Alexandria Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1's discharge record was complete and accurately reflected Resident 1's clinical condition and care needs at the time of transfer to a boarding care facility. This deficient practice had the potential to result in the receiving facility being inadequately informed of the resident's needs, placing the resident at risk for inappropriate care, unmet needs, avoidable outcomes, and an unsafe transition.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician - ordered treatment was transcribed to the Treatment Administration Record (TAR) and implemented for one of three sampled residents (Resident 1). This deficient practice had the potential to delay necessary treatment and compromise Resident 1's skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan titled, Resident is at risk for elopement related to: Resident expresses desire to leave the facility prematurely (not medically ready for discharge), Cognitive loss/dementia quarterly for one of two sampled residents (Resident 1). This failure had the potential to result in a lack of continuity of care based on Resident 1's condition and in staff being unaware of Resident 1's elopement risk interventions, which could compromise Resident 1's safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medical records for one of two sampled residents (Resident 1), when the facility failed to ensure the Minimal Data Set (MDS) nurse accurately documented diagnoses of unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), insomnia (trouble falling asleep or staying asleep), and dementia (a progressive state of decline in mental abilities) in section I of Resident 1's Minimum Data Set (MDS - a resident assessment tool). This failure had the potential to result in inaccurate representation of Resident 1's condition and lack of documentation in the medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of garbage when: a. The trash can was not completely closed when not in use in the kitchen. b. The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) contained dried brown residue on its exterior and the surrounding floors had visible trash and debris. These failures had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 164 of 164 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 15, 155,10, and 147) reviewed for physical restraints by failing to ensure: 1. Resident 15 did not have bilateral (both right and left side) foam wedge cushions (firm, triangular-shaped foam cushion used to elevate parts of the body) tucked under the fitted sheet while the resident lay in bed. 2. [...]

Inspectors wroteBased on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care to two of five sampled residents (Residents 13 and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and adequate supervision to prevent accidents for three of six sampled residents (Residents 140, 110, and 155) reviewed under the Accidents care area by failing to: 1. Ensure medications were not left at the bedside readily available for resident self- administration for Residents 140, 110, and 23. These deficient practices had the potential to result in resident harm from omission of medications, overdose of medications, and residents ingesting medications not intended for their use. 2. Ensure Resident 155's bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was turned on when it was in use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care was provided to residents consistent with professional standards of practice for three (3) of six sampled residents (Resident 9, 61, and 135) reviewed for respiratory care by failing to:1. Ensure that Resident 9's oxygen (O2) nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor.2. Ensure the oxygen concentrator (a medical device that pulls in regular room air, filters out the nitrogen, and delivers purified oxygen for you to breathe) humidifier (a refillable plastic bottle that infuses the normal flow of oxygen with water droplets) was labeled with a date, and the oxygen was running at the rate ordered by the physician for Resident 61.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for one of five sampled residents (Resident 4) reviewed for Unnecessary Medications by failing to ensure the Licensed Nurse (LN) administered as needed (PRN) oxycodone with acetaminophen (an opioid, also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment, received services consistent with professional standards of practice, by failing to ensure: 1. Licensed Nurses (LNs) followed the physician's order for a 1200 cc (cubic centimeter - unit of measurement used for liquids, (1cc equivalent to 1 ml (milliliter) - metric unit of measurement used for liquids) a day fluid restriction (limiting the total amount of liquids you consume each day) and monitored Resident 14's fluid intake. 2. LNs obtained a physician's order to monitor Resident 14's intake and output (I&O - the measurement of all the fluids that go into a person's body and all the fluids that leave it). 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to safely use bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) for four of four sampled residents (Resident 14, 77, 82 and 108) by failing to ensure: 1. Resident 14's half (1/2) bed rails (a 1/2 (half-length) bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and complete bed rail assessment on its use. 2. Resident 77's 1/2 bed rails had a physician's order, informed consent and a comprehensive, person-centered care plan for its use. 3. [...]

