Almond Vista Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow an infection prevention and control program designed to provide a safe and sanitary environment for one of three sampled Residents (Resident 4) when Licensed Vocational Nurse (LVN) 3, Certified Nursing Assistant (CNA) 3 and CNA 4 were observed assisting Resident 4 who was on Enhanced Barrier Precautions (EBP - special infection-control practices to prevent the spread of germs that are resistant to antibiotics) up in bed for lunch without wearing the required Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive care plan was implemented for one of four sampled residents (Resident 1) when Resident 1 was diagnosed with cellulitis of the right foot surgical wound and started on antibiotics with no implementation of a comprehensive care plan. This failure had the potential for Resident 1's needs to go unmet. (cross reference F658)During a concurrent observation and interview on 2/16/26 at 10:03 a.m. with Resident 1, Resident 1 was lying in bed, there was gauze secured by an ace bandage on his right foot and the second, third and fourth toes had surgical pins (small, thin metal rods used to hold broken bone pieces together while they heal) sticking out. Resident 1 stated he had foot surgery in mid-February on his right foot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice for one of four sampled residents (Resident 1) when the nursing staff failed to keep Resident 1's surgical dressing dry and did not notify the physician the bandage was soiled according to the physician's post-operative order. This failure had the potential to cause Resident 1's wound to dehisce (surgical complication where the edges of a closed incision separate) or become infected (pathogens enter the wound and cause symptoms such as pain, increased redness and swelling). (cross reference F657)During a concurrent observation and interview on 2/16/26 at 10:03 a.m. [...]

Inspectors wrote2. During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed being fed by CNA 11. Resident 69 was wearing a gown, with the head of the bed elevated, right and left bed rails up at the head of bed, and a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was hung on the lower bed rail with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) were not separated for 169 residents and visitors to view. This failure resulted in 169 residents and visitors not knowing how many direct care hours were provided daily for each resident by licensed and unlicensed staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the garbage was disposed of properly for 159 of 169 residents who received food from the kitchen when one gray plastic container and four beige dumpsters were found uncovered with brown cardboard boxes and clear, white and black plastic bags stacked higher than the container rim. This failure had the potential to attract or harbor pests which could increase the risk of cross contamination (the unintentional transfer of harmful bacteria or other contaminants from one food, surface, or object to another, often leading to foodborne illnesses and the growth of microorganisms).

Inspectors wroteDuring a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, observed no EBP sign on the door of Resident 69's room. Resident 69 was observed lying in bed with the head of his bed raised, being fed by CNA 11 who was standing next to Resident 69 wearing no gown or gloves. A urinary catheter bag hung on the lower bed rail next to CNA 11, with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP-professional who ensures healthcare workers and residents are doing all the things they should to prevent infections) had training on Enhanced Barrier Precaution (EBP-an infection control measure in nursing homes aimed at preventing the spread of multidrug-resistant organisms (MDROs-germ that is resistant to many antibiotics) measurement for residents with indwelling medical devices (temporary or permanent devices inserted into the body to serve a specific function, such as fluid drainage, ventilation, or feeding) and open wounds. [...]

Inspectors wroteDuring a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed in bed wearing a gown, head of bed elevated with a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag hung on the lower rail of the bed without a dignity covering (a cover put over a urinary catheter bag to preserve one's privacy and dignity). Resident 69 was being fed by CNA 11 who stated Resident 69 was non-verbal. Resident 69 did not answer any questions. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for four of thirteen sampled residents (Resident 58, Resident 115, Resident 132 and Resident 203) when: 1. Resident 58, Resident 115, and Resident 132 were administered antipsychotic medication and informed consent was not obtained prior to medication administration. 2. [...]

