PRIVACY AND CONFIDENTIALITY: Based on observation it was determined that the facility failed to provide one resident with personal privacy during wound care.

CHEMICAL RESTRAINTS: Based on review of 27 clinical records and staff interview it was determined that the facility utilized a chemical restraint to most readily control one resident's behaviors with less staff effort.

STAFF TREATMENT OF RESIDENTS: Based on clinical record and select policy review and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 27 sampled residents to rule out abuse, neglect or mistreatment.

DIGNITY: Based on review of select facility policy and post fall investigation reports, observation, and staff interview, it was determined that the facility failed to provide an environment which would maintain resident dignity for four of 27 sampled residents.

SOCIAL SERVICES: Based on clinical record review and staff interview it was determined that the facility failed to provide therapeutic social service interventions to promote the psychosocial well-being of two of 27 sampled residents exhibiting maladaptive behaviors.

QUALITY OF CARE: Based on review of 27 clinical records and facility policy and staff interview, it was determined that the facility failed to timely and accurately assess two residents' displays of signs and symptoms of pain and the effectiveness and/or clinical necessity of their pain management regimens.

PRESSURE SORES: Based on review of clinical records, facility policy and procedure, and staff interview, it was determined that the facility failed to timely identify changes in skin integrity and implement aggressive measures to prevent the development of a pressure sore for one of 27 residents (Resident 20). The facility failed to accurately assess pressure areas for three of 27 sampled residents.

URINARY INCONTINENCE: Based on 27 clinical records reviewed and staff interview it was determined that the facility failed to consistently implement planned measures to improve one resident's urinary incontinence and failed to timely evaluate the effectiveness of this toileting program and develop and implement individualized interventions to manage one resident's urinary incontinence and restore or maintain as much of the residents' normal bladder function as possible.

ACCIDENTS AND SUPERVISION: Based on review of 27 clinical records and select incident/accident reports and staff interview it was determined that the facility failed to adequately supervise and provide one resident with sufficient assistance to prevent a fall with injury.

UNNECESSARY DRUGS: Based on clinical record review and staff interview, it was determined that the facility failed to provide medical justification for the utilization of an anti-anxiety medication and to consistently attempt non-pharmacologic interventions prior to medication administration for one of 27 sampled residents.

SANITARY CONDITIONS: Based on observation, review of facility policy and staff interview, it was determined that the facility failed to properly store nutritional supplements on one of two resident pantry areas.

DRUG REGIMEN REVIEW: Based on clinical record review and staff interview, it was determined that the facility failed to identify and report drug irregularities for one of 27 sampled residents.

PHARMACY SERVICES: Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to consistently maintain a system to promote accurate drug records and accounting of controlled medications for two of 27 sampled residents. The facility failed to assure accurate medication labeling consistent with standards of practice for one resident.

INFECTION CONTROL: Based on observation, select policy review and staff interview, it was determined that the facility failed to consistently practice infection control techniques to prevent the potential spread of infection in three of 27 sampled residents.