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) by failing to:1. Ensure Licensed Vocational Nurse (LVN) 7 administered benazepril (medication to treat high blood pressure), aspirin (medication that helps prevent blood clots [clumping of blood]), fish oil (supplement to treat high cholesterol), and refresh tears eyes drops (medication to treat dry eyes) per the physician's orders on 5/18/2026. during the routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely) for one of six sampled residents (Resident 140) reviewed for Accidents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately in one of two medication rooms (Med Room Station 1) and one of four medication carts (Med Cart Station 3) observed during the Medication Storage and Labeling task by failing to: 1. Label the house supply of tuberculin purified protein derivative (PPD) (Aplisol - an injectable solution used in the skin test to detect tuberculosis [TB - a bacterial infection that primarily affects the lungs] infections) with an open date in accordance with manufacturer's requirements in Med Room Station 1. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu to meet the nutritional needs of 68 to 164 residents, when staff did not provide the three (3) ounce (oz, unit of measurement) portion size of pork roast indicated on the menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) and served 1.5 oz portion instead. This failure had the potential to result in a decrease in food flavor, a decrease in food and nutrient intake that could result in unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature and flavor when hot foods were not served hot and pork roast, and seasoned black beans were not seasoned well and tasted bland. These failures had the potential to result in 157 of 164 facility residents including Resident 149, Resident 34, Resident 50, and Resident 163 to be at risk of unplanned weight loss, a consequence of poor food intake and receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed corn bread was too sticky and did not fall from the spoon during the spoon tilt test (a method used to determine the stickiness of the food and ability of food to hold together) and the puree smothered cabbage did not hold its shape and it was flat on the plate causing it to touch the other food items. These failures had the potential to result in difficulty swallowing and difficulty in eating, and a decrease in food and nutrient intake to 33 of 33 residents on a puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/18/2026. This deficient practice had the potential to result in hunger and frustration for 157 to 164 residents, including Resident 163.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen and storage areas were not free from dirt and debris. a. Walk-in refrigerator racks had white dirt residue, black dirt and dry food particles. b. Walk-in refrigerator floor contained dry lettuce, trash and tape debris. c. Dry storage floor had cream of wheat particles. 2. Kitchen storage surfaces were not of cleanable surfaces a. Two (2) metal racks in the walk-in freezer had amber discoloration and rust. b. Four (4) of 4 racks had paint coming off in the dry storage area. c. Sixty-six (66) of 66 residents' trays had cracks, chips, and scratches. d. Three (3) drying racks were rusted with amber discoloration. 3. Mislabeled foods in the dry storage room area indicated expired foods. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two (2) of five sampled residents (Resident 83 and 141) reviewed for medication administration task by failing to:1. Ensure that the Psychotropic Medication Administration Disclosure had the physician's signature, and date when the resident signed the consent. 2. Ensure that Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 5 accurately documented Resident 141's administered medications as ordered on 5/16/2026 and 5/19/2026. These deficient practices had the potential to result in incomplete, inaccurate, and delayed records that could lead to miscommunication between healthcare providers and resident harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for one of one sampled resident (Resident 16) reviewed under hospice and end of life care area who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to: 1. Ensure Resident 16's medical records included documentation of the Certified Home Health Aide (CHHA) visit notes, the hospice plan of care, and the hospice calendar. 2. Ensure Hospice Provider (HP) 1 hospice calendar was followed for the CHHA visits on multiple days for the month of 1/2026 and 2/2026. These deficient practices had the potential to negatively affect Resident 16's physical comfort, psychosocial well-being, and had the potential to result in a delay or a lack of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 by failing to ensure: 1. A disposable (one time use) yellow gown with a tear hanging on the washing machine was disposed of properly in the trash after being used. 2. Five out of six linen carts on the units were not covered with a permeable (material that allowed liquid or gas to pass through)/mesh material observed during infection control task. These deficient practices had the potential to cause cross-contamination (the invisible transfer of harmful germs, allergens, or chemicals from one object, surface, or food to another) of infection among residents and staff.

