Woodstock Valley Health and Rehabilitation

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, monitoring, use of safety devices, and fully implement their smoking policy to ensure safety for two of 16 current residents, resident #10 (R10) and R11. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, isolated. Also, the facility staff failed to provide interventions for adequate supervision for one of 16 residents in the survey sample, Resident #7.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 16 residents in the survey sample, Resident #2, was free from mental abuse resulting in psychosocial harm on 3/29/25.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to provide evidence of an updated hospital transfer agreement for one of one agreement reviewed, potentially affecting all residents, a census of 86.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure the required QAPI (Quality Assurance and Performance Improvement) committee members attended for three of three quarterly meeting reviews, (October 2024 through December 2024, January 2025 through March 2025, and April 2025 through June 2025).

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two of 16 residents in the survey sample, Residents #3 and #4.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a clean, comfortable, and homelike environment for one of 16 residents in the survey sample, Resident #7, three of three reusable bed pads observed in the laundry room, and in six of 27 resident rooms observed.

Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, facility staff failed implement the comprehensive care plan for six of 16 current residents in the survey sample, Residents #10 (R10), R11, #7, #2, #3 and #6.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medications and treatment per the physician's orders for three of 16 residents in the survey sample, Residents #3, #2 and #7.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for two of 16 residents in the survey sample, Residents #3 and #6.

Inspectors wroteFor Resident #2 (R2), the facility staff failed to administer pain medications per the physician order to manage the resident's pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. R2 stated on 3/29/25, she was going into withdrawal symptoms related to not getting her pain patch (Fentanyl - an opioid used to treat severe pain) (1) as prescribed. She stated she was sick to her stomach, diarrhea and just didn't feel well. She stated her daughter had been in the facility on 3/28/25 and noticed that her pain patch was dated 3/17/25. [...]

Inspectors wroteBased on resident interview, staff interview and facility document review, the facility staff failed to maintain sufficient nursing staff to meet the resident's needs for two of two resident units, Dogwood and Rosewood units.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to meet RN (registered nurse) requirements for 16 of 31 days reviewed.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to complete an annual performance review for four of five CNA (certified nursing assistant) reviews.

Inspectors wroteBased on facility staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for two of 16 residents in the survey sample, Residents #3 and #7.

Inspectors wroteBased on observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of two facility units, Rosewood Unit.

Inspectors wroteBased on resident interview, staff interview and facility document review, facility staff failed to provide HS (hours of sleep) snacks on two of two resident units, Dogwood and Rosewood units.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to provide evidence of an updated contract with an outside provider for one of eight contracts reviewed, potentially affecting seven residents who received respiratory equipment services.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that facility staff failed to promote a resident's dignity for one of 16 current residents in the survey sample, Residents #8 (R8).

Inspectors wroteBased on resident interview, facility document review and clinical record review, the facility staff failed to maintain a resident's right to be treated with respect and dignity, including the right to retain their personal belongings for one of 16 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to secure confidential resident clinical records for one of 16 residents in the survey sample, Resident #1.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure discharge needs were met for one of 16 residents in the survey sample, Resident #4.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop a baseline care plan for one of 16 residents in the survey sample, Resident #3.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 16 residents in the survey sample, Residents #1, and #3.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care and services for one of 14 residents in the survey sample, Resident #110.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary medications for one of 16 residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to provide services in compliance with State code for one of 16 residents in the survey sample, Resident #1.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for three of 16 residents in the survey sample, Residents #3, #2, and #1.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for one of 14 residents in the survey sample, Resident #104.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to meet nurse staffing information requirements for 31 of 31 days reviewed.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services for resident safety for seven of 43 residents in the survey sample, Residents #38, #235, #58, #42, #61, #47, and #25. For Resident #38, the facility staff failed to assess the resident to safely leave the facility property independently. Resident #38 was observed on Main Street on the sidewalk, approximately 150 yards for the facility front door, on 5/20/24. For Resident #235, the facility staff failed to assess the resident the resident to safely leave the facility property independently. Resident #235 was observed getting on public transportation with a rollator walker on 5/20/24. For Resident #58, the facility staff failed to assess the resident to safely leave the facility property independently. [...]

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess, monitor and/or implement treatment for pressure injuries for two of 43 residents in the survey sample, Residents #45 and #85. For Resident #45, the facility staff failed to implement treatment for a pressure injury (1) and the wound became larger in size, thus causing harm to the resident.

Inspectors wroteBased on family interview, staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician and/or responsible party of a change in a resident's condition for five of 43 residents in the survey sample, Residents #64, #336, #13, #47, and #13.

