Acc Care Center

Inspectors wroteBased observation, interviews, and a review of facility records, the facility failed to implement a care plan intervention for one of three sampled residents (Resident 1) with history of falls when fall mats were not in place at Resident 1's bedside. This failure had the potential to increase Resident 1's injury related to falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1), when Resident 1 was left alone in the shower room two times by a Certified Nursing Assistant (CNA 1). This failure resulted in Resident 1 not being supervised while in the shower room increasing the risk potential for accidents for the resident. A review of Resident 1's clinical record indicated, Resident 1 was admitted in March of 2026 with a diagnosis of encounter for orthopedic aftercare. A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 3/17/26 indicated Resident 1 was cognitively intact. During an observation and interview on 4/2/26 at 12:09 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting in her wheelchair with her right leg raised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 34 sampled residents (Resident 102 and Resident 8) received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plans, when:1. The facility did not follow Resident 102's physician's order for Speech Therapy evaluation and treatment (ST or SLP, a Speech Language Pathologist; an assessment and treatment of swallowing disorders) and did not follow ST recommendations from prior assessment;2. Resident 8's hold parameters for blood pressure (BP) medications were not followed as ordered; and,3. Resident 8's weight changes were not reported to the physician as orderedThese failures placed Resident 102 at risk for complications related to her swallowing and had the potential to affect Resident 102 and Resident 8's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate catheter care was provided for two of 34 sampled residents (Resident 4 and Resident 8) when: 1. Resident 4's straight catheter (intermittent catheter- use of thin, hollow tube to drain urine from the bladder) was not accurately documented, care planned and evaluated for continued use; and 2. Resident 8's suprapubic catheter (a tube inserted directly into the bladder to drain urine) care and monitoring were not done as ordered. These failures increased the risk for Resident 4 and Resident 8 to develop trauma and bladder infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate was below 5% for two of 34 sampled residents (Resident 110 and Resident 45) when:1) Licensed Nurse 1 (LN 1) administered the wrong dose of physician ordered medication;2) LN 1 prepared medication for administration with disregard for manufacturer specifications;3) LN 1 administered medication not in accordance with physicians order and manufacturer specifications; and,4) A medication was not available for timely administration by LN 8. As a result, 4 errors were identified out of 33 opportunities for error during the observation of medication administration; the facility medication error rate was 12.12%.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure medications were stored correctly, when:1) pharmaceutical products were not stored in the proper temperature range; and,2) a medication cart was left unlocked and unattendedThese failures had the potential for residents to receive medications with unsafe and reduced potency from improper storage and the potential for unauthorized residents, staff, and or visitors to misappropriate and or tamper with resident medications and supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety when: 1. Shelving surfaces on the food plating island, as well as in the walk-in refrigerator were observed to be discolored with white and/or rust-colored markings, indicating deterioration and potential contamination risk.2. Nonstick pans used in food preparation were visibly scratched, compromising the integrity of the cookware and increasing the risk of nonstick coating flaking into food.3. A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation. These failures had the potential to contribute to foodborne illness for the 93 residents who consumed meals prepared by the facility's kitchen. 1 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 93 when staff did not wear appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for residents on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of drug-resistant organisms during high contact resident care activities). This failure decreased the facility's potential in preventing transmission of diseases among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs were accommodated for 2 of 34 sampled residents (Resident 19 and Resident 2) who had impaired vision, when Resident 19's and Resident 2's call light (a device used to request assistance from facility staff) were not accessible. This failure resulted in Resident 19 and Resident 2 experiencing frustration and anxiety about not having needs met in timely manner and endangered their safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of 34 sampled residents, (Resident 42) was free of unnecessary psychotropic medications (drugs that affect the mind and brain, altering mood, perception, and behavior) when Resident 42 received quetiapine (an antipsychotic medication) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorders (mental illnesses that are characterized by mood swings that range from the lows of depression to elevated periods of emotional highs) for an inadequate indication and contrary to the risk of adverse consequences of black box warning (a prominent, bold-faced warning placed on the labels of prescription medications to alert healthcare professionals and patients about serious risks associated with the drug) where the attending physician did not provide [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 17) received appropriate treatment and services for diagnosis of vascular dementia (impairment of brain function caused by damage to the blood vessels in the brain), by failing to offer non-pharmacological interventions and document the rationale prior to initiation of Seroquel (a psychotropic medication that affect brain activities associated with mental processes and behaviors and indicated for treating psychiatric conditions). In addition, there was no evaluation and rationale provided when Resident 17 was diagnosed with psychosis (a severe mental condition in which thoughts and emotions so affected that contact with reality is lost). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to account for and reconcile administered controlled medication for one of five residents, Resident 111. This failure had the potential for accidental medication exposure to Resident 111 and had the potential for drug diversion.