Inspectors wroteBased on observation, interview and record review the facility failed to treat one of one sampled resident (Resident 161) with respect and dignity when Certified Nurse Assistant (CNA) 3 failed to maintain privacy for Resident 161 while providing Activities of Daily Activities (ADL - basic tasks that must be accomplished every day for an individual to thrive) care. This deficient practice had the potential to cause emotional distress and affect the resident's self-esteem and cause a loss of dignity and decline in psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 4) reviewed for unnecessary medications by failing to ensure bupropion (medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]) was prescribed and monitored for specific, measurable behavioral manifestations. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of five sampled residents (Resident 14) addressing the resident`s use of Insulin ( a medication to treat high blood sugar level) Aspart injection solution (a fast-acting, man-made version of human insulin). This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to administer wound care treatments per the physician's orders when calcium alginate dressings (a dressing that absorbs wound fluid resulting in a gel-like substance that promotes moist wound healing) were applied without a physician's order for one sampled resident (Resident 11). These deficient practices had the potential to result in a delay of healing or worsening of wounds on Resident 11's left toe and left leg.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 171) received proper care and services by failing to ensure the resident`s urinal bottle (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) was labeled with a date it was given, the resident's initials, and room number. This deficient practice had the potential to increase the risk for urinary tract infection (UTI - when germs infect the urinary tract or bladder infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of six sampled residents (Resident 140) reviewed for Accidents by failing to ensure Licensed Vocational Nurse (LVN) 7 administered benazepril (medication to treat high blood pressure) per the physician's orders on 5/18/2026 during the routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). This deficient practice had the potential to result in increased blood pressure in the resident leading to organ damage and possible hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of four sampled residents (Resident 1) by failing to ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC) on 3/26/2026 related to the resident's reported facial trauma. This deficient practice had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician regarding a resident's significant change of condition for one of three sampled residents (Resident 1). The facility identified Resident 1 had shortness of breath on 1/16/2026 at 7 p.m. while on (BiPAP) machine (a noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) but did not notify the Medical Doctor. This deficient practice placed Resident 1 at risk of developing complications.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) to address that Resident 1 had a personal history of other venous thrombosis (or deep vein thrombosis, DVT - is a serious condition where a blood clot forms in a deep vein, most commonly in the legs or thighs, and is dangerous if the clot breaks loose and travels to the lungs), and embolism (is an obstruction or blockage in a blood vessel). This failure had the potential to delay provision of necessary care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to residents and/or responsible party notification rights for one of three sampled residents (Resident 1) when Resident 1 received an order for x-ray (a photographic or digital image of internal parts of the body) of bilateral (both sides) hips, which Resident 1 or responsible party were not informed about. This deficient practice denied Resident 1 and the responsible party the rights to know, to understand, and to make informed decisions related to Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2) by:Failing to accurately document notification of the physician on 1/10/2026, when Resident 2 had an incident of fall. Failing to ensure Registered Nurse 2 (RN 2) documents her (RN 2) intervention on 1/20/2026, after Resident 2's fall incident. Failing to completely document incidents on Resident 2's fall on 11/13/2025. Failing to document date and time of Family Member 1 (FM 1) notification on 5/16/2023, of Resident 2's change in condition. These failures had the potential to result in the medical records containing inaccurate and incomplete documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) were free from physical restraint (a strap or other thing that holds a person in place) by failing to monitor Resident 2 on the use of bed alarm device (a safety tool used in hospitals, nursing homes, and home care to detect when a person is attempting to leave their bed, alerting caregivers to prevent falls, or potential emergencies). This failure had the potential to result in unnecessary restraint and placed the residents at risk of agitation (a state of extreme mental and physical restlessness) and entrapment (situation where a resident becomes caught, trapped, or tangled in the bed frame, mattress, or side rails while attempting to move, get out of bed, or during the use of restrictive device).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 2). This failure had the potential for confusion of care and had the potential to result in Resident 2's fall.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to provide clean and sanitary utensils to Resident 1. This failure had the potential to place Resident 1 at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage) and placed Resident 1 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to clarify the physician's order for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses clarify the two physician orders of famotidine (medication used to decrease amount of acid in the stomach). On 11/1/2025 to 11/4/2025, Resident 1 received two doses of famotidine at 6:30 a.m., and at 9 a.m. 2. Ensure licensed nurses follow the physician order to administer guaifenesin (medication used to treat chest congestion) and dextromethorphan (medication used to treat cough)- guaifenesin medication every six hours as needed. On 11/20/2025, Resident 1 received the two medications with only three hours in between. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for two of three sampled residents (Residents 2 and 6) who were on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to:a. Ensure Registered Nurse 4 (RN 4) wore a mask, gloves, and gown before disconnecting and flushing (pushing fluid through an intravenous [IV-within a vein]) Resident 2's IV line. b. Ensure Licensed Vocational Nurse 2 (LVN 2) wore a mask, gloves, and gown at Resident 2's bedside. c. Ensure LVN 3 wore a gown at Resident 3's bedside while providing gastrostomy tube (gtube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) care. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by:Failing to develop a care plan on legionnaires disease (a severe form of a lung infection called pneumonia caused by a bacterium known as legionella) when Resident 1 had presumptive positive (a test administered by local health professionals is positive) legionella (naturally found in [NAME], but becomes a health risk when they grow in man-made water systems and the contaminated water is aerosolized - tiny particles suspended in the air, leading to inhalation and causing lung illness) upon return to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to accurately document oxygen device used by Resident 1 on [DATE]. This failure had the potential to result in confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) program and infection prevention and control program for one of three sampled residents (Resident 1) by failing to monitor Resident 1 for the use and adverse effects (undesired or harmful effects) of azithromycin (antibiotic medication used to treat infection) on 11/29/2025 to 12/2/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) with indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to:1. Ensure Resident 1's urinary catheter stoma (a surgically created opening on the abdomen that allows waste to be diverted from the body to the outside) had a wound dressing (a material placed directly on a wound to protect it and help it heal).2. Ensure Resident 1's indwelling urinary catheter tubing was anchored (secured) to the resident's thigh.3. Ensure Resident 1 was monitored for the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract). 4. Ensure licensed nurses provided Resident 1's urinary catheter care as indicated on the resident's Care Plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four emergency exit doors (Exit Door 3) was free from obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach consisting of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within residents reach for three of three sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in the delay in the residents' care and not receiving assistance timely.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was followed on the use of low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers [a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear and may lead to deep tissue injury]). This deficient practice had the potential for delayed provision of necessary care and services and had the potential for the development of pressure ulcers or injuries for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by failing to ensure the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) machine was functioning as indicated in the Operators Manual. This deficient practice had the potential for Resident 1 to develop pressure ulcers or injuries.