Inspectors wroteDuring an observation, interview and record review, the facility failed to ensure five out of 22 sampled residents (Resident 20, Resident 353, Resident 112 and Resident 118) had a comfortable and homelike environment when: 1. Resident 20's personal belongings inventory was not updated and was observed wearing Resident 353's shirt and Resident 112's personal belongings were not inventoried. These failures had the potential to result in a loss of Resident 20, Resident 353, and Resident 112's personal belongings. 2. Dining Hall (DH) 1, the only available dining space, was used to store 20 cardboard boxes that contained mattresses and lighting fixtures. This failure resulted in Resident 118 not having access to a comfortable and homelike dining environment which led to Resident 118 feeling like DH 1 was crowded.

Inspectors wrote3. During a concurrent observation and interview on 4/28/25 at 3:08 p.m. with Resident 207 in Resident 207's room, Resident 207 was observed laying in bed wearing a gown and wearing a nasal cannula with oxygen flowing at a rate of 1.5 L/min, no label was observed on the oxygen tubing indicating when it was connected to the concentrator. Resident 207 was unable to answer questions. During a concurrent observation and interview on 4/28/25 at 3:19 p.m. with CNA 10 in Resident 207's room, Resident 207's oxygen tubing was observed to be without a label indicating when it was connected to the oxygen concentrator. CNA 10 stated Resident 207's oxygen tubing was not labeled with the date it was connected. CNA 10 did not know why the tubing needed to be labeled with the date. CNA 10 stated the nurses were responsible for changing and labeling residents' oxygen tubing. [...]

Inspectors wroteDuring a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, Resident 74 was observed sitting in bed wearing a gown. Resident 74 stated she had been at the facility for one week. Resident 74 stated the facility was a non-smoking facility, so she used a vape pen. Resident 74 stated there were a group of smokers who used to smoke cigarettes, but now used vape pens. A vape pen was observed on Resident 74's bedside table and a box of cigarettes was observed inside her bedside drawer. Resident 74 stated she did not have matches. Resident 74 stated she went with a group to vape with no supervision from staff. During a review of Resident 74's AR, dated 5/2/25, the AR indicated Resident 74 was re-admitted to the facility from an acute care hospital on 4/25/25 with an original admission on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent when the facility ' s medication error rate was 7.41 percent. There were 27 opportunities for errors and two medication errors occurred with two of five sampled residents (Resident 134 and Resident 26) when: 1. Resident 134 was administered the incorrect dose of K2 Plus D3 (potassium vitamin and vitamin D) Oral Tablet [PHONE NUMBER] MCG [microgram]-UNIT This failure resulted in Resident 134 receiving the incorrect dose of medication. 2. Licensed Vocational Nurse (1) did not follow the order for Lidocaine External Patch 4 % (topical anesthetic that numbs pain by blocking the nerve signals to the skin) for Resident 26. This failure had the potential to result in ineffective pain management for Resident 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately store and label medication for three of eight medication carts and one of four medication storage rooms and had incomplete 41 of 106 Narcotic (substance used to treat moderate to severe pain) medication disposal sheets when: 1. Medication cart on station three had: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe food preparation standards when Worcestershire sauce and Dutch Cocoa powder with expired labeled use by (UB) dates were found in the walk-in refrigerator and dry storage. This failure had the potential for 159 of 169 sampled residents to be served food prepared with expired ingredients which could increase the risk of food contamination and the development of food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of seven sampled residents (Resident 57) when Resident 57 toenails were not cut for more than eight months. This failure resulted in result in resident 57's toenails to become long which had the potential to result in Resident 57 toenails to become painful, ingrown or to break off causing infection.

