Fairfield Nursing & Rehabilitation Center

Based on surveyor observation, facility staff interview, and surveyor record review it was determined that the facility failed to follow appropriate respiratory care and services. This finding was found to be evident in 1 (Resident #42) out of 1 Resident reviewed for respiratory care and services.The findings include:On tour of the long-term care (LTC) unit on 11/17/2025 at 7:45 AM the surveyor observed Resident #42 in bed with an oxygen concentrator and an oxygen emergency tank in the room. Additionally, it was observed that the oxygen humidifier bottle was dated 9/16. There was no oxygen signage posted on Resident #42's room door upon entry to the room. Resident #42 stated that he/she had not used oxygen in a while.In an interview at 8:22 AM on 11/17/2025 with the RN Unit Manager, the surveyor conveyed that Resident #42 had an oxygen concentrator and an oxygen emergency tank in the room, however there was no oxygen signage on Resident #42's room door. The RN Unit Manager observed with the surveyor the oxygen concentrator, the oxygen emergency tank, the oxygen humidifier bottle,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, it was determined that the facility failed to adhere to professional standards of practice for medication disposition. This was found to be evident in 1 out of 2 carts reviewed for medicine storage.The findings include:On 11/20/2025 at 9:28 AM, during surveyor review of a medication storage cart with LPN #11 and found the following expired medications: gabapentin 100 mg, glimepiride 2 mg, carvedilol 6.25 mg, pantoprazole 40 mg, dexamethasone 2 mg and trazodone 100 mg. The expired medications were in blister packs, lodged between the locked medication box and a drawer divider. The surveyor also found expired therapeutic nutritional supplements, Suplena and Boost, on the cart. The Director of Nursing removed the expired medications and supplements from the cart on 11/20/2025 at 9:30 AM. She stated the pharmacy recently completed a review of the carts and stated the facility would need to perform further review.

Based on observation and interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu. This was evident for 1 (#10) 2 residents reviewed for food during the survey.The findings include:On 11/21/25 at 12:30 PM, the surveyor reviewed the lunch that was provided to Resident #10 along with the meal ticket. The surveyor noted there was no nectar thickened tomato juice nor pureed fresh baked roll, which were both listed on the meal ticket. The surveyor asked Resident #10 if these items had come on the lunch tray. Resident #10 stated that they didn't and that if they were available, he/she would like these items.Next the Surveyor reviewed the scheduled lunch menu. The regular menu was breaded Fried fish, stewed tomatoes, fresh baked roll, cream pie and macaroni & cheese cup.On 11/21/25 at 12:37 PM, the surveyor interviewed the Certified Dietary Manager (CDM). During the interview the CDM confirmed that he did not have nectar thick tomato juice available. He further stated that the kitchen does not puree rolls. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined that the facility failed to perform hand hygiene between resident encounters. This was evident for 1 (Resident #72) out of 6 medication passes observed during the recertification survey.The findings include:During a med pass on 11/20/2025 at 8:32AM, the surveyor observed LPN #19 exit Resident #72's room and begin preparing medications for another resident without performing hand hygiene. When asked the facility policy for performing hand hygiene between residents LPN #19 stated, I am supposed to perform hand hygiene after each resident encounter. A bottle of hand sanitizer sat on the medication cart. The Director of Nursing acknowledged the concern of the missed opportunity for hand hygiene during an interview on 11/20/2025 at 9:30 AM.