Inspectors wroteBased on 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) for one of three sampled residents (Resident 2) by failing to ensure the physician order was followed. This deficient practice had the potential to result in medication error and can cause hypotension (low blood pressure).

Inspectors wroteBased on interview and record review the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2). This deficient practice resulted to Resident 2's medical records contain inaccurate documentation and had the potential to cause confusion in Resident 2's care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of two sampled residents (Resident 2) when on 2/17/2025 at 6:25 p.m., Certified Nursing Assistant (CNA) 1 witnessed Resident 3 hit Resident 2 with closed fits, hitting Resident 2 on the right side of Resident 2's head. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 3 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (CP-a document outlining a detailed approach to care customized to an individual resident's needs) by failing to: 1. Develop and implement a care plan for Resident 145's use of side rails (SR or bed rail, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of five sampled residents reviewed under the Accidents care area. This deficient practice had the potential to result in a delay in the provision of necessary care and services for residents using SRs. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for three (3) of three (3) sampled residents (Resident 51, 137, and 129) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. The deficient practice increased the risk that Residents 51,137, and 129 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four (4) of five (5) sampled residents (Residents 94, 21, 27 and 129's) investigated under accidents by failing to: 1. Ensure there was no furniture or equipment on top of Resident 94, 21, and 27's floor mats for a long period of time. 2. Ensure Resident 129's bed was not left in the elevated/high position while unattended by staff. These deficient practices had the potential to place Residents 94, 21, 27, and 129 at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death.

Inspectors wroteBased on interview and record review the facility failed to: a. Dispose of medications in a manner that was not retrievable (able to get back) in one (1) of two (2) inspected Medication Rooms (Medication Room Station 2). b. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled or Antibiotic Drug Record accountability logs for three (3) of six (6) sampled records awaiting disposal (removal, destroying) in the Controlled Substances (CS - also known as Controlled Drug and Controlled Medications [CD, CM - medications which have a potential for abuse and may also lead to physical or psychological dependence]) locked cabinet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents' drug regimen were free from unnecessary drugs (any drug in excess) for two (2) of four (4) sampled residents (Resident 10 and 141) for unnecessary medication review. 1. Resident 10's duplicate medication orders for the same indication remained as active drugs on the Medication Administration Record (MAR - a record of medications administered to a resident), starting 1/19/2025. 2. Resident 141 did not have monitoring for the side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Pradaxa (an anticoagulant [blood thinner] medication used for atrial fibrillation [Afib - irregular, often rapid heart rate that commonly causes poor blood flow]), between 1/1/2025 and 1/30/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 21 and 358) drug regimen was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (a medication that affects brain activity associated with mental processes and behavior) medications by failing to ensure: 1. Resident 21 had a specific, measurable target behavior related to the use of sertraline (an antidepressant [against depression] medication used for depression or bipolar disorder), starting 12/7/2024. 2. Quetiapine fumarate (an antipsychotic [a class of medication used to treat psychiatric disorders]) and sertraline HCl (a medication to treat depression [persistent feelings of sadness)] were prescribed, administered, and monitored for specific measurable behavioral manifestations for Resident 358. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.35% affecting two (2) of five (5) residents observed for medication administration (Resident 109 and 257). The medication errors were as follows: 1. Resident 257 did not receive a form of aspirin (a medication used to treat peripheral vascular disease [PVD - a condition that affects blood vessels] and Deep Vein Thrombosis [DVT - a condition that forms blood clots in the body] in those with atrial fibrillation [an irregular, fast heart rate]) as ordered by Resident 257's physician. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three (3) of three (3) sampled residents (Resident 51, 129 and 137) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Store seven (7) ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solutions in the foil pack (package made of foil protecting the inhalation solution from light and degradation) for Resident 72, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 1 T2). 2. Remove and discard from use one (1) expired eye drop medication bottle for Residents 115 in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 2 T). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of: a. Twenty seven (27) of 27 residents on puree diet (diet consisting of food with soft pudding-like consistency) and 15 of 15 residents on soft mechanical diet (diet consisting of chopped and soft foods), received less portion for pureed rice and pureed corn as staff did not level off number eight (#8, ½ cup) scoop. b. Seven (7) of 7 residents on puree diet and ten (10) of 10 resident on regular texture (no restriction) got mashed potatoes with their tacos in substitution for rice. c. 1 of 1 sampled resident had no alternate menu posted in Station 3 and the room. These failures had the potential to result in decreased food and nutrient intake resulting to unintended (not planned) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appetizing temperature when sliced pears were dished out at 11:45 a.m. with temperature of 68 degrees Fahrenheit (°F, a degree of temperature) and the coleslaw was left out in trayline from 12:00 to 12:25 p.m. with a temperature of 75°F. This failure had a potential to result in 149 of 155, including Resident 91, facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree tortilla was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) and puree corn did not hold its shape for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 27 of 27 residents on puree diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. Refrigerator and Freezer floors had dirt build up. b. Vents had dust buildup 2. Preparation [NAME] 1 washed the towel cloth in the preparation sink area while the chicken was thawing on the other sink causing water splatters to go the chicken. 