Inspectors wroteBased on observation, interview and record review, Resident 19's allergy to onion was not accommodated when resident was served with mixed vegetables containing onion. This failure had the risk potential for an allergic reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1) when Resident 1's prophylactic (intended to prevent disease) aspirin was discontinued incorrectly. This failure resulted in Resident 1 not receiving aspirin as ordered and had increased potential for developing blood clots.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of property for a census of 84 when multiple doses of controlled pain medications and count sheets were missing and unaccounted for. These failures resulted in the facility's lack of accountability of residents controlled medications with potential for uncontrolled pain and suffering.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed when Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). This failure resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate accountability of controlled medications (that have high potential for abuse, misuse and are addictive) for a census of 84 when: 1. Multiple doses of and Controlled Drug Records (CDR) for Oxycodone (medication used to treat moderate to severe pain) were missing and unaccounted for; 2. Random controlled medication audits of the Medication Administration Record (MAR) and CDRs for seven of nine sampled residents (Residents 1, 2, 3, 6, 7, 8, and 9) did not reconcile to indicate they were given to the residents; and 3. Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. There were metal pans and cooking pans found stored away in the clean and ready-to-use storage areas: a. Several various sizes metal sheet pans were found stacked wet with white substances and food debris on the inside and outside surfaces of the pans. b. Three various sizes of cooking pans were found stored wet, had food debris, significant scrapes on the cooking surfaces and black greasy substances on the cooking surfaces. 2. Ice machine in the kitchen was not clean. 3. There were outdated food items found in the resident's food refrigerator located in the family room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment was maintained in safe operating condition when the dishwashing machine's required minimum temperatures and sanitizer concentration levels were not reached. This failure placed 89 out of 91 residents who received food from the facility kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations and staff competency in skills and techniques for five of five sampled Certified Nursing Assistants (CNAs; CNA 7, CNA 8, CNA 9, CNA 10, and CNA 11). This failure increased the risk of residents receiving poor-quality care from the CNAs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for one of five sampled residents (Resident 29), when: 1. A Licensed Nurse (LN) crushed and administered the following uncrushable medications: oxybutynin ER (an Extended Release medication for overactive bladder) 100mg (milligram, unit of measure) and pantoprazole DR (a Delayed Release medication to reduce stomach acid) 20 mg; and, 2. An LN did not administer Resident 29's calcium-vitamin D (a combination of a vitamin and a mineral) 600-200 mg-u (milligram-unit, unit of measure) as ordered by the physician. These failures resulted in three errors identified out of 33 opportunities during the observation of medication administration; the facility medication error rate was 9.09%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. An expired vial of insulin was not removed from a medication cart; 2. A multi-dose inhaler did not have an open date label to determine its expiration date; and, 3. 16 pills were stored in a plastic cup without a proper pharmaceutical product label and expiration date. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date and incorrect medications from inadequate labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person normally prescribed by a physician) during the lunch meals on 8/5/24 and 8/6/2024 when: 1. Six residents (Resident 14, 20, 29, 34, 64, and 545) were on fortified (enriched with extra nutrients) diets who did not receive extra melted butter on the vegetables; 2. Four residents (Resident 25, 31, 47 and 49) who were on small portion diets received the incorrect portion of salmon for their meals; 3. Three residents were on Dysphagia Mechanical Soft (a modified texture diet is soft and moist for people who has chewing or swallowing issues) texture diet when: a. Resident 46 and 85 received the incorrect consistency for their meal; and, b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required in-service training and competency in skills and techniques for seven out of seven sampled facility employed Certified Nursing Assistants (CNAs; CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, and CNA 13) and two out of two Contracted Certified Nursing Assistants (CCNA; CCNA 14 and CCNA 15), when: 1. Four of seven CNAs (CNA 8, CNA 9, CNA 10, and CNA 11) and one of two CCNAs (CCNA 14) had no abuse prevention training. Two out of seven CNAs (CNA 7 and CNA 13) and two out of two CCNAs (CCNA 14 and CCNA 15) had no dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) management training. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was promoted for one of 19 sampled residents (Resident 22) when a Certified Nursing Assistant (CNA) stood up in front of the resident while assisting with her lunch meal. This failure had the potential to result in Resident 22 not attaining her highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two out of 19 sampled residents (Resident 148 and Resident 4), when: 1. No activities care plan was developed or implemented for Resident 148; and, 2. No care plan was developed or implemented for a skin laceration with staples for Resident 4. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one of 19 sampled residents (Resident 71), when the nutrition care plan was not updated after an added intervention ordered by the physician. This failure had the potential to result in Resident 71 not attaining her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two out of 19 sampled residents (Resident 4 and Resident 65) when: 1. An assessment was not found for a new laceration to Resident 4's index finger; and, 2. Oxygen was not provided per physican's orders for Resident 65. These failures had the potential of worsening the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the communication needs were met for two of 19 sampled residents (Resident 148 and Resident 40), when there were no communication sheet or device accessible at the bedside for the staff to communicate with the residents. This failure had the potential to result in not meeting the resident's highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 63) received a specialty mattress used to treat a Stage 4 pressure injury (PI, injury to the skin and underlying tissue from prolonged pressure on the skin. Stage 4, full thickness skin loss, wound can extend to muscle and bone). This failure had the potential for the wound to worsen and increased pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures for one out of five sampled residents (Resident 29), when calcium-vitamin D (a type of vitamin and mineral) was not available to be given to the resident during medication pass. This failure resulted in Resident 29 not receiving her morning medication as prescribed by the physician.