Inspectors wrote2. During a review of Resident 132's admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a means to contact caregiver for two of the 22 sampled residents (Resident 206 and Resident 253) when call lights were not within reach of Resident 206 and Resident 253. This failure did not allow Resident 206 and 253 to call for assistance and put Resident 206 and 253 at risk of not having their needs met and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review, revise, and implement a person-centered comprehensive care plan for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a left hip hemiarthroplasty (a surgical procedure where only one half of a joint is replaced, typically the ball portion of the hip joint, while the socket remains intact) on [DATE] and the care plan did not indicate how often Resident 1's left hip dressing should be changed, how Resident 1 should bathe, and if Resident 1 can bear weight on the left leg. This failure placed Resident 1 at an increased risk to develop a surgical site infection to the left hip, further injury to the left hip, and had the potential to result in Resident 1's care needs to go unmet. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury. These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. Resident 1 was diagnosed with a broken left hip and required administration of fentanyl (a medication for severe pain) to control the pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate supervision to prevent accidents when Resident 1 was admitted on [DATE] from an acute care hospital with known history of difficulty swallowing, assessed need for strict aspiration precautions (safety measures to prevent patients from breathing in foreign objects, like food or liquids, into their lungs), Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) indicating moderate cognitive deficits (a stage of dementia where a person has significant difficulty with complex tasks and navigating new places) and need for assistance with meals and a care plan was not developed to address nursing staff to provide supervision during meals. [...]

Inspectors wroteBased on interview and facility assessment reviews, the facility failed to create and implement a comprehensive Facility Assessment to determine what resources the facility needs to meet the needs of its residents which had the potential to affect 161 residents residing in the facility.

Inspectors wroteBased on interview, review of facility documents, and facility policy review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed and implemented to drive quality assurance (QA) measures. This failure had the potential to affect all 161 residents who currently live in the facility.

Inspectors wroteBased on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 161 residents who currently live in the facility.

Inspectors wrote3. Review of R68's undated ''admission Record'' located in the EMR under the ''Profile'' tab included an original admission date of 05/28/23 and most recent readmission on [DATE]. Review of R68's ''Clinical Census'' located in the EMR under the ''Census'' tab indicated on 08/10/23 a hospital leave with readmission on [DATE]. Review of R68's ''Progress Note,'' located in the EMR under the ''Progress Note'' tab and dated 08/10/23, included transfer to the Emergency Department (ED) for foley catheter evaluation and possible obstruction/malfunction with bleeding. No documentation was located in the EMR indicating a transfer/discharge notice was provided to the resident or representative. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure five out of five sampled residents who were reviewed for hospitalization (Residents (R)126, R151, R99, R69, R102) were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility.

Inspectors wroteBased on interview, review of facility documents, and facility policy review, the facility failed to ensure bed hold audits were completed per the performance improvement project. This failure had the potential to affect residents who were emergently sent out to the hospital.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when the residents completed therapy or skilled nursing services for two of three residents (Residents (R) 76, and R102) reviewed for beneficiary notices. This failure had the potential of a resident or responsible party to make an informed decision related to continuing to receive Medicare A services, by having the facility continue services and bill Medicare A, continue the services, and bill the resident, or no receive the services.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure two out of two residents (Resident (R) 78 and R203) reviewed for restraints out of total of 32 sampled residents were free from physical restraints. R78 was positioned in bed in a manner to prevent him from getting out of bed as a fall intervention. R203 was observed with his hand to mid forearm wrapped with a bandage with a sock worn over it on his left hand/arm that he was not able to remove. Unnecessary physical restraints created the potential for psychological distress to R78 and R203.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 95) reviewed for ''Pre-admission Screening and Resident Review (PASARR)'' had a level two assessment completed. Specifically, the facility failed to re-submit a positive PASSAR Level I screening, after a PASARR Level II was not able to be conducted. This failure placed the resident at risk for unmet care needs and not receiving appropriate mental health support/services as needed.