3. Three (3) of four (4) light bulbs in the dry storeroom area were not covered 4. Two (2) dented cans were found with non-dented cans. 5. Twenty one of 21 resident's trays were cracked and chipped. 6. Pots and pans stacked wet. 7. Staff was wearing a bracelet during food preparation. 8. Expired food items of three (3) residents in the refrigerator 9. Residents' freezer temperature was not monitored; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. The trash in the handwashing area was not lined with plastic b. The dumpster's (large trash container designed to be emptied into a truck) surroundings had liquid, food juices spills and trash on the ground and the dumpster was not fully covered. These failures had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 149 of 156 facility residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two of three sampled residents (Resident 33 and 94) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of three sampled residents (Resident 10) investigated under the Environmental Task by failing to maintain the cleanliness of Resident 10's electric stand fan. This deficient practice has the potential to negatively affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for one (1) of one sampled resident (Resident 95) investigated during a review of the physical restraints care area when the facility failed to obtain a physician's order, perform an assessment, obtain an informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment), and develop a care plan for the use of pillows tucked underneath the fitted [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for one of five sampled residents (Resident 48) investigated under PASRR care area, by failing to submit a new Level 1 PASRR for Resident 48, who had a discrepancy in the previous PASRR Level I screening and ensure it was completed accurately. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident comprehensive care plans (CP - a written course of action that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) regarding smoking were updated after a change of condition for one of five sampled residents (Resident 62) reviewed under the Accidents care area. This deficient practice had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives regarding the resident's care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident's physical, mental, psychosocial needs for one of one sampled resident (Resident 147) investigated under rehab and restorative care area by failing to: 1. Conduct the interdisciplinary team meeting (IDT-a coordinated group of experts from several different fields) with the resident's responsible party regarding the resident's refusals to participate in physical therapy treatments. 2. Inform Resident 147's physician regarding the resident's refusals to participate in physical therapy treatments. These deficient practices had the potential to result in Resident 147's decline in mobility, strength, and overall physical function, leading to increased dependence to providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 86) investigated under pressure injury by failing to ensure Resident 86's low air loss mattress (LALM, a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) had a physician's order and care plan developed. This deficient practice had the potential for the development and worsening of pressure injuries to Resident 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) out of one sampled resident (Resident 137) investigated under the urinary catheter or UTI care area when the facility failed to ensure Residents 137's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential to result in the resident's urine to not flow freely which may lead to the development of an UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor Resident 69's change in condition for significant weight loss for one of two sampled residents (Resident 69) investigated under the nutrition care area. This deficient practice had the potential to place the resident at risk for further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe and appropriate use of side rails (SR or bed rail - adjustable, rigid, plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of five sampled residents (Resident 145) reviewed under the Accidents care area by failing to: 1. Attempt to use appropriate alternatives prior to installing bilateral (both sides) upper (at the head and shoulder area) SRs. 2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral upper SRs use. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards to two of two sampled residents (Resident 116 and 120) by failing to document if Resident 116's Humulin (a hypoglycemic medication/insulin-a hormone that lowers the level of sugar in the blood) and Resident 120's Lispro (a hypoglycemic medication) doses were administered or not administered. This deficient practice had the potential to result in inaccurate documentation in the medical records regarding the residents' medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 by failing to: 1. Ensure resident urinals were labeled with a resident identifier for one of two sampled residents (Resident 357) reviewed during the Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) care area. 2. Ensure resident's hand-held nebulizer (HHN - a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing was placed inside the plastic storage after use for one (1) out of two (2) sampled residents (Resident 21) reviewed under the Respiratory care area. This deficient practice had a potential to spread infections and illnesses among residents.