Inspectors wrote4. A review of Resident 3's admission record indicated she was admitted in 1/24 with diagnoses including dementia, diabetes, and vitamin deficiency. During a current observation, interview and record review on 8/5/24 at 12:51 p.m., with Resident 3, Resident 3's tray ticket (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, likes) indicated Resident 3 should have a Healthshake (high protein supplement) and Udon (Japanese noodles) soup with her meal. A Healthshake and Udon soup was not present with Resident 3's meal, there was a tomato soup present. Resident 3 stated the tomato has no taste and she likes Udon soup it's good Japanese soup . A concurrent interview with Restorative Nursing Aide 1 (RNA 1), RNA 1 confirmed that the Healthshake and soup weren't present. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection practices were followed for three out of 19 sampled residents (Resident 47, Resident 63, and Resident 35) when: 1. Resident 47's oxygen and nebulizer tubing were not dated; 2. Licensed Nurses (LN) touched multiple items after performing a bandage change on Resident 63 who had Methicillin-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics) in his wound; and, 3. Unlabeled and undated oxygen tubing and face mask were found by Resident 35's bedside. These failures had the potential to spread infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident walked out of the facility unnoticed. This failure resulted in resident's injury and with the potential for further falls and injuries not maintaining his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident needs and preferences were accommodated for four of 25 sampled residents (Resident 14, Resident 23, Resident 13, and Resident 51), when: 1. Resident 14 did not receive bottled water and food requests; 2. Resident 23 did not receive food requests and an adaptive device; and 3. Resident 13 and Resident 51's call light buttons were found on the floor out of their reach. These failures had the potential to result in the residents not attaining their unmet needs, not maintaining their highest practicable physical, emotional and psychosocial well-being, as well the potential to result in compromised resident safety.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plan for two out of 25 sampled residents (Resident 41 and Resident 53), when: 1. Resident 41's communication care plan intervention was not implemented; and 2. Resident 53's care plan did not include interventions to monitor for side effects of an anticoagulation (blood thinner) medication. These failure had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents Resident 22, Resident 314, and Resident 315) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 84. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 11.11% error rate when three medication errors out of 27 opportunities were observed during a medication pass for two of five Residents (Residents 21 and 512). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: - Medication carts were kept securely locked when left unattended; - Opened biologicals, multi-dose inhalers, and inhalation solutions were dated with an open and discard date, to ensure they were not used beyond the discard date; - Medications and single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; - Food was stored separately from resident medications in the Medication Storage Room refrigerator; - Expired medications were not available for resident use; and - Biologicals were stored in accordance with facility policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 67 residents eating facility prepared meals, when: 1) Two concentrated juice boxes were not labeled and dated; 2) Five plastic tubs were found wet, stacked in the ready to use shelves; 3) Five pieces of equipment were found worn, dirty and/or rusted; 4) One diet aide did not cover his beard adequately while working around food; and 5) One cook failed to follow food safety/sanitation procedures while preparing pureed meals. These failures had the potential to lead to food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was promoted for two of 25 sampled residents (Resident 7 and Resident 46), when the urinary catheter bags were exposed. This failure had the potential to negatively impact Resident 7 and Resident 46's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 25 sampled residents (Resident 512), when nursing staff failed to verify the contents of a probiotic (a supplement to support and promote gut health) administered to Resident 512. This failure resulted in Resident 512 receiving the incorrect probiotic and the potential for worsening of their clinical condition or complications related to gut health such as diarrhea, nausea and vomiting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the communication needs were met for one of 25 sampled residents (Resident 41), when there was no communication sheet or device accessible for the staff to communicate with the resident. This failure had the potential to result in not meeting the resident's highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety and supervision for one of 25 sampled residents (Resident 8), when the resident was left in a wheelchair unattended and unsupervised during care with hot water left running in the resident's room sink. This failure had the potential to result in accidents and falls and not maintaining the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 25 sampled residents (Resident 13), when an outdated nebulizer mask (breathing treatment device) was still in use and should have been discarded. This failure increased the potential risk for respiratory infection.