Based on observations, staff interviews and record reviews, it was determined that the facility failed to ensure that a Resident's environment was free from accident hazards related to the compatibility of a Resident's mattress and bed frame. This finding was found to be evident in 1 (Resident #12) out of 1 Resident reviewed for accident hazards and Resident beds.The findings include:On the initial tour of the nursing facility on 11/17/2025 at 7:45 AM the surveyor observed Resident #12 in bed in the Resident room in no distress. The surveyor observed that Resident #12 had a gap between the end of the mattress and the footboard of the bed frame. Additionally, the surveyor observed that there was a long blue pillow in the gap between the end of the mattress and the footboard of the bed.In an interview with the Director of Nursing (DON) on 11/17/2025 at 1:09 PM the surveyor conveyed that Resident #12 had a pillow between the end of the mattress and the footboard of Resident's bed and that this was a concern for Resident's safety. The DON acknowledged the surveyor and Resident #12's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined the facility failed to 1) ensure that the resident's call system was functioning properly and 2) failed to have a call light device accessible for a Resident to call for staff assistance. This was found to be evident for 1 (Resident #25) for call light function and 1 (Resident #42) out of 8 Residents reviewed for Resident call system accessibility. The findings include:1) On 11/17/25 at 10:24 AM, the surveyor asked Resident #25 to push his/her call button. On 11/17/25 at 10:25 AM, the surveyor observed Unit Manger #6 walk into Resident #25's room. On 11/17/25 at 10:25 AM, the surveyor asked UM #6 if Resident #25's call button was on. UM #6 stated that she had heard the call light on at the nurse's station but was not sure who's call light it was. She stated that no light was on in the hallway above Resident #25's room. The surveyor asked UM #6 to push the call button to see if the light would come on. UM #6 then pushed the call button. Again, no light came on in the hallway above Resident 25's room. Resident #25 stated that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and record reviews it was determined that the facility failed to provide a safe, functional, sanitary and comfortable environment for a Resident and staff. This finding was found to be evident for 2 (Resident #24 & #33) out of 33 Residents reviewed for a safe, functional, sanitary and comfortable environment and in the laundry and parking lot area. The findings include: 1. The surveyor conducted an initial tour of the facility on 11/17/2025 at 7:45 AM. The surveyor observed Resident #24's room. The toilet in Resident #24's bathroom was observed as inoperable, specifically the toilet was not attached to the sewer hole/line, and the toilet was resting next to the sewer hole/line with a cloth stuck in the hole in the floor. Resident #24 was sitting in a wheelchair in the room and stated that the toilet had been broken since last week and maintenance was working on it. In an interview with the Director of Nursing (DON) and the RN Unit Manager at 9:45 AM on 11/17/2025 the surveyor conveyed that Resident #24 had a toilet in the bathroom that was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and facility staff interviews, it was determined that the facility failed to ensure all corridors had firmly installed handrails on each side.The findings include:On 11/20/25 at 11:29 AM, the surveyor observed a resident in a wheelchair grasping with both hands the hall handrail adjacent to the kitchen hallway. Next the surveyor observed Human Resource Director Staff #17 assist the Resident off the handrail and wheeled him/her to the requested destination. The surveyor observed that there were no hallway handrails in the hallway of the front entrance nor back past the dining area towards the Atlantic units. The resident was observed between these two areas.On 11/21/25 at 7:20 AM, the surveyor reviewed the observations with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA agreed that there were no handrails in the front lobby or hallway leading to the dining room areas and agreed that residents use these areas.

Based on complaint, interview, and medical record review, it was determined the facility failed to follow professional standards of practice when administering medications. This was evident for 4 (#14, #8, #17, #20) of 25 residents reviewed during a complaint survey.The findings include:The 6 rights of medication administration are the right patient, the right drug, the right does, the right route of administration, the right time, and the correct documentation. Administering medications at a time that was intended by the prescriber. Certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Nurses should not deviate from the time by more than 1 hour to avoid consequences. Nurses must sign off that medications were given immediately after the medication was given to prevent double dosing and ensuring accuracy.1.On 9/12/25 at 11:37 AM a review of complaint 323366 alleged that Resident #14 was given Metformin (diabetic medication) after he was instructed to not take the medication for 2 days after a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint, medical record review, observation, and interview, it was determined the facility staff failed to provide showers twice weekly to residents. This was evident for 5 (#19, #13, #17, #24, #15) of 