Inspectors wroteBased on interview and record review, the facility failed to provide in writing the completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a notification to the resident or responsible party [RP] of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) and the Notice of Medicare Non-Coverage (NOMNC - a notification to inform the resident or RP of the pending termination of coverage and of his/her right to an expedited review of service determination) for two of three sampled residents (Residents 13 and 118) reviewed during the Beneficiary Notification task. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the admission diagnosis and the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) on 12/13/2024 for one (1) of four (4) residents (Resident 21) sampled for unnecessary medications by omitting a diagnosis of schizophrenia (a mental zdisorder characterized by disordered thinking, behaviors, and emotions that impairs daily functioning) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, making it difficult to carry out day-to-day tasks.) This deficient practice increased the risk that Resident 21 may not have received care planning and treatment according to Resident 21's needs possibly leading to a decline in Resident 21's overall health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) for two of three sampled residents (Resident 1 and Resident 2) were managed by failing to: 1. Ensure Resident 1 and Resident 2 had their enteral feeding supplies labeled with the licensed nurse's signature, date, and time. 2. Ensure Resident 1 received the enteral feeding at the required time. 3. Ensure Resident 1 and Resident 2's total amount of enteral feedings were monitored. These deficient practices had the potential to result in residents receiving inaccurate amount of formula as ordered and enteral feeding supplies harboring bacteria and transmitting to residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 5) who was refusing to shower. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 4). On 12/17/2024, at 7:10 p.m., Resident 4 walked out of the facility unassisted with no front wheel walker (FWW- a mobility aid that helps people with limited upper body strength or who need help bearing weight while walking). This deficient practice resulted to Resident 4's elopement and can potentially place Resident 4 at risk for injury, fall and accidents.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for two of three sampled residents (Resident 4 and Resident 5) by: 1. Failing to accurately document Resident 4's history of elopement (the act of leaving a facility unsupervised and without prior authorization) in the Elopement Evaluation on 12/17/2024 after Resident 4 had elope. 2. Failing to accurately document shower was provided to Resident 5 on 12/2024. These deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and safe temperature level for two of four sampled residents (Resident 3 and Resident 4) by failing to ensure the facility temperature was between 71 degrees Fahrenheit (°F, unit of measurement for temperature) to 81°F as indicated in the facility ' s policy and procedure (PnP). This deficient practice had the potential to cause serious medical problems and altered comfort level.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of four sampled residents (Residents 2) by failing to ensure Resident 4 was not in procession of a sharp tool. A wire cutter was in Resident 2 ' s possession in the resident ' s room. This deficient practice had the potential to cause injury or harm to Resident 2 and other residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident ' s medical doctor and responsible party timely when a resident was noted with purple discoloration to the left eye for one of three sampled residents (Resident 1). This deficient practice could have resulted in a delay of appropriate necessary care and treatment to Resident 1 and had the potential for missed opportunities by the responsible party to be involved with care and decision-making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 10 (CNA 10) knock and request permission before entering the resident`s room for three of four sampled residents (Resident 42, 45, and 155) reviewed under dignity care area. This deficient practice has the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care by failing to: 1. Ensure Resident 7 had a care plan addressing her extrapyramidal symptoms (movement disorders that include muscle spasms, motor restlessness, tremors [shaking or trembling movements in one or more part of the body], decreased body movement, rigidity, and abnormal movements) and movement disorder diagnosis for one of three sampled residents reviewed under activities of daily living care area. Cross-reference F676 2. Ensure Resident 29 had a care plan for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use for one of one sampled resident reviewed under insulin care area. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites for: 1. One of five sampled residents (Resident 1) investigated during review of unnecessary medications. 2. One of four sampled residents (Resident 306) investigated during review of medication administration facility task. This deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on 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) for four of seven sampled residents (Residents 13, 99, 67, and 306) investigated under the Medication Administration and Storage and Labeling task, by failing the following: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for four of five sampled residents (Residents 112, 27, 54, and 126) investigated during review of unnecessary medications by: 1. Failing to monitor behavioral manifestations and side effects (an often harmful and unwanted effect) of psychotropic (any drug that affects behavior, mood, thoughts, or perception) use for Residents 112, 27, 54, and 126. 