Inspectors wrote2. Review of R253's undated admission Record, located in the EMR Profile tab, revealed R253 was admitted on [DATE] with diagnoses including secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall with hospice services. Review of the EMR revealed a POLST (Physician Order for Life Saving Treatment) completed by R253 on 07/21/24 located in the Documents tab of the EMR which documented R253 did not want resuscitation. Review of the Orders tab of the EMR revealed a physician order for DNR (Do Not Resuscitate), dated 07/21/24. Review of the care plan, dated 07/22/24 and located in the EMR Care Plan tab, revealed there was not a care plan for advance directives or her code status. During an interview on 08/02/24 at 4:00 PM, the MDS Director confirmed a care plan for code status should have been initiated when R253 was admitted . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of one residents (Resident (R) 204) reviewed for bowel and bladder out of a total sample of 32 residents received timely care for constipation. The bowel protocol was not initiated until R204 failed to have a bowel movement for five days. R204 went a total of ten days without having a bowel movement putting him at risk for a fecal impaction.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of three residents (Resident (R) 204) reviewed for nutrition/hydration out of 32 sampled residents received sufficient fluids to maintain adequate hydration status. R204 was not assessed timely for fluid requirements even though he was prescribed intravenous (IV) fluids twice within the first ten days of admission due to poor nutritional and fluid intake. R204's care plan goal for fluids was inadequate to meet his fluid needs, and his supplement intake was not monitored. R204 was at risk for dehydration and weight loss.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)78) reviewed for unnecessary medications out of 32 sampled residents did not receive an as needed antianxiety medication for more than fourteen days without a physician rationale for extending the use and without the stop date specified. This failed practice increased the risk of experiencing adverse reactions to medications which they may not need to treat a clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three residents (Resident (R) 81 and R79) reviewed for catheters out of 32 sampled residents received catheter care in a manner to prevent cross-contamination. Nursing staff did not change gloves appropriately while providing catheter care to R81 and the facility failed to ensure R79's catheter bag was kept off the floor. This failure has the potential for staff to spread infections between residents.

Inspectors wroteBased on interview and record review, the facility neglected to provide goods and services when they did not obtain and administer a medication ordered that was necessary to avoid physical harm and psychosocial distress to one of three sampled Residents (Resident 1) when Resident 1 was ordered an antiviral medication upon admission which was not acquired by the facility nor administered for seven days. This failure resulted in Resident 1 being neglected by staff and experienced psychosocial harm and anxiety which prompted Resident 1 to leave the facility against medical advice (AMA) for fear of physical harm due to the gap in the administration of his medication regimen and potential for risk of a worsening viral infection.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality when one of three sampled residents (Resident 1) was not administered his anti-viral medication (medication used to help the body fight off harmful viruses which can ease symptoms and shorten the length of a viral infection) for seven days, as ordered on admission and staff did not follow up with the pharmacy or notify the physician as required according to the facility ' s policy and procedure titled, Unavailable Medications. This failure resulted in increasing the risk of worsening Resident 1 ' s viral infection and possibly cause harm and mental and emotional distress (anger and frustration).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free of accident hazards for one of three sampled residents (Resident 1), when one Certified Nursing Assistant (CNA) assisted during briefs (adult diaper) change alone, not using two - person assist (two staff members to one resident) as required. This failure resulted in Resident 1 falling out of bed during briefs change and sustained a sprained (soft tissue injury) right ankle.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when 1. The facility placed 9 of 10 sampled Residents (Residents 3, 7, 10, 20, 44, 65, 564, 565, and 566) at serious risk for infection and Forty-three additional residents (Residents 1, 5, 11, 16, 26, 33, 34, 36, 41, 42, 47, 49, 57, 58, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 567, 568, 569, 570, 571, 572 and 573) identified as potentially at risk due to their requiring blood glucose testing with the use of the glucometer (a small portable device used to measure sugar in the blood) machine. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Nurses (LN) possessed specific competencies required for the use of Insulin Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for three of seven sampled resident's (Resident 141, Resident 564 and Resident 567) when one of four LN (Registered Nurse [RN]) 1 failed to follow the manufacturer's instructions of use for administering insulin with the Flex Pen. RN 1 did not use the indicated needle attachment made for use with Insulin (medication for the treatment of diabetes - a disease with high blood sugar levels) Flex Pens, and instead, withdrew insulin out of the pen using a non-intended syringe with needle and administered insulin to Resident's 141, 564 and 567. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with known risk for falls received adequate supervision and assistances to ensure residents were free from accidents and injury for one of two sampled residents (Resident 15) when Certified Nurse Assistant (CNA 22) left Resident 15 unsupervised in her room during the mechanical lift [Stand-Up Lift device) preparation procedure which resulted in Resident 15 falling forward and fracturing (broken bone) her right hand little finger.