25 residents reviewed during a complaint survey. The findings include: 1.On 9/12/25 at 9:04 AM a review of complaint 323357 alleged that Resident #19 was being neglected at the facility. On 9/12/25 at 9:04 AM a review of Resident #19's medical record revealed the resident was admitted to the facility in February 2024 with diagnoses that included but were not limited to systemic lupus erythematosus, chronic pain, heart failure, muscle wasting, and a cognitive communication deficit.Review of Resident #19's physician's orders documented the resident could shower on Tuesdays and Thursdays in the evening.Further review of Resident #19's medical record revealed the facility staff assessed the Resident on 3/23/24 to require substantial/maximal assistance for showering and bathing. Review of geriatric nursing assistant (GNA) shower/bathing documentation revealed in April and May…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, observations, and interview, it was determined the facility failed to maintain a working call bell system. This was evident for 1 (Capitol) of 2 nursing units observed during a complaint survey.The findings include:On 9/16/25 at 10:30 AM a review of complaint 323371 was conducted and it was alleged that the family pushed the call bell button in room [ROOM NUMBER]-A, which was on the Capitol unit, and the light did not illuminate in the hall. It was alleged that the family was told that the call bell was not in working order at the desk or the volume was turned down. On 9/16/25 at 10:45 AM the surveyor went in room [ROOM NUMBER] A. The resident was not in the room at that time. The surveyor pushed the call bell button and walked outside in the hallway. There was no audible sound in the hallway, however the light was illuminated over the doorway. The surveyor went back into room [ROOM NUMBER] and went to bed B and asked permission from the resident to activate the call bell. The surveyor pushed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint, observations, and interview, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, visitors, and staff. This was evident in 2 of 2 outside areas during a complaint survey.The findings include. On 9/11/25 at 8:15 AM a review of complaint 323356 alleged that the resident's outside area is a disgrace. Wooden planter boxes falling apart and crumbling concrete. On 9/11/25 at 12:34 PM observation was made with the Maintenance Director (staff #4) of the courtyard where the residents were permitted to smoke. The wooden flower bed planter boxes were grayish colored old wooden boards that were dilapidated and falling apart. There were multiple concrete areas on the patio that had broken, crumbled, and chipped pieces of concrete that made the area uneven to walk on and there were multiple sizes of rocks scattered throughout the area. Staff #4 stated that the flower beds had not been used in 6 to 7 years, and he said a couple of people have wanted to come in and fix them. Staff #4 stated that the flower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 1 (#15) of 25 residents reviewed during a complaint survey.The findings include: On 9/11/25 at 9:00 AM a review of complaints 323365 and 323375 was conducted and alleged that call lights were either not answered timely or not available for the residents. On 9/11/25 at 10:20 AM observation was made of Resident #15 lying in bed. There was a small hand bell on the bed tray table. The surveyor observed a white cord attached to the wall activated call bell system. The cord was lying on the floor on the right side of Resident #15's bed. The surveyor asked why the resident had a bell on the tray table. Resident #15 stated, “so I can call the nurse.” Resident #15 stated, “most of the time I just yell because they don't come when I ring the bell.” The surveyor rang the hand bell at 10:24 AM. There was no response so at 10:28 AM the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #4). This was evident for 1 of 3 residents reviewed for MDS assessments during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #4's medical record on 9/11/25 revealed the Resident was admitted to the facility in 2015 and has a diagnosis of dysphagia. Dysphagia is the medical term for difficulty swallowing food or liquids. Review of Resident #4's weights documented by facility staff revealed the Resident weighed 213 pounds on 9/5/24. Review of Resident #4's 10/2/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint, medical record review, and interview, it was determined that the facility failed to have a care plan meeting after an MDS assessment. This was evident for 1 (#13) out of 14 residents reviewed for complaints during a complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 9/11/25 at 8:15 AM a review of complaint 323367 alleged that Resident #13 was sent back to the facility from the hospital after a 6 week stay and there was no care plan meeting held to discuss the patient's treatment and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint, medical record review, and staff interview, it was determined the facility staff failed to provide wound care treatment as prescribed by the physician. This was evident for 2 (#19, #14) of 4 residents reviewed for wound care during a complaint survey.The findings include:1.On 9/12/25 at 9:04 AM a review of complaint 323357 alleged Resident #19 had a wound on the left leg that had become infected and did not have proper wound care.Review of Resident #19's medical record revealed the resident