2. Failing to provide an adequate indication and by failing to monitor behavioral manifestations for Resident 126's use of quetiapine. These deficient practices placed the residents at risk of receiving unnecessary psychotropic medications without monitoring and evaluating the effectiveness of the antipsychotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.71% affecting two of four sample residents (Resident 67 and 306) observed for medication administration performed by Licensed Vocational Nurse (LVN) 2 and LVN 3. The facility failed to: 1. Ensure LVN 2 did not mix Resident 67's aspirin (medication used to reduce pain and inflammation) and thiamine (also known as vitamin B1, supplement used for growth, development, and function of cells) together and administer through Resident 67's gastrostomy tube (GT - a soft tube inserted during surgery into the stomach through the belly to deliver food and medications a person with difficulty or inability swallowing, also known as an enteral tube). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus are developed and prepared to meet resident choices by failing to: 1. Follow the diet menu and the dietician's recommendation to have 1/2 cup of apple sauce during lunch and dinner for one of 14 sampled residents (Resident 22) investigated during review of dining observation task. This deficient practice had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices and of their preference. 2. Used small scoop size to serve corn for residents on regular diet and on dysphagia advanced diet (includes moist foods in bite sized pieces for residents who have chewing and or swallowing difficult) and served less protein to residents on renal diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved texture, appearance and served at appetizing temperatures for 152 out of 158 residents who received food from kitchen and for residents 7, resident 71 and resident 74 who complained the food did not look appetizing to eat. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutritional supplements during lunch on 1/8/2024 as ordered by the physician for 17 out of 60 residents who were on nutritional supplements. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated or labeled in the walk-in refrigerator. One box of beef patties and one box of pork sausage links were stored uncovered in the walk-in freezer. One juice box containing orange juice blend with manufactures use by date of 11/10/2023 exceeding storage period for juice was connected to the juice machine and in use. 2. One can opener blade was dirty, serving utensils/scoops were dirty with dried food, floor, and walls behind the range area (stove and oven) were dirty. The floor next to the oven was dirty with sticky and greasy residue and the back wall of the oven had orange color stains. Under the food preparation counter next to oven was not maintained clean and there were food debris. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for four of four sampled residents (Resident 110, 28, 105, and 126) investigated addressing hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to: a. Ensure there was documented evidence interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meetings were held to collaborate with hospice representatives the hospice plan of care for Resident 110. b. Ensure hospice staff, including licensed vocational nurse (LVN) and hospice aide (HA), provided nursing and visitation notes to the facility for Residents 28, 105, and 126. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures for nine of 18 sampled residents investigated addressing the care area of infection control (Resident 1, 7, 12, 42, 45, 155, 48, 66, 103, and 146) by: 1. Failing to label the urinal bottle (a container used to collect urine) of Resident 1 to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). 2. Failing to label the respiratory breathing treatment (involve inhaling medications using a nebulizer/humidifier device [a small machine that turns liquid medicine into a mist that can be easily inhaled]) tubing of Resident 112 of when it was last changed. 3. Failing to keep Resident 7's oxygen tubing off the floor. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) for the administration of olanzapine (a medication used to treat mental disorder including schizophrenia [chronic and severe mental disorder that affects how a person thinks, feels, and behaves, and bipolar disorder [a condition that causes extreme mood swings that include emotional highs and lows]) was completed to include the dosage (amount of medicine), route (way a medication is taken), frequency, and indication (valid reason) for one (Resident 3) out of two sampled residents investigated under the dementia care area. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one out of three sampled residents (Resident 22) investigated during review of environment facility task. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that a resident or the resident's representative was provided information on home health (a wide range of health care services that can be given in the home for an illness or injury) services and durable medical equipment (DME - equipment that is considered medically necessary as prescribed by a physician for use in a patient's home) upon discharge for one (Resident 152) out of three sampled residents investigated during review of closed records. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) when Resident 7 was not provided services to address Resident 7's extrapyramidal symptoms (movement disorders that include muscle spasms, motor restlessness, tremors [shaking or trembling movements in one or more part of the body], decreased body movement, rigidity, and abnormal movements) and movement disorder for one of three (Resident 7) sampled residents reviewed under activities of daily living care area. This deficient practice had the potential for Resident 7 to have decreased oral intake and decline in independence with eating.