Accel at Willow Bend

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 residents (Residents #1, #2, and #3) reviewed for pressure ulcers.1. The facility failed to provide wound care to Resident #1's left buttocks pressure wound on 05/04/2026, 05/05/2026, 05/14/26, 05/15/26 and 05/22/26 and failed to follow the physician orders for Resident #1 while providing wound care on 06/12/26.2. The facility failed to provide wound care to Resident#2's left buttock on 05/02/26, 05/04/26, 05/05/26, 05/14/26, 05/15/26, 05/17/26, 05/22/26, and 05/28/26 and failed to follow the physician orders for Resident #2 while providing wound care on 06/12/26.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (breakfast on 06/12/26) reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for the breakfast meal on 06/12/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2 observed for infection control. The facility failed to ensure LVN A performed hand hygiene and changed gloves during wound care for Resident #2. This failure could affect the residents by placing them at risk for worsening conditions and cross-contamination

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #2) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Resident #2 had their call light within reach. This failure could place residents at risk of not having their needs and preferences met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care for approximately 6 hours on 05/28/26, which resulted in Resident #1 being soaked with urine and soiled through her brief, draw sheet, and bed sheets. This failure could place the residents at risk for decreased feeling of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 5 of 20 rooms (Rooms #501, #508, #510, #705, and #712) reviewed for accident hazards. The facility failed to ensure the sharps containers, which were used to store used needles, in Rooms #501, #508, #510, #705, and #712 were not overfilled. This failure could place residents at risk of exposure to bloodborne pathogens. Observation on 05/18/26 at 9:10 AM revealed the sharps container for room [ROOM NUMBER] was overfilled and two syringes were protruding out of the safety flap. Observation on 05/18/26 at 9:13 AM revealed the sharps container for room [ROOM NUMBER] was overfilled, and the safety flap could not be operated. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure pharmacy services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident was done for 4 of 10 residents (Residents #1, #2, #3, and #4) reviewed for medication administration. The facility failed to consistently monitor the blood sugar levels and administer insulin accordingly for Residents #1, # 2, #3, and #4. This failure could place residents at risk of untreated high or low blood sugar levels, resulting in a worsening of their medical conditions. Resident #1Record review of Resident #1's admission MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of diabetes. Resident #1's BIMS score was 15, indicating she was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 5 residents (Resident #1) reviewed for nutritional status. The facility failed to monitor Resident #1 weight as ordered, resulting in unexpected weight loss of 4.8%. This failure could place residents at risk of unrecognized weight loss and malnutrition. Record review of Resident #1's admission MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included diabetes, post operative spinal surgery, and chronic pain. She was 64 inches tall and her current weight was 189. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Residents #1, #2 and #3) reviewed for infection control practices.1. MA A failed to disinfect the blood pressure cuff before checking Resident #1's blood pressure after she removed the cuff from her (MA A's) wrist.2. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #2 and Resident #3. These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents and staff for 1 (Door #1) of 7 entry doors reviewed for environment. The facility failed to safely monitor individuals who gained access to the facility using the posted security code next to Door #1. This failure could affect the safety of all the residents and staff at the facility and diminish residents' quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #1) reviewed for accident hazards/supervision/devices The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #1 from his wheelchair to the bed and then from her bed back to the wheelchair on 01/06/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 3 (Resident #3, Resident #13, Resident #30) of 5 residents reviewed for care planning.1. The facility failed to accurately complete the Physician Orders section on the baseline care plan, to indicate Resident #3 was being admitted to the facility with psychotropic medications.2. The facility failed to have a baseline care plan for Resident # 13 and Resident #30 This failure could place newly admitted residents at risk of not having their needs met, not receiving appropriate medications, not receiving necessary treatments, resulting in poor quality of life. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plan development. The facility failed to complete Resident #3's comprehensive care plan in a timely manner after his comprehensive assessment was completed. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #3 had the following diagnoses: Anxiety Disorder, Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood circulation), Heart Failure, Diabetes and Asthma. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (300 Hall Nurses Cart and 200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure: 1- 300 Hall Nurses Cart did not have:o 1 insulin pen for Resident #64 without an open date on 08/19/25. o 1 insulin pen for Resident #58 without an open date on 8/19/25. o 1 insulin pen for Resident #7 without an open date on 08/19/25. o 1 insulin pen for Resident #51 without an open date on 08/19/25. 2- 200 Hall Nurses Cart did not have: o 1 insulin pen for Resident #44 without an open date on 08/19/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in:1. The facility failed to ensure food items in the facility walk-in refrigerator, walk-in freezer and dry storage were dated or labeled.2. The facility failed to ensure food stored in the freezer were properly closed and sealed to prevent exposure to the air. 3. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 8/19/25.4. The facility failed to take temperatures of all food being served during lunch service on 8/19/25.5. The facility failed to place serving spoons on a sanitized surface during lunch services on 8/19/25. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section for 1 of 5 residents (Resident #3) reviewed for unnecessary medications.1. The facility failed to have an adequate indication for the use of the medication Quetiapine Fumarate (Seroquel - an antipsychotic) for Resident #3. 2. The facility failed to monitor behaviors and side effects of Quetiapine Fumarate (an antipsychotic) for Resident #3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Residents #66, #38) reviewed for care plans.1. The facility failed to develop the following comprehensive person-centered care plans for Resident #66: playing music calmed her her representative preferred her nightstand lamp to stay on at night the need for bilateral (left and right) palm guards due to hand contractures.2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #56) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #56 had his fingernails cleaned and trimmed on 8/19/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death.), and elevated blood pressure. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 (Resident #66) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #66's contracture to her left hand on 04/22/25. The facility failed to ensure physician orders were written for bilateral ( left and right) palm guards for Resident #66 on admission on [DATE]. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #41) of two residents reviewed for incontinence care. The facility failed to ensure CNA P provided appropriate perineal care for Resident #41 after an incontinent episode when she failed to clean the resident's labia on 08/19/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #12) reviewed for quality of care. The facility failed to ensure LVN I followed physician ordered water flushes between each medication administration given via the G-Tube (a feeding tube surgically inserted through a small opening in the abdomen directly into the stomach, used to deliver nutrition, fluids, and medications when a person cannot ingest enough by mouth) for Resident #12 on 08/20/25. This failure could place residents at risk of nausea, shortness of breath and a decrease potential fluid overload. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #42) residents reviewed for respiratory care. The facility failed to ensure Resident #42's oxygen was administered at the correct setting of 2 liters per minute on 8/19/25 as ordered by the physician. The deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #42's admission record dated 8/21/25 reflected an [AGE] year-old male with an admission date of 7/6/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure 200 Hall Nurses Cart did not have 1 insulin pen for Resident #67 with an expired open date on [DATE]. This failure could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications. Record review and observation on [DATE] at 9:27 AM of the 200 Hall Nurses Cart, with LVN I revealed: The pen of insulin Lantus 100 unit/ml for Resident #44 with an expired open date of [DATE]. Observation of the pen reflected it was used. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented in the resident's medical record that the identified drug irregularity had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 6 Residents (Resident #66) whose psychotropic medications were reviewed. Resident #66's attending physician failed to address the pharmacist's recommendation to consider a gradual dose reduction. Resident #66 had been receiving Citalopram (antidepressant) 20 mg and Risperidone once a day every day since October 2024 and Alprazolam .25 mg twice a day everyday since October 2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #10, Resident #56, and Resident #61) of 5 residents reviewed for infection control. The facility failed to ensure MA N disinfected the blood pressure cuff in between blood pressure checks for Residents #10, Resident #56, and Resident #61. This failure could place residents at-risk of cross contamination which could result in infections or illness. 1. Record review of Resident #10's Quarterly MDS assessment, dated 07/25/25, reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 23 residents (Resident#13, Resident#30, Resident #4) reviewed for resident call system. 1) The facility failed on 08/19/2025 to ensure the call light system was adequately equipped, the call light string was lying on the floor in the shared resident toilets located inside the resident rooms.2) The facility failed to ensure the call light device was within the reach of Resident #4 on 08/19/2025 when the resident was lying in bed in his room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that includes written standards, policies, and procedures for the program for 1 (Resident #1) of 4 residents reviewed for infection control. 