was admitted to the facility in February 2024 with diagnoses that included but were not limited to systemic lupus erythematosus and history of venous thrombosis and embolism.Review of a 5/29/24 wound management note documented a venous wound of the left calf with undetermined thickness. The treatment plan was, skin prep apply every shift (3 times a day) for 30 days.Review of a 6/5/24 wound management note documented the treatment plan was, silver sulfadiazine apply once daily for 30 days; alginate calcium apply once daily for 30 days.Review of a 6/12/25 wound management note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#7) 3 residents reviewed for pressure ulcers during a complaint survey.The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 9/16/25 at 11:30 AM a review of Resident #7's medical record revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility staff failed to follow recommendations from the dietitian timely and notify the Resident's physician or nurse practitioner of the Resident's continued weight loss (Resident #4). This was evident for 1 of 3 residents reviewed for nutritional status during a complaint survey. The findings include: Review of Resident #4's medical record on 9/11/25 revealed the Resident was admitted to the facility in 2015 and has a diagnosis of dysphagia. Dysphagia is the medical term for difficulty swallowing food or liquids. Review of Resident #4's weights documented by facility staff revealed the Resident weighed 213 pounds on 9/5/24. Further review of Resident #4's medical record revealed Staff #36 (former Dietitian) saw the Resident on 2/4/25 for weight loss and documented the Resident's weight as 200.8 pounds. At that time the Dietitian ordered Med Pass 2.0 twice a day for 30 days. Med Pass is a fortified nutritional shake that provides a way to supplement calories and protein. Further review of Resident #4's medical record revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and facility staff interviews, it was determined that the facility staff failed to ensure that either the attending physician, physician assistant or nurse practitioner visited residents at the required intervals of every 60 days (Resident #4). This finding was evident in 1 of 3 residents reviewed for physician visits during a complaint survey. The findings include: Review of Resident #4's medical record on 9/11/25 revealed the Resident was admitted to the facility in 2015 and transferred to the hospital on 9/6/25. Review of Resident #4's physician, physician assistant and nurse practitioner notes from January 2025 until 9/6/25 revealed the Resident was not seen from 4/25/25 until 7/11/25 for a total of 76 days. During interview with Staff #35 on 9/17/25 at 9:00 AM, Staff #35 stated she could not see any physician, physician assistant or nurse practitioner notes from 4/25/25 until 7/11/25. Interview with the Assistant Director of Nursing on 9/17/25 at 9:45 AM confirmed Resident #4 has no documented visits from a physician, physician assistant or nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff, it was determined the facility failed to timely provide medication to meet the needs of the residents. This was evident for 1 (#8) of 25 residents reviewed during a complaint survey. The findings include: On 9/10/25 at 9:37 AM Resident #8's medical record was reviewed and revealed Resident #8 was admitted to the facility on [DATE] from an acute care facility for rehabilitation. Resident #8's diagnoses included but were not limited to paralytic syndrome following cerebral infarction, pain, hypertension, dementia, restless leg syndrome, neuralgia/neuritis, and a sacral ulcer. Review of June 2025 physician's orders revealed a 6/19/25 order for Tramadol 50 mg. to be given 4 times a day at 9:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM was written. Tramadol is a strong opioid pain medication prescribed for the treatment of moderate to moderately severe pain in adults. Review of Resident #8's June 2025 Medication Administration Record (MAR) documented the Tramadol was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor a resident's blood pressure when there were physician ordered blood pressure parameters. This was evident for 1 (#8) of 25 residents reviewed during a complaint survey.The findings include: On 9/10/25 at 9:37 AM Resident #8's medical record was reviewed and revealed Resident #8 was admitted to the facility on [DATE] from an acute care facility for rehabilitation. Resident #8's diagnoses included but were not limited to paralytic syndrome following cerebral infarction, pain, hypertension, dementia, restless leg syndrome, neuralgia/neuritis, and a sacral ulcer. Review of June 2025 physician's orders revealed there were 3 medications ordered for blood pressure, which were Isosorbide Monotrate 30 mg., Lisinopril 20 mg., which were to be administered at 9 AM once a day and hydralazine 25 mg. which was to be administered 3 times a day at 9 AM, 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, observation, staff interview, and documentation review, it was determined that facility staff failed to keep medication carts locked when unattended, failed to date medications when opened, and refrigerate medication that required refrigeration. This was evident on 1 of 2 nursing units observed during random observations made during a complaint survey. On 9/10/25 at 8:30 AM a review of complaint 323371 was conducted and alleged that on the weekends medication carts were left unlocked all day.On 