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to one of two sampled residents (Resident 85) reviewed under the pressure ulcer care area by failing to ensure the residents' low air-loss mattresses (LALM, an air mattress covered with tiny holes) were set according to the physician's order. The deficient practice had the potential for development and worsening of pressure ulcers to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a nutritional supplement to a resident who had a weight loss of 18.57% in six months for one out of 13 (Resident 92) sampled residents investigated during review of dining observation task. This deficient practice placed Resident 92 at risk for continued weight loss and complications related to nutritional and hydration status.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe professional standards of quality to one out of one sampled resident (Resident 157) by: 1. Failing to document insertion of intravenous (IV - therapy that delivers medications directly into a vein) line for Resident 157. 2. Failing to label the peripheral IV site with the date the line was inserted to indicate how long the IV line had been on Resident 157's left wrist. These deficient practices had the potential to expose Resident 157 to infection and IV therapy complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice by failing to administer Resident 7's supplemental oxygen as ordered by the physician for one out of three sampled residents (Resident 7) reviewed under the respiratory care area This deficient practice had the potential for Resident 7 to desaturate (condition of low blood oxygen level) and experience respiratory problems.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to pain management to one out of two sampled residents (Resident 13) reviewed under the pain management care area by failing to assess and document the resident's pain every shift per physician's order. This deficient practice placed the resident at risk for having unmanaged pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident diagnosed with dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being by failing to implement person-centered care plan interventions for Resident 105, who was observed with door closed during multiple observations when the resident was exhibiting verbal outbursts for one of three sampled residents (Resident 105) reviewed under the dementia care area. This deficient practice had the potential to affect Resident 105's safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who is receiving Eliquis (Apixaban, used to prevent serious blood clots from forming due to a certain irregular heartbeat or after hip/knee replacement surgery) is monitored for side effects (an often harmful and unwanted effect) as indicated in the plan of care for one of one sampled residents (Resident 55) reviewed for anticoagulant use. This deficient practice placed the residents at risk for unnecessary medication and undetected side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of seven medication carts (Med Cart #4) inspected while investigating medication and labeling tasks. The facility failed to discard the insulin glargine injection pen (medication that lowers the level of glucose [sugar] in the blood) after 28 days of opening per facility protocol for Resident 20. The insulin glargine injection pen was opened on 12/8/2023. This deficient practice had the potential for administering less potent (lessening of physical or chemical effect) medication that is ineffective in controlling blood sugar levels.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented by: 1. Failing to document Resident 7's pregabalin (also known as Lyrica, a medication used to treat nerve and muscle pain) oral capsule 100 milligrams (mg - a unit of measure) administration on [DATE] at 6:00 a.m. for one of two sampled residents reviewed under the pain care area. This deficient practice had the potential for facility staff to not know if the medication was administered or not and administer an additional dose of medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on interview and record review, the facility failed to submit and transmit the Minimum Data Set (MDS, a standardized assessment and care screening tool) timely for three of three sampled residents (Resident 89, 96, and 14) investigated under the Resident Assessment facility task. These deficient practices had the potential to result in care that does not address the resident's specific care needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS-a standardized assessment and care screening tool) Assessment the discharge destination of a resident who was discharged to the community (refers to private home/apt., board/care, assisted living, or group home) for one of three sampled residents (Resident 152) investigated during review of closed records. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control program during a Coronavirus Disease-2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (a sudden increase in occurrences of a disease) for three of five sampled staff (admission Director [AD], Licensed Vocational Nurse 1 [LVN 1] and Certified Nursing Assistant 1 [CNA 1]) by: 1. Failing to ensure admission Director wore a N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while walking in the front lobby. 2. Failing to ensure CNA 1 wore a N95 respirator while walking in the hallway carrying a clear plastic bag of thrash. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 1) by failing to ensure Resident 1's urinary collection bag was covered with a privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 1.

Inspectors wroteF842 Resident Records - Identifiable Information §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; [...]

Inspectors wroteF842 Resident Records - Identifiable Information §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident ' s rights to be free from physical abuse by failing to implement safety measures to prevent resident to resident altercations for three of six sampled residents (Resident 1, Resident 2, and Resident 6). This deficient practice resulted in Resident 1, Resident 2, and Resident 6 experiencing physical abuse.