Inspectors wrote5. The facility staff failed to post notice of employee rights regarding abuse reporting in a conspicuous location in the facility for staff. On [DATE] at 9:25 a.m., an observation was made of the facility employee break room, no abuse reporting employee rights posting was observed. On [DATE] at 9:27 a.m., a request was made to OSM (other staff member) #11, the director of social services for the location of the posting, OSM #11 stated that she thought there was a poster in the employee break room and proceeded to check the bulletin boards located in the room. On [DATE] at 9:29 a.m., ASM (administrative staff member) #1, the administrator, stated that there was a posting hanging on the bulletin board in the employee break room at the facility. ASM #1 observed the bulletin boards in the break room and stated that it was not there and may have been taken down by mistake. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to report allegations of abuse in a timely manner for five of 43 residents in the survey sample, Residents #17, #59, #64, #136, and #38.

Inspectors wroteBased on staff interview, facility documentation, clinical record review the facility staff failed to report allegations of abuse in a atimely manner for 5 of 43 residents in the survey sample (Residents #17, #59, #64, #136, and #38) 1. For Resident #17 (R17), the facility staff failed to report an allegation of misappropriation of R17's property in a timely manner. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Please see F605 and F607 for additional details regarding R17. 2. For Resident #59 (R59), the facility staff failed to report an allegation of abuse and misappropriation of property in a timely manner. On 5/22/24 at 10:32 a.m., ASM #5 was interviewed. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 43 residents in the survey sample, Residents #45, #13, #16, #47, and #25.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for six of 43 residents in the survey sample, Residents #42, #61, #48, #58, #45, and #73.

Inspectors wroteBased on staff interview, resident interview, and clinical record review, it was determined the facility staff failed to provide care and services to promote the highest level of well-being for four of 43 residents in the survey sample, Residents #45, #235, #13 and #336.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to staff accordingly to ensure the director of nursing did not serve as a floor nurse for five of 30 days reviewed for nurse staffing.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications at a error rate of less than 5%. There were eight errors out of 28 opportunities, with a medication error rate of 28.57%.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to maintain an effective training program for six of ten employee record reviews and failed to develop and implement a training program based on the facility assessment.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training on QAPI for five of seven employee records reviewed, CNA (certified nursing assistant) #8, CNA #5, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper.

Inspectors wroteBased on staff interview and employee record review it was determined that the facility staff failed to ensure that four of five CNA (certified nursing assistant) records reviewed received the required 12 hours of annual training, and/or received annual dementia training, CNA #8, CNA #3, CNA #9 and CNA #10.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for one of 43 residents in the survey sample, Resident #17.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect one of 43 residents in the survey sample, Resident #136, from verbal abuse from another resident, Resident #38.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident from misappropriation of medication for one of 43 residents in the survey sample, Resident #64.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to prevent a resident from being chemically restrained for one of 43 residents in the survey sample, Resident #17.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide the receiving facility the care plan goals upon transfer for one of 43 residents in the survey sample, Resident #45.

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the baseline care plan for two of 43 residents in the survey sample, Resident #235, and Resident #336.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 43 residents in the survey sample, Residents #58, and #336.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to ensure communication devices were in place for one of 43 residents in the survey sample, Resident #47.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to dependent residents for two of 43 residents in the survey sample, Residents #25 and #17.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide individualized resident centered activities for one of 43 residents in the survey sample, Resident #47.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for 2 (two) of 43 residents in the survey sample, Residents #76 (R76) and R16.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for one of 43 residents in the survey sample, Resident #63.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician oversight of a resident's care for one of 43 residents in the survey sample, Resident #336.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility failed to have sufficient staffing for the nurse to give the medications in the prescribed timeframe on one of two units.

Inspectors wroteBased on staff interview and employee record review it was determined that the facility staff failed to ensure that three of five CNA (certified nursing assistant) records reviewed received annual performance reviews, CNA #3, CNA #9 and CNA #10.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for two of 43 residents in the survey sample, Residents #61, and #48.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to prevent residents from receiving unnecessary psychoactive medications for one of 43 residents in the survey sample, Residents #17.

Inspectors wroteBased on staff interview, and clinical record review, and facility document review, it was determined that facility staff failed to obtain physician ordered laboratory tests for 1 (one) of 43 residents in the survey sample, Residents #65 (R65).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for three of 43 residents in the survey sample, Residents #48, #47, and #336.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control measures for three of 43 residents in the survey sample, Residents #17, #25, and #85.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training on effective communication for one of seven employee records reviewed, CNA (certified nursing assistant) #8.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training on resident rights and facility responsibilities for one of seven employee records reviewed, CNA (certified nursing assistant) #8