1. RN (Registered Nurse) A failed to perform proper hygiene during a routine medication administration for Resident #1. RN (Registered Nurse) A knowingly used a syringe that had its plunger seal fall on the ground to administer medication to Resident #1. 2. RN (Registered Nurse) A failed to perform proper Syringe Protocol during routine medication and tube flushing for Resident #1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Residents #18, #25 and #323) reviewed for resident rights. 1. The facility failed to ensure Resident #323's call light was within reach. 2. The facility failed to ensure Resident #25's call light was within reach. 3. The facility failed to ensure Resident #18's call light was within reach. These failures could put residents at risk of not being able to call for assistance, have their needs met, and increases their risk for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for three of four residents (Resident #5, Resident #44 and Resident #176) reviewed for catheter and incontinence care. 1. The facility failed to ensure the Staffing Coordinator and CNA F maintained the foley catheter drainage bag below Resident #5's bladder during a mechanical lift transfer. 2. The facility failed to ensure CNA G provided appropriate and timely incontinence care for Resident #44 on 07/23/24. 3. The facility failed to ensure the Therapist did not place the urine catheter bag on the floor during the transfer of Resident #176 from his bed to the wheelchair. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 carts (Med Aide cart hall 500) reviewed for pharmacy services. The facility failed to ensure LVN S and LVN R, responsible for Med Aide cart hall 500, counted controlled drugs every shift change and signed the narcotic sheet form after the count. This failure could place residents at risk of not having the medication available due to possible drug diversion.

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 1 of 1 facility kitchen reviewed for food safety. 1. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 2. The facility failed to ensure food item in the walk-in refrigerator had use-by date and labeled . 3. The facility failed to ensure a bin of hard-boiled eggs in the walk-in refrigerator was appropriately covered . These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 16 residents (Resident #7, Resident #18, Resident #13, Resident#16, Resident#176, and Resident#5) reviewed for infection control. 1. The facility failed to ensure MA L disinfected the blood pressure cuff in between blood pressure checks for Residents #7 and #18. 2. The facility failed to ensure MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #13 and #16. 3. The facility failed to ensure CNA K performed hand hygiene while providing incontinence care to Resident # 176. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one of five (Resident #50) reviewed for comprehensive care plans. The facility failed to ensure Resident #50's care plan was person centered and comprehensive and did not address the resident's resistance to care and resistance to eating and drinking. This failure could place residents at risk of not having individual needs met, not to receive needed services, and negatively impact their psychosocial health and wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one of six residents (Resident #57) reviewed for ADL care. The facility failed to ensure Resident #57 had her fingernails trimmed. This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, including tracheostomy care and tracheal suctioning, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one of one resident (Resident #44) reviewed for tracheostomy care. The facility failed to ensure LVN I maintained a sterile/clean field for supplies necessary for tracheostomy care. The facility failed to ensure LVN I kept her dominant (right) hand sterile while providing trach care and tracheal suctioning for Resident #44. These failures could place residents at risk for respiratory infections.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of 10 residents reviewed for abuse. CNA A, who was assigned to Resident #1 for the night shift from 12/31/23 to 1/1/24 failed to provide care or check on Resident #1 during the entire shift from 10:00 PM 12/31/2023 - 6 AM 1/1/2024 and CNA B who failed to provide care on her shift from 6 AM 1/1/2024 to 10:22 AM 1/1/24. As a result, Resident #1 was not provided incontinent care or repositioned for over 13 hours on 12/31/23 9:05 PM to 01/01/24 at 10:22 AM. These failures could affect the residents by placing them at deprivation of goods abuse, risk for a delay in ADL care including incontinent care and life-saving treatments, which could result in psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prevent abuse to ensure residents were free from abuse for one (Resident #1) of 10 residents reviewed for abuse. 1) The facility deprived goods abuse for Resident #1. 2) CNA B, LVN C, LVN D, and Staffing Coordinator reported an allegation of abuse and neglect on 01/01/24 to the Administrator, who is the Abuse Coordinator immediately when they found Resident #1 soaked in urine and bowel movement. These failures could affect the residents by placing them at risk for a delay in intervention and Providing ADL care including incontinent care and life-saving treatments that could lead to psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of 10 residents reviewed for ADLs. The facility failed to provide incontinent care to Resident #1 for 13 hours on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. CNA A was assigned to Resident #1 and failed to provide care to Resident #1 on night shift. Resident #1 was not provided incontinent care for over 13 hours (including 8 hours of night shift of 12/31/23 and part of 1/1/24 day shift) on 12/31/23 9:05 pm to 01/01/24 at 10:22 AM. On 01/01/24 when Staffing Coordinator and CNA B provided incontinent care and found Resident #1's clothing and bedding soaked urine. Resident #1's brief was soaked in urine and had bowel movement. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of 10 residents reviewed for neglect. The facility staff failed to immediately report a 13 hour delay in incontinent care for Resident # 1 to the abuse coordinator. This deficient practice could place residents at risk for not having potential neglect reported and investigated by the abuse coordinator.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of seven residents (Resident #1 and Resident #3) observed for infection control. The facility failed to ensure: 1-MA BB donned the face mask correctly when she entered Resident#3' isolation room. 2-ADON B and CNA O performed hand hygiene during incontinence care for Resident # 1. These failures could place the residents at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to establish and implement policies addressing resident admission to the facility for one (Resident #1) of three residents reviewed for admissions in that: Resident #1 was not provided a signed admission agreement or information upon admission to the facility on [DATE]. Resident was discharged on 12/26/23 without a signed admission agreement. This failure could affect residents by placing them at risk for not being aware of what services the facility is providing.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for two (room [ROOM NUMBER] and room [ROOM NUMBER]) of five bedrooms reviewed for environment, - The facility failed to ensure room [ROOM NUMBER] did not contain a red sticky substance on the floor and oxygen machine - The facility failed to ensure room [ROOM NUMBER] did not have crumbs on the floor, a thick white substance on the floor, and used medical supplies on the bedside table. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for one of three (Resident #1) residents reviewed for confidentiality of records. The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information to include some of her medications. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #58 and #28) of seven residents reviewed for significant weight loss, in that: 1. Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for one (Resident #58) of the four residents reviewed for enteral tube feeding, in that: 1. Dietitian failed to communicate and follow-up on Resident #58's significant weight loss of 18 pounds from 01/31/23 to 05/10/23 to the facility and verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #58. Dietitian also failed to implement resident centered enteral tube feeding nutrition plan for Resident #58. 2. LVN G, LVN I and LVN F failed to administer enteral feedings to Resident #58 as ordered by the physician for last 72 hours (May 13, May 14, and May 15). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for two (Resident #58 and Resident #28 ) of six residents reviewed for notification of changes. 1. The facility failed to notify the physician and responsible party of Resident #58's change of condition of significant weight loss on 05/10/23. 2. The facility failed to notify the physician and responsible party of Resident #28's change of condition of significant weight loss on 05/02/23 and 05/12/23. These failures could place residents at risk for not notifying the physician for a change in condition.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #58 and #61) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan to address Resident #58's significant weight loss interventions of 7.85% for 3 months and 3.5% in 1 week. The facility failed to develop a care plan for Resident #58's behavior of moving about in the night and accidentally disconnecting the feeding pump. 2. The facility failed to develop a comprehensive person-centered care plan to address Resident #61's oxygen therapy use. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #29, Resident #61) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #19 had his fingernails cleaned and trimmed. 2- Resident #29 had her fingernails cleaned. 3- Resident #61 had his fingernails trimmed and lotion applied to his feet and legs. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for one (Resident #32) of 17 residents reviewed for resident rights. The facility failed to ensure Resident #32 had an opportunity to participate in planning her care. This failure could place residents at risk for decreased quality of care and a lack of notification of services and treatments being provided.

Inspectors wroteBased on observations, interview and record review the facility failed to have physician orders for the resident's immediate care for one (Resident #61) of eight residents reviewed for admission physician orders. The facility failed to have a physician order for Resident #61's oxygen use. This failure could affect residents by placing them at risk for not receiving the appropriate care and treatment services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #48) of one resident reviewed for respiratory care. LVN D failed to maintain a sterile/clean field for supplies necessary for tracheostomy care and failed to keep her dominant (Right) hand sterile while providing trach care for Resident #48. This failure could place residents with tracheostomies at risk for respiratory infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #29) observed for infection control. Facility failed to ensure CNA N performed hand hygiene while providing incontinence care to Resident #29. This failure could place the residents at risk for infection.