down and eating directly from the plate with her mouth. The resident was tearful when recounting this experience. The facility failed to provide R84 with the appropriate skin/scalp care to prevent the excessive shedding of skin to the resident's clothing.

Inspectors wroteBased on observations, interview with the Director of Maintenance (DOM), and review of facility policies and procedures, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment for four bedrooms on one of six units affecting four resident rooms (bedrooms 210, 200, 204, 208.) 2. The facility failed to ensure two of two residents reviewed for property in a sample of 40 residents R12 and R44 who reported missing clothing after sent to the laundry and provided no process in place to find their clothing or replace their clothing or put a system in place to ensure tracking of resident's personal property.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure menus were followed for four of 40 sampled residents (Resident (R)12, R44, R69, R105) for residents on pureed diets, for residents who were part of the resident council, and for a resident who wished to remain anonymous. Menu substitutions were made without documentation or Dietitian approval. A food group (bread) was consistently omitted for residents on pureed diets and small portions were served.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the food was palatable for seven of 40 sampled residents (Resident (R)6, R12, R21, R44, R64, R69, R105) for residents who were part of the resident council, and for a resident who wished to remain anonymous. Specifically, food was not consistently served at the appropriate temperatures, was not appetizing, and/or was not appealing.

Inspectors wroteBased on observation, interview with facility staff and resident family members (F1), and review of facility policies, the facility failed to ensure that one resident (R34) of 27 sampled was free from misappropriation of property.

Inspectors wroteBased on observation, staff interview and family member (F1) interview, and review of facility policy the facility failed to report misappropriation of property to the state survey agency related to one of four residents reviewed for property in a sample of 40 residents, (R34).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a pre-admission screening and resident review (PASARR) Level II was completed on a Resident (R), with a serious mental disorder, admitted to their facility for one of two sampled residents (R17) for PASSAR II compliance. This failure could negatively impact R17 due to R17 not receiving a comprehensive evaluation in order to determine if R17 needed or qualified for specialized services.

Inspectors wroteBased on observation, record review, and interview of one resident (Residents (R) 12) with a history of pressure ulcers in a sample of six residents reviewed for pressure ulcers from a sample of 40 residents showed the facility failed to replace a sagging mattress to provide support and comfort for the resident.

Inspectors wroteBased on observation, interview with facility staff and review of the electronic medical record (EMR), the facility failed to ensure that one resident (R14) of eight residents reviewed for range of motion in a sample of 40 residents received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion.

Inspectors wroteBased on observation, electronic medical record (EMR) review, and interviews the facility failed to ensure that three of five residents in a sample of 40 residents reviewed for falls (Resident (R) 59, R14, and R103 were provided a safe environment to prevent and decrease residents risk for falls. The facility failed to ensure R59 remained free of accidents to prevent harm when the facility failed to secure a pressure reduction cushion properly to the wheelchair causing R59 to fall out of a chair resulting in a major injury.

Inspectors wroteBased on Clinical Record Review and Staff Interview, the facility staff failed to complete a Pre-admission Screening and Resident Review for five Residents (Residents #59, 5, 50, 23, and 60 ), in a survey sample of 33 Residents. 1. For Resident #59, the facility staff failed to complete a Pre-admission Screening and Resident Review (PASARR). 2. For Resident #5, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 3. For Resident #50, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 4. For Resident #23, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 5. [...]

Inspectors wroteBased on resident interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that a resident received necessary, safe, transfer assistance in a timely manner, for one resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff allowed the resident (who was a quadriplegic) to remain suspended over the floor in a hoyer lift for approximately 30 minutes unattended.

Inspectors wroteBased on Resident interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that a Resident was free from Neglect, for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff allowed the resident (who was a quadriplegic) to remain suspended over the floor in a hoyer lift for approximately 30 minutes unattended.

Inspectors wroteBased on Resident interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement abuse and neglect policies and procedures for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff did not implement abuse and neglect policies and procedures after the allegation was made by a Resident.

Inspectors wroteBased on Resident interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to report to authorities an allegation of Abuse/Neglect per federal regulation, in a timely manner for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff did not report an allegation of abuse/neglect for 2 weeks after the allegation was made by a Resident.

Inspectors wroteBased on observation, staff interview, clinical record and facility documentation review, the facility staff failed, for 1 resident (Resident #67) of the survey sample of 33 residents, to implement interventions to prevent pressure ulcers. 1. The facilty staff failed to provide services to prevent skin breakdown (heel/boot protectors) for one resident (Resident #67) to ensure prevention of pressure ulcers. Resident #67 was admitted on [DATE]. His most recent readmission after hospitalization occurred on 7/11/2018. readmission diagnoses included: Parkinson's disease, muscle weakness, chronic kidney disease (Stage 3, moderate), and Type II Diabetes Mellitus. His most recent MDS (Minimum Data Set) was a Quarterly assessment dated [DATE]. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, the facility staff failed to ensure a system of prompt identification of potential diversion of controlled medications and provide safekeeping of hard scripts for all controlled drugs for 1 resident (Resident # 85) in a survey sample of 23 residents. 1. For Resident # 85, the facility staff failed to ensure a method of disposition of written prescriptions for narcotics to prevent potential diversion of controlled drugs. The facility staff failed to send a hard copy script dated 7/16/2018 for the narcotic, Hydrocodone/APAP Lortab 5/325 MG (milligrams) to the Pharmacy.

Inspectors wroteBased on observation, interview and clinical record review the facility failed to ensure 1 Resident (Resident #54) was free from unnecessary psychotropic medication in a survey sample of 33 residents. For Resident #54 the facility failed to ensure that Resident #54 had an appropriate diagnosis for receiving Seroquel (an anti-psychotic medication).