Inspectors wrote2. During a review of the clinical record for Resident 162, the admission Record dated 7/16/19, indicated Resident 162 was discharged home from the facility on 4/30/19. During an interview with the Medical Records Assistant (MRA), on 7/16/19, at 9:54 a.m., the MRA stated Resident 162 was discharged home. The MRA stated she did not know if the Ombudsman was notified for Resident 162's discharge. The MRA reviewed Resident 162's clinical record and stated she could not find notification of discharge to the Ombudsman in the resident's record. During an interview with the Director of Social Services (DSS), on 7/16/19, at 11:02 a.m., the DSS stated a letter of the last covered day needs to be sent to the Ombudsman to notify of the residents' discharge. The DSS stated medical records should have sent a copy to the Ombudsman. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 51, Resident 138, and Resident 15) when: 1. Resident 51 did not have a care plan for the use of an indwelling urinary catheter. This failure resulted in Resident 51's indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) care not being properly implemented by licensed nurses. 2. Resident 138 did not have a care plan for walking without feet protection. This failure resulted for Resident 138's feet not assessed by licensed nurses for potential injuries and signs infection. 3. Resident 15 Fall care plan failed to address the identify the need to use a mechanical lift for safety during transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of 20 sampled Certified Nursing Assistants (CNAs). These failures had the potential for residents' needs to go unmet by CNAs whose competence had not been determined through annual performance reviews.

Inspectors wroteBased on observation, interview and record review, the facility failed store medications and biological in a manner that conforms with state requirement and the standard of practice when: 1. The facility stored and made available for resident use expired medications, medications for external use, medical supplies and medications labeled for individual's use with the over-the counter (OTC) oral medications in the medication storage area in Station 2. 2. The facility stored medications for external use with OTC oral medications in the central supply storage room in Station 3. 3. The facility stored medications for external use with the OTC oral medication in the medication storage in Station 3. 4. The facility stored medications for internal use mixed with oral medications in the medication cart in Station 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food services staff had appropriate competencies for safely and effectively carrying out the functions of food services when [NAME] 1, 2 and Dietary Aide were unable to verbalize the cool down process and did not follow the cooling down policy and procedure. This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. Potentially hazardous foods (PHF) were not cooled down according to the cool down policy and procedures. 2. Several dry foods containers were opened and stored without opened date label. 3. Frozen products in the walk in freezer were removed from the original containers and were not labeled or had used by date. 4. The kitchen staff did not have a red bucket sanitation chemical monitoring process and did not perform red sanitation water buckets testing to ensure the water contained adequate levels of sanitation chemical. 5. Wet Pans were stack on top of each other to air dry. These failures to ensure effective dietetic service operations placed the residents at risk for food borne illness and the growth of microorganisms (bacteria).

Inspectors wroteBased on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak.