9/11/25 at 10:55 AM observation was made of an unlocked and unattended medication cart sitting in the 200 hallway outside of room [ROOM NUMBER]. The surveyor heard the nurse in room [ROOM NUMBER], however the nurse (staff #20) had her back to the door and was standing up towards the head of the resident's bed and the medication cart was not in her sight. The surveyor was able to open the cart and observed the top drawer with a cup of pre-poured medications. There were 12 whole pills and 2 half pills in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility staff failed to obtain follow up dental services for a resident (Resident #4). This was evident for 1 out of 3 residents reviewed for dental services during a complaint survey. The findings include: Review of Resident #4's medical record on 9/11/25 revealed the Resident was admitted to the facility in 2015 and had a diagnosis of dysphagia. Dysphagia is the medical term for difficulty swallowing food or liquids. Further review of Resident #4's medical record revealed a Nurse Practitioner (NP)'s note on 2/10/25 that stated, Nursing reports patient had a 12 lb weight loss in a month. Per patient, he/she reports not having proper fitting dentures. Spoke with nursing manager regarding this. Informed that nurse manager will follow up with dentist regarding this to have patient refitted for dentures. Further review of Resident #4's medical record revealed the Resident was examined by the Registered Dental Hygienist (RDH) on 6/24/25. The RDH documented, Patient has pain on #29 and also wants dentures. Dentist will be seeing patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident received their prescribed diet with the prescribed consistency. This was evident for 2 (#6, #9) of 8 residents observed in the dining room during a complaint survey.The findings include:On 9/11/25 at 1:40 PM observation was made of 8 residents sitting in the dining room eating lunch. The surveyor walked around to each table to ask the residents how their food was. Resident #6 complained that the food was not good. Review of Resident #6's lunch tray ticket documented the resident had a house, mechanical soft, ground, minced moist diet. The first entree was ground chicken parmesan. Observation of the food on Resident #6's plate revealed cubed chicken parmesan. The meat was not ground.Observation was made of Resident #9's lunch tray ticket. It was documented that Resident #9 had a house mechanical soft ground meat diet. The first entree on the tray ticket was, ground alternate entree. The meat on the plate was in chunks and was not ground.On 9/11/25 at 1:40 PM Staff #25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint, medical record review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#19) of 25 residents reviewed during a complaint survey.The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. On 9/12/25 at 9:04 AM a review of complaint 323357 alleged that Resident #19 was being neglected at the facility. The complaint alleged that Resident #19 was often not fed due to short staffing and the resident's spouse had to visit to feed the resident to ensure the resident was fed.On 9/12/25 at 9:04 AM a review of Resident #19's medical record revealed the resident was admitted to the facility in February 2024 with diagnoses that included but were not limited to systemic lupus erythematosus,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to arrange Hospice services for a resident who requested the services. This was evident for 1 (#7) of 25 residents reviewed during a complaint survey.The findings include:On 9/16/25 at 11:30 AM a review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] from an acute care facility.A 2/12/25 at 22:00 PM nursing note documented that Resident #7's sister stated Resident #7 has had cancer for 2 years and it had spread to the resident's brain. The sister stated Resident #7 had 10 rounds of radiation and it was not successful. The sister stated she talked to a hospice nurse at the hospital and did not know if Resident #7 was now admitted to the facility for rehabilitation, palliative or comfort care.A 2/15/25 at 13:00 PM nursing note documented, Pt. and family states pt. wants hospice services. Pt stated [he/she] is tired and wants to go peacefully and comfortably r/t 2 yr. battle. Pt.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to conduct and document timely care plan meetings for residents. This was evident for 4 (#46, #4, #69 and #21) out of 6 residents reviewed for care planning. The findings include: 1. A review of Resident #46's clinical record on 4/17/24 revealed that the resident had a care plan conference on admission but not since. There was no evidence that the resident and/or responsible party were invited to a meeting. The Social Work Director was interviewed on 4/17/24 at 9:58 AM. She said the resident had a meeting on admission but not since. She said she could not find any invitations to a care plan meeting. She returned on 4/19/24 with a copy of a care plan conference report. It only showed a care plan invite by phone on 10/5/23. The resident should have had care plan meetings on or before 1/3/24 and 4/3/24. A review of Resident #4's clinical record on 4/25/24 revealed that the last care plan conference was held on 9/14/23.