Grievance Information Not Posted or Accessible: The facility failed to provide 7 confidential residents with accessible information on how to file grievances or concerns. During Resident Council, residents stated they did not know they could file grievances anonymously and had not seen the grievance procedure posted in prominent locations. Surveyors observed the lobby postings did not include the grievance policy, filing instructions, or where to obtain a form, while the ADM stated forms were available near the staff break room and could be submitted anonymously in the same box as blank forms.
Resident Council meetings were held in the dining room instead of a private space, with staff and other residents coming in and out during the meetings. Residents stated they filtered what they said because of the lack of privacy, and the AD and Administrator both acknowledged the dining room was not private and that no sign was posted when council was in session.
Unlabeled refrigerated food items were observed in the kitchen, including red gelatin, sausage patties, and two pitchers of tea. The DS confirmed the items were not labeled and stated the tea was not labeled before being served at lunch, while the ADM stated all food in the refrigerator should be labeled and dated per facility policy.
Improper Foley Catheter Care During Incontinent Care: A resident with dementia and neurogenic bladder had an indwelling catheter, but a CNA did not secure the catheter tubing while providing incontinent/catheter care. The DON and ADM stated the tubing should be secured during care, and the CNA acknowledged she was not aware she had failed to do so despite prior training.
Loose pills were found in a medication cart drawer during an observation with an LVN. The pills were identified by the DON and ADON as Lisinopril/HCTZ, Oxybutynin, Eliquis, and Carvedilol. The LVN, DON, and ADM stated medications should be stored in blister packs or original manufacturer bottles, and the facility policy required drugs and biologicals to be stored in the packaging they were received in.
Failure to Use EBP PPE During Wound Care: A resident with a wound and severely impaired cognition was receiving ordered wound care when the DON and ADON entered the room, washed hands, and donned gloves but did not wear gowns before starting care. EBP signage and PPE were present at the bedside, and both leaders later stated they forgot to put on gowns even though the resident was on EBP for an open wound and the facility policy required gown and glove use for wound care.
Activities Program Not Directed by Qualified Professional: The facility failed to ensure its activities program was directed by a qualified professional. The Activity Director stated she was not certified, had only completed part of an online training program, and previously worked as the facility receptionist with no prior activity director background. The Administrator confirmed the Activity Director was not licensed, was unsure of her certification status, and stated the facility had been without a certified Activity Director since 11/2025; no policy for the Activity Director was available.
A facility failed to maintain infection control during care for two residents. During incontinence care, a CNA removed gloves and applied clean gloves without hand hygiene before placing a clean brief on a resident who was dependent for toileting hygiene and always incontinent. During ostomy care, an LVN handled a resident’s colostomy, wiped stool from the stoma, and continued care without removing soiled gloves, sanitizing hands, or putting on clean gloves. The DON stated staff were expected to perform hand hygiene between glove changes.
Bathroom emergency call light strings were observed too short for three residents to reach from the floor. One resident had muscle weakness, lack of coordination, and dementia; another had dementia, HTN, and depression; and a third had COPD, DM2, HTN, and major depressive disorder. Their MDS assessments showed varying levels of cognitive and toileting assistance needs, and staff confirmed the strings should be long enough for residents to reach if they needed help.
Missing Qualified Activities Professional: The facility did not have a qualified Activities Professional to direct the activities program, and the AD position remained open while residents reported that preferred activities such as bingo, ice cream socials, group crafts, and visiting musicians had not been offered for the past 2 months. Record review showed inconsistent activity calendars, and interviews with HR, corporate HR, and the Administrator confirmed the facility was still seeking a qualified candidate and had no one meeting the AD requirements.
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