Inspectors wrote2b. During a concurrent observation in Resident 6's room and interview with Resident 6, on 7/9/19, at 3 p.m., Resident 6 stated she received dialysis service for about 15 years now. Resident 6 stated she went for dialysis treatments three times a week every Monday, Wednesday and Friday at 10:30 a.m. During a review of Resident 6's undated face sheet indicated resident was admitted with diagnoses which included Hypertensive Chronic Kidney Disease (elevated blood pressure caused by kidney disease), End Stage Renal Disease, dependence on Renal Dialysis. During a review of Resident 6's dialysis, 11 (eleven) communication forms dated 6/1/19, 6/3/19, 6/5/19, 6/10/19. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen equipment was safely maintained when excess ice build up was found inside the walk in freezer above the two freezer fans. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote care for residents in a manner and in an environment that maintained and enhanced each resident's dignity and respect in full recognition of his or her individuality when residents in the dining room were not served meals to all residents at the same table at the same time while residents watched others eating and they sat and waited for their meal affecting eight of 21 residents (Resident 158, 87, 14, 37, 89, 134, 55, and 40). This failure denied Residents 158, 87, 14, 37, 89, 134, 55, and 40 the right to a dignified and pleasant dining experience.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident's right to be informed of treatment for one of two sampled resident (Resident 80) when Resident 80 did not have a medication informed consent for an antipsychotic medication (affecting mental activity, behaviors, and perceptions). This failure resulted in Resident 80 or legal representative not being fully informed of the risks and benefits of the antipsychotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of seven sampled residents, Resident 133 when Resident 133's call light (a device used to alert staff when a resident needs assistance) was found on the floor and out of Resident 133's reach. This failure had the potential for Resident 133 not to receive assistance when needed and in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, sanitary, and comfortable environment for one of three sampled residents (Resident 3) when dried feces was found in Resident 3's bathroom on the toilet seat and inside of the toilet. This failure caused Resident 3 to be exposed to an unsanitary and none homelike environment with a potential to cause infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse reporting policy and procedure for one of one sampled resident, (Resident 9), when the facility failed to report Resident 9's injury of unknown origin to the State Survey Agency in accordance with State law. This failure led to the delayed of immediate investigation of the cause of Resident 9's fracture (broken) rib bone to rule out the potential for abuse.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) once every 3 months for two of two sampled residents (Resident 2 and Resident 3). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to accurately conduct and document resident Minimum Data Set (MDS-patient assessment tool) assessments for two of three sampled residents (Resident 3 and Resident 137) when: 1. Resident 3's MDS assessment section C, Brief Interview of Mental Status (BIMS assessment) was inaccurately assessed. This deficient practice resulted in the documentation of an inaccurate BIMs assessment and had the potential to cause inaccuracy in identifying resident strengths to maintain and improve medical, functional, and psychosocial status. 2. Resident 137's dental assessment did not reflect the resident's actual dental status. This failure resulted in the delay in meeting Resident 137's dental need that would improve Resident 137's quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a baseline care plan for smoking within 48 hours of the resident's admission for one of one sampled residents (Resident 160). This failure placed Resident 160's health and safety at risk for potential burn or safety when Resident 160 smoking needs were not care planed.

Inspectors wroteBased on staff interview and record review, the facility failed to revise a care plan on Falls that address the identified need for a safe mechanical lift transfer for one of two sampled residents, Resident 562. This failure placed Resident 562's health and safety at risk when the care plan did not include two person assistance with the use of a mechanical lift.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for 44 of 46 sampled residents (Residents 1, 3, 5, 7, 10, 11, 15, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) when: 1. Registered Nurse (RN) 1 used non-intended syringe with needle to withdraw insulin from an insulin flex pen (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication [for the treatment of diabetes - a disease that causes high blood sugar levels] administration). RN 1 did not use the indicated needle attachment made for use with Insulin Flex Pens, and instead, withdrew insulin out of the pen using a non-intended syringe with needle and administered the insulin to Resident's 141, 564 and 567. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper maintenance and care for residents with an indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) for two of 12 sampled residents (Resident 33 and Resident 51) when: 1. Resident 33 and Resident 51's indwelling urinary catheter was not placed below the bladder. This failure had the potential for urine backflow that could lead to urinary tract infection (an infection in the bladder). 2. Nursing staff did not document Resident 51's indwelling urinary catheter urine output in the intake and output log. This failure had the potential for Resident 51's urine output to go unmonitored and placed resident at risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Psychotropic Drug (medications that affects brain activities associated with mental processes and behavior) as needed prescriptions were limited to 14 days for one of three sampled residents (Resident 38) when Resident 38's Xanax (anxiety medication) This deficient practice had the potential to expose Resident 38 to unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that meets resident's daily nutritional dietary needs and preference for one of one sampled resident (Resident 137) when the physician's diet order was not followed. This failure placed Resident 137 at risk for unplanned weight loss and unmet nutritional dietary needs.