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview it was determined that the facility failed to: 1) maintain a resident's bed in the low position, maintain a clean floor in a resident's room, ensure a resident's safety fall mats were in place, ensure medication carts were secured at all times when not in use and 2) failed to implement measures to reduce resident safety risks when building doors and patio gates were unlocked during the after hours. This was evident for 2 (#4 and #14) out of 56 sampled residents, 1 random observation of medication carts, and four doors of building entrances/exits observed during the annual survey. The findings include: 1. A care plan is a formal process that includes identifying an issue and/or need that is addressed through a carefully considered plan of action. A review of Resident #4's clinical record revealed that the resident had a care plan to address being at risk for falls. The facility developed an approach which included the intervention that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents who eat the food prepared in the facility's kitchen. The findings include: During an initial tour of the facility's kitchen conducted on 04/15/24 at 8:30 AM, the Surveyor observed the dry food storage space in a corner of the food preparation area of the kitchen. The Surveyor noted an opened and unlabeled 25lb bag of Sysco sugar, 25lb bag of flour, and 25lb bag of Par Excellence whole grain brown rice stored in large, covered containers setting on the floor. The Surveyor also noted an opened and unlabeled 1 gallon jug of teriyaki sauce, 5lb plastic container of classic mashed potatoes, bottle of soy sauce, 5lb container of creamy peanut butter, and an expired bag of powdered pancake mix wrapped in plastic wrap setting on a shelving unit. During a continued tour of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure the call light system was available, functional and operational for all residents. This was evident for 6 residents (Resident #15, #33, #8, #18, #22, and #36) out of 76 residents screened during the initial phase of the recertification survey. The findings include: The Brief Interview for Mental Status (BIMS) assessment is a 15-point cognitive screening used to screen and identify the cognitive condition of residents. It's a structured evaluation aimed at evaluating aspects of cognition in elderly patients. The BIMS score interpretation is, 0 - 7: Severe cognitive impact, 8 - 12: Moderate impairment, 13 - 15: Intact cognitive response. On 04/15/2024 11:18 AM surveyors toured the unit and entered Resident #15's room. Surveyors observed that Resident # 15 was laying in bed, the call light device was unplugged from the wall with the activation button resting on the bedside table out of the resident's reach. Surveyors did not observe any other call device within resident reach or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure residents are offered two showers each week. This was evident for 1 (#28) out of 56 residents in the survey sample. The findings include: This surveyor interviewed Resident #28 on 4/16/24 at 11:30 AM. The resident stated he/she gets only bed baths and has not had a shower in two years. Review of Resident #28's clinical record revealed the resident has only received bed baths since 1/1/24. The resident stated a preference for having showers. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed on 4/30/24 at 3:00 PM. They were informed of the resident's statement that showers have not been provided. They replied that the resident was initially admitted to the rehabilitation side and the resident was informed that the resident has to let the facility know when a shower is requested. They said the resident refused showers because of his/her preference. The DON said she asked the resident if he/she wanted a shower and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure residents were offered an opportunity to complete Advance Directives upon admission. This was evident for 3 (#14, #38, #46) out of 9 residents reviewed for Advance Directives. The findings include: 1. Resident #14's clinical record was reviewed on 4/16/24 at 1:50 PM. An Advance Directive was not found in the clinical record nor was there evidence that it had been offered to be completed. 2. Resident #38's clinical record was reviewed on 4/16/24 at 1:58 PM and again on 4/19/24 at 9:30 AM. An Advance Directive was not found in the clinical record nor was there evidence that it had been offered to be completed. 3. Resident #46's clinical record was reviewed on 4/17/24 at 10:20 AM and again on 4/19/24 at 9:15 AM. An Advance Directive was not found in the clinical record nor was there evidence that it had been offered to be completed. The Social Work Director was interviewed on 4/19/24 at 8:36 AM. She said, when a resident is admitted , a Maryland Order for Life Saving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation it was determined that the facility nursing staff failed to ensure a resident's medical information was kept private. This was evident for 1 (#59) out of 56 residents that are in the survey sample. The findings include: During the facility task of observing medication administration on 4/25/24 at 9:23 AM, Staff #3 was observed leaving the medication cart to enter a resident's room. Staff #3 locked the cart but left a medication packet on top of the cart. The medication packet had Resident #59's name and a list of their medications on it. The medications were risperidone (treats mental illness), Eliquis (an anti-coagulant), Lasix (diuretic), and potassium chloride (mineral pill). The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were informed of the findings on 4/30/24 at 3:00 PM.