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training compliance and ethics for two of seven employee records reviewed, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training on meeting behavioral needs for four of seven employee records reviewed, OSM (other staff member) #3, an occupational therapist, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide the care and services to treat a pressure injury for one of seven residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services for a urinary catheter for one of seven residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the care plan for one of seven residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff to prevent the misappropriation of resident property, specifically narcotic medications, for five of 37 residents in the survey sample, Resident #128, #52, #22, #129, and #27. This is cited as past non-compliance.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) care for one of 37 residents, Resident #276.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services for indwelling urinary catheter care for one of 37 residents, Resident #276.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure medications were available for administration for two of 37 residents, Resident #276 and Resident #48.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain two of two shower rooms in a sanitary manner, Rosewood and Dogwood hall shower rooms.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review an advanced directive periodically for one of 37 residents in the survey sample, Resident #51.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to notify the physician of the inability to administer newly ordered medications for one of 37 residents in the survey sample, Resident #276.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of the required documents sent to the receiving facility upon transfer, for two of 37 residents in the survey sample, Residents #30 and #48.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to develop and implement a baseline care plan for one of 37 residents in the survey sample, Resident #276.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 37 residents in the survey sample, Residents #51 and #66.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the medication administration for two of 37 residents in the survey sample, Resident #13 and Resident #48.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to administer oxygen per the physician's order for one of 37 residents in the survey sample, Resident #66.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store food in a safe manner in one of two unit nourishment rooms, the dogwood nourishment room, and failed to serve food in a sanitary manner on one of two units, the rosewood unit.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement their policy for ensuring that all staff were fully vaccinated for COVID-19, or who have been granted exemptions for three of 79 employee records reviewed.

Inspectors wroteBased on observation, staff interview, facility document review, clinical record review, and during the course of a complaint investigation, it was determined that the facility staff failed to provide behavioral health services such as conducting individualized assessments and person centered planning, related to residents who demonstrated or expressed suicidal ideation, for six of 41 residents in the survey sample, Resident #230, Resident #59, Resident #20, Resident #24, Resident #61 and Resident #13. On 8/25/21, Resident #230 expressed thoughts of self- injury documented on the MDS-Section D-Letter I., and was not further assessed by facility staff. Safety interventions and behavioral health services were not put in place. On 8/31/21, Resident #230 was found by staff at approximately 3: [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence notification to the ombudsman of hospital transfer/discharges for four of 41 residents in the survey sample, Residents #331, #71, #129, and #45. 1. The facility staff failed to notify the ombudsman of Resident #331's discharge to the hospital on 9/17/21. 2. The facility staff failed to provide written notification of transfer to the ombudsman for Resident #71, when the resident was transferred to the hospital on 9/26/21. 3. Resident #129 was transferred to the hospital on 9/20/21. The facility staff failed to provide written notification of the transfer to the ombudsman. 4. The facility staff failed to evidence that the ombudsman was notified of a facility-initiated transfer on 08/05/2021 for Resident # 45.

Inspectors wroteBased on observation, resident interview, family interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 41 residents in the survey sample, Residents #53, #26, #33, #8, #24, #28, #129, and #59.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care and services for the treatment of a pressure ulcer for two of 41 residents in the survey sample, Residents #26 and #33. The facility staff failed to provide preventative pressure ulcer treatments, and failed to provide treatments for Resident #26's pressure ulcer and Resident #33's pressure ulcer on multiple dates in August, September, and October 2021.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services related to dialysis consistent with the plan of care for one of 41 residents in the survey sample, Resident #26. The facility staff failed to ensure assessments of Resident #26 prior to, and post dialysis appointments as ordered, and failed to communicate with the dialysis center on multiple occasions during August, September, and October 2021.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to evidence documentation that COVID-19 testing was completed for fourteen of 45 employee reviews. The facility staff failed to evidence documentation that COVID-19 testing was completed and the results of each staff test for multiple employees in September 2021 and October 2021.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an operational call bell system for two of 41 residents in the survey sample, Residents #8 and #130.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care in a manner to ensure dignity for one of 41 residents in the survey sample, Resident #28. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) in a dignified manner. Urine in the catheter bag was observed from the hall while Resident #28 was lying in bed.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide accommodation of needs for two of 41 residents in the survey sample, Residents #8 and #28. The facility staff failed to ensure Resident #8 and Resident #28's call bell or ring bell was within reach.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to notify the physician of a possible need to alter treatment for two of 41 residents in the survey sample, Residents #24 and #129. The facility staff failed to notify Resident #24's physician when the medication Eliquis was not available for administration on 7/5/21 and 7/29/21, and failed to notify Resident #129's physician when the medication guaifenesin was not available for administration on 9/28/21, 9/29/21 and 9/30/21.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for one of 17 residents in the survey sample, Resident #102. Resident #102 was observed on multiple occasions sitting in a Broda chair (specialized reclining wheelchair) which was observed with dried yellow material on the right side of the headrest cushion and both armrests and multiple tears in the headrest cushions.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence transfer discharge requirements transfer to the hospital for one of forty-one residents in the survey sample, Resident #71. The facility staff failed to evidence required transfer documentation/documents, to include: contact information of the practitioner responsible for the care of the resident, resident information including contact information, advance directives, comprehensive care plan goals, special care instructions, and all other necessary information as applicable to ensure safe and effective transition of care for Resident #71, were provided to the receiving hospital on 9/26/21, when the resident was transferred to the hospital .

