Staff members worked without completed criminal history background checks.
Facility staff were not adequately trained on notifying nurses and caring for residents after incidents.
Administrator failed to ensure implementation of facility policies and procedures.
Ineffective corrective action to prevent recurrence of resident falls.
Administrator did not monitor incident patterns or develop interventions.
Hot water temperatures were not consistently maintained within safe range.
Toxic chemicals were stored in unlocked areas accessible to residents.
Nursing services lacked clear coordination and follow-up on outside agency recommendations.
Residents did not consistently receive medications and treatments as ordered.
Facility nurse did not perform timely assessments after changes in resident health status.
Medication distribution system had unsecured medications and improper labeling.
Medication refrigerator temperatures were not monitored or documented daily.
Not all ordered PRN medications were available to residents at all times.
Registered Nurse did not consistently assess residents prior to admission.
Residents' service agreements were not updated to reflect significant health changes.
Facility nurse did not consistently document resident assessments or counseling on medication refusals.
Facility did not obtain history and physical results for all residents upon admission.
Behavior plans with interventions were not developed for residents exhibiting problematic behaviors.
As-worked schedules did not document times administrator or nurses were present.
No staff had current Certified Food Protection Manager certification.
Staff lacked specialized training for mental illness, dementia, and developmental disabilities.