Based on record review and interview with staff, it was determined that the facility failed to notify the resident or resident representative in writing of the reason for transfer to the hospital. This was found to be evident for 2 (Resident #69 and Resident #35) of 4 residents reviewed for hospitalizations during the investigative portion of the annual survey. The findings include: On 4/17/24 at 10:15AM, a review of Resident #69's electronic medical record revealed that the resident was transferred to the hospital on 1/17/2024 due to a dislodged foley catheter with bleeding and returned on 1/22/24 for ongoing care. Additional review of the electronic medical record and the physical chart revealed that there was no documentation to indicate that the resident nor his/her representative was notified in writing of the hospital transfer on 1/17/24. On 4/22/24 at 12:42PM, a review of Resident #35's electronic medical record revealed that the resident was transferred to the hospital on 3/13/24 for altered mental status and to rule out a stroke and he/ she returned to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure baseline care plans were developed for the residents. This was evident for 1 (#28) out of 6 residents reviewed for care plans. The findings include: A review of Resident #28's clinical record revealed the resident was admitted on [DATE] and had care plan conferences on 8/1/23 and 10/26/23. A baseline care plan that should have been created within 48 hours of admission was not in the clinical record nor was there a comprehensive care plan within 48 hours of admission. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed on 04/30/24 at 03:00 PM. They were informed of the absence of a baseline care plan. An explanation was not provided and a baseline care plan was not shown to this surveyor prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, observation, and clinical record review it was determined that the facility staff failed to: 1) ensure a resident had the opportunity to participate in an activity program, and 2) provide an ongoing resident-centered activities program to improve or maintain the resident's mental and psychosocial well-being. This was evident for 3 (#28, #46 and #6) out 5 residents reviewed for activities. The findings include: 1. Resident #28 was interviewed on 4/16/24 at 11:47 AM. The resident stated that he/she is okay with never being out of the room but was unclear if ever encouraged to leave. The resident stated he/she likes music. A review of the resident's clinical record revealed that the last note from the Activities Director was in January. This surveyor observed the resident on 4/16/24, 4/18/24, 4/19/24, 4/22/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, and 4/29/2024. The resident was observed and neither the television nor the radio were on. The Activities Director (Staff #22)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview it was determined that the facility staff failed to ensure a resident was repositioned. This was evident for 1 (#28) out 56 residents in the survey sample. The findings are: Resident #28 was observed on 4/16/24 at 11:46 AM to be on their back in bed and with their feet up against the footboard of the bed. Resident #28 was observed on 4/18/24 at 1:54 PM lying in bed on their back while being fed lunch. Resident #28 was observed on 4/23/24 at 2:15 PM lying in bed on their back. Resident #28 was observed on 4/24/24 at 12:30 PM lying in bed on their back. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed on 4/30/24 at 3:00 PM. The findings were presented to them. They said they could not explain why the resident was on his/her back but stated they would investigate.

Based on resident interview, staff interview, and observation it was determined that the residents are not provided with an adequate and/or varied diet. This was evident for 2 (#30 and #28) out of 56 residents reviewed in the survey sample. The findings include: 1. Resident #30 was interviewed on 4/16/24 at 9:39 AM. The resident stated the food is always cold and they are given only one choice for an entree. They can choose what to have in a salad on Monday, Wednesday, and Friday but sometimes there is no stuff for a salad. Resident #30 was observed to have a bag of 8-12 cups. When asked, the resident stated that the cups in the bag are cups of breakfast cereal that the resident keeps in case of hunger. 2. Resident #28 was interviewed on 4/16/24 at 11:39 AM. The resident stated that food choices are not honored, and the breakfast never changes. Survey team member interviewed the cook (Staff #8) on 4/24/24 at 5:58 AM. Staff stated that they have a standard breakfast menu with some alternatives available. When asked if they have enough food in their food supply, she reported there is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, it was determined that the facility failed to: 1) ensure a resident's personal information was not in another resident's clinical record and 2) ensure medical records were complete by voiding an old MOLST when a new MOLST was completed. This was evident for 2 (#13 and #33) of 56 residents sampled during the annual survey. The findings include: 1. A review of Resident #13's clinical record on [DATE] at 11:38 AM revealed Resident #13's Physician Order Report was in the clinical record. Facility nursing staff was informed of the finding. 2. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. Palliative or Supportive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure proper infection control practices were followed. This was evident for 3 random observations made during annual survey. The findings include: 1. During observation of the medication administration on 4/25/24 at 9:08 AM Staff #1 (certified medication aide) did not wash hands or use hand sanitizer prior to administering the medications and she administered Ocusoft eyelid cleanse wipes without gloves. 2. On the second day of medication administration this surveyor observed that the nurse (Staff #14) walked into room [ROOM NUMBER] on 4/29/24 at 9:06 AM and washed her hands in the bathroom sink. There was a poster on the door instructing nursing staff and visitors to use hand sanitizer before entering the room. She did not use hand sanitizer. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed on 4/30/24 at 3:00 PM. The findings were presented to them. ADON stated reeducation for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined that the facility failed to update a resident's care plan related to wandering. This was evident for 1 of 25 residents (#24) reviewed during the complaint survey. The findings include: Review of the medical record for Resident #24 on 1/24/24 at 10:36 AM revealed documented occurrences of an attempted elopement on 9/13/23 with documented aggression towards staff from Resident #24. Secondary to this incident, staff felt necessary to contact the facility psychiatric physician who placed Resident #24 on intramuscular Haldol due to the reported and documented aggressive behaviors. A review of the care plans failed to reveal any documentation of the medication addition or any interventions for the identified behaviors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of a facility reported incident, medical record review and interview, it was determined that the facility failed to appropriately transfer a resident. This was evident 1 of 3 residents reviewed for transfers during a complaint survey. (#19) The findings include: Review on 1/24/24 at 12:00 PM of the facility reported incident related to Resident #19 revealed an allegation that s/he fell while being transferred from the chair to the bed on 10/24/23. The facility investigation noted that Resident #19 was admitted with a fracture of the right humerus. A physician order implemented on admission [DATE] was for transferring with 2 people. According to the facility report, Staff GNA #13 stated that she did transfer Resident #19 with the mechanical lift from the chair to the bed independently. A review of the employees file revealed that she was trained on policies and procedures and completed the new hire checklist on 7/12/23. Employee #13 was retrained on the use of the mechanical lift to always use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a tour of the facility and interview, it was determined that the facility staff failed to maintain infection control procedures while providing patient care. This was evident on 1 of 2 units. The findings include: During a tour of the facility on 1/24/24 at 8:40 AM surveyor identified a staff member later identified as staff GNA #8 enter a resident room. Upon closer inspection this resident's room had a sign posted on the door stating, 'Enhanced Barrier Precautions.' The sign further stated that to provide any hands-on care to wear gloves and a gown. Resident #25 was heard asking staff to adjust him/her in bed. Staff RN # 9 was also in the room at this time. She was observed putting gloves on and proceeding to the resident's bed to adjust him/her. The surveyor stayed at the door and observed staff GNA #8 on the right side of the bed from the resident's perspective and pulled him/her up. Staff GNA #8 then exited the room, proceeded to the food cart and opened the door. He said, Oh. Then went and sanitized his hands. At this point this surveyor approached and introduced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility failed to ensure that items used for personal hygiene in a bathroom shared by Residents #4 and #25 were appropriately labeled. This was evident for 2 of 32 residents reviewed during the survey. The findings include: On 4/30/19 at about 11:50 AM, a bedpan was observed inside a wash basin and sitting on the floor in the bathroom shared by Residents #4 and #25. When the Unit Manager (#1) was interviewed, she confirmed the findings but stated, Resident #4 moves items into the bathroom and leaves them on the floor. This was confirmed in the care plan for Resident #4. However, when UM #1 was asked to look at the bedpan and wash basin to see if they were labeled with resident names, she confirmed they were not labeled. The facility is responsible to ensure that items used for personal hygiene by residents in a shared room are labeled appropriately to help prevent potential cross-contamination of infection.

Based on observation and resident and staff interview it was determined the facility failed to ensure that a call light was within reach of Resident #4. This was evident for 1 of 32 residents reviewed during the survey. The findings include: On 4/30/19 at 11:33 AM, Resident #4 was observed sitting in bed with the head of the bed up and eating breakfast. The call light was observed clipped to the right top of the bed, but the cord was caught under the bedside table. It appeared when the head of the bed was raised, the cord had pulled the call light button all the way up to where the cord was clipped. When the resident was asked if he/she could reach the call light, he/she stated, No. Unit Manager #1 confirmed the findings.