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for three of 41 residents in the survey sample, Residents #130, #229 and Resident #230. 1. The facility staff failed to develop a baseline care plans for Resident #130 who was admitted to the facility on [DATE]. 2. The facility staff failed to develop a baseline care plans for Resident #229 admitted to the facility on [DATE]. 3. The facility staff failed to develop a baseline care plan to address Resident #230's mood and statements regarding self harm.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 41 residents in the survey sample, Residents #331 and #8. The facility staff failed to revise the comprehensive care plan for Resident #331 to address a urinary catheter and failed to review and revise Resident #8's comprehensive care plan for the use of bed rails.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 41 residents in the survey sample, Resident #33. The facility staff failed to clarify two conflicting physician orders for treatment of a Stage 3 pressure ulcer.

Inspectors wroteBased on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care assistance to one resident dependant on staff for care, (Resident #53), in a survey sample of 41 residents. Resident #53, who was coded as being dependent on the assistance of staff for personal hygiene and bathing, was not provided a shower or bed bath by facility staff on multiple occasions during August and September 2021.

Inspectors wroteBased on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to maintain the highest level of well-being for two of 41 residents in the survey sample, Residents #26 and #129. 1. The facility staff failed to monitor Resident #26's fluid intake as ordered by the physician. 2. a. The facility staff failed to ensure the medication guaifenesin (1) was available for administration to Resident #129 on 9/28/21, 9/29/21 and 9/30/21. 2. b. The facility staff failed to obtain Resident #129's weekly weight per physician's order on 8/16/21.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care and services for a Foley catheter for two of 41 residents in the survey sample, Residents #28 and #331. 1. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) tubing and bag in a manner to prevent infections. The resident's tubing and bag were observed directly touching the floor on 10/20/21. 2. The facility staff failed to ensure medical justification for Resident #331's indwelling catheter and failed to ensure the catheter was discontinued as soon as clinically warranted.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record, it was determined that the facility staff failed to provide respiratory services consistent with professional standards for one of 41 residents in the survey sample, Resident #129. The facility staff administered oxygen to Resident #129 without a physicians order.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement a complete pain management program for one of 41 residents in the survey sample, Resident #70. The facility staff failed to attempt non-pharmacological interventions for Resident #70 prior to the administration of as needed acetaminophen (Tylenol) on 9/19/21, 10/6/21, 10/12/21 and 10/16/21.

Inspectors wroteBased on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet the needs of two of 41 residents in the survey sample, Residents #53 and #129. 1. The facility did not provide sufficient staffing to ensure a shower/bath was provided on multiple occasions in August and September 2021, to Resident #53, who was assessed as being dependent on the assistance of staff for personal hygiene and bathing. 2. The facility staff failed to provide sufficient staffing to obtain Resident #129's weight per the physician's order on 8/16/21.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of three CNA record reviews, (CNA #6) The facility staff failed to complete an annual performance review for CNA #6.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide pharmacy services for two of 41 residents in the survey sample, Resident #24 and Resident #53. 1. The facility staff failed to assure the medication Eliquis (1) was available for administration to Resident #24 on 7/5/21 and 7/29/21. 2. The facility staff failed to assure the medication Diazepam was acquired, and received for administration to Resident #53, per the physician order on 10/21/21 through 10/23/21.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to ensure a resident was free from a significant medication error for one of 41 residents in the survey sample, Resident #24 The facility staff failed to administer the blood thinning medication Eliquis (1) to Resident #24 on 7/5/21 and 7/29/21.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide laboratory testing for one of 41 residents in the survey sample, Resident #26. The facility staff failed to provide laboratory testing ordered for Resident #26 on 9/30/20.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate medical record for two of forty-one residents in the survey sample, Resident #230 and Resident #2. 1. The facility failed to provide a complete and accurate medical record for Resident #230, for documentation on the TAR (treatment administration record) for the wound vacuum continuously running as ordered on 8/24/21 night shift and 8/30/21 day shift, and ostomy care every shift as ordered on 8/24/21, 8/25/21 and 8/26/21 as well as day shift on 8/30/21. 2. The facility failed to provide a complete and accurate medical record for the documentation of pain levels prior to the administration of pain medication on the MAR (medication administration record) for Resident #2.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service trainings for two of three CNA record reviews, (CNA #5 and CNA #6). The facility staff failed to ensure CNA #5 completed annual abuse training and failed to ensure CNA #6 completed annual dementia or abuse training.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to post current nurse staffing information. Nurse staffing information for 10/19/21 was not posted on 10/19/21. Instead, nurse staffing information for 10/8/21 was posted.