Alta Gardens Care Center

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the discharge and transfer process was thoroughly completed for one of eight sampled residents (Resident 6). * The facility failed to ensure Resident 6 was provided with the Notice of Proposed Discharge/Transfer form in a language and manner the resident understood. * The facility failed to show the documentation of the actual date, time, mode of transportation, and notification to the resident's representative when Resident 6 was transferred out to another SNF facility. In addition, the facility failed to ensure a report was provided the receiving SNF facility. * The facility failed to ensure the Long-Term Care Ombudsman was notified of Resident 6's transfer to another facility until after the resident was transferred. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of eight sampled residents (Resident 1). * The facility failed to follow the physician's order to administer Resident 1's TPN continuously as ordered by the physician. This failure had the potential for Resident 1 to develop adverse effects due to interruption of treatment, including unstable metabolic activity, and nutritional deficits. * The facility failed to monitor Resident 1's blood glucose level every six hours as ordered by the physician while receiving TPN. This failure had the potential for Resident 1's to develop adverse effects from unrecognized hyperglycemia or hypoglycemia and delayed medical intervention. [...]

Inspectors wroteBased on observation, interview, medical record, and facility P&P review, the facility failed to ensure appropriate respiratory care was provided for one of two sampled resident (Resident 1) reviewed for respiratory care. * The facility failed to ensure Resident 1 received oxygen as ordered. This failure had the potential to affect the resident's respiratory health and overall well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate parties were notified when one of three sampled residents (Resident 1) was discovered to be missing from the facility. * The facility failed to ensure the police department was notified when Resident 1 was discovered missing from the facility. This failure had the potential to delay locating Resident 1.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to maintain the resident's highest practicable well-being for three of five sampled residents (Residents 1, 2, and 3). * The facility failed to ensure the transportation services were properly coordinated to and from the dialysis clinic for Resident 2's hemodialysis treatment. Resident 2 was not picked-up from the dialysis clinic on 3/4/25, as a result, Resident 2 took two public buses and walked the remainder of the way back to the facility. In addition, Resident 2 felt fear and anxiety and was prescribed antianxiety medications related to the incident. [...]

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for five of five residents reviewed for unnecessary medication (Residents 9, 25, 28, 38, and 47). * The facility failed to ensure the informed consent was obtained from Resident 28 or their representative before administering the sertraline (antidepressant medication) medication to Resident 28. In addition, the facility failed to ensure the informed consent was obtained from Resident 28 or their representative when the Ativan (antianxiety medication) medication was changed to be administered routinely (once a day from as needed). [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 3, 9, 28, 38,and 47) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 47 was monitored for the number of episodes of nightmares related to the use of prazosin (medication used to treat high blood pressure; also widely used as off-label medication to manage nightmares and sleep issues). * The facility failed to ensure the nonpharmacological interventions were provided to Resident 28 when Resident 28 had six behavior episodes related to the use of Ativan (medication used to relieve anxiety). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * Food items in the refrigerator and dry storage area used for residents' food were not properly labeled and dated. * Expired food were not discarded. * Food contact surfaces were not clean or in a cleanable condition. * The facility failed to ensure the refrigerated food item brought in by visitors was properly labeled and dated. In addition, the refrigerator was not clean and the temperature for the freezer and the refrigerator was not consistently monitored. * The ice machine was not clean. * The hair restraint was not worn by one staff member entering the kitchen. * Hand hygiene practices were not completed prior to wearing gloves. * The blender was not washed in between the preparation of each pureed food. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of March 2025 through January 2026. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure two resident basins were labeled in a shared resident restroom. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain a homelike environment for three of six residents interviewed (Residents 20, 22, and 66) during Resident Council meeting, and one nonsampled resident (Resident 109). * Residents 20, 22, 66, and 109 enjoyed watching television in their rooms; however, their televisions were not functioning. This failure had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 105) reviewed for abuse was free from abuse. * The facility failed to protect Resident 105's right to be free from physical abuse by another resident (Resident 3). Resident 105 was blocking the hallway while Resident 3 was trying to get through. Resident 3 reached out his hand and slapped Resident 105 on the face. Resident 105 had some redness on the face and forehead. This failure had the potential for Resident 105 to be seriously injured or have psychosocial harm.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop/implement the comprehensive plan of care to reflect the individual care needs for two of 24 final sampled residents (Resident 3 and 12). * The facility failed to develop a care plan problem to address Resident 3's risk of elopement. * The facility failed to develop a care plan intervention to offload Resident 12's heels and ankles. In addition, the physician's order to offload Resident 12's heels and ankles while in bed was not implemented. These failures posed the risk of not providing appropriate, consistent, and individualized care to Residents 3 and 12.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for four of 24 final sampled residents (Residents 4, 7, 14, and 105). * The facility failed to ensure the neurological evaluation was completed after the fall incident of Resident 105. In addition, the facility failed to ensure the physician was notified and the resident was monitored when Resident 105 was found to have discoloration of the right eye. * The facility failed to ensure the insulin injection site was rotated for Resident 4. * The facility failed to ensure Resident 14's wheelchair was evaluated as ordered by the physician. Resident 14's wheelchair was observed too high and the resident's feet were dangling. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three final sampled residents (Resident 12) reviewed for pressure injuries. * The facility failed to offload Resident 12's heels, as ordered by the physician, to prevent pressure injuries. This failure had the potential for Resident 12 to develop pressure injuries, complications, or worsening of the existing pressure injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of three final sampled residents (Residents 18 and 25) reviewed for falls remained free of accident hazards. * The facility failed to ensure the bedside table was not placed on top of the floormat for Resident 18. * The facility failed to ensure the post fall assessment and IDT (Interdisciplinary Team) assessment were conducted after Resident 25 sustained a fall. These failures had the potential to put Residents 18 and 25 at risk for serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the nutritional recommendations from the RD were followed for one of five final sampled residents (Resident 48) reviewed for nutrition. * The facility failed to follow the RD's recommendation for an appetite stimulant for Resident 48. This failure had the potential for adverse nutritional outcomes and to negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain IV (intravenous-through the vein) access for one of one final sampled resident (Resident 48) reviewed for IV care. * The facility failed to label Resident 48's IV site with the date, time, and initials of the licensed nurse when the IV was inserted. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Resident 48.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management were provided for two of two final sampled residents (Residents 18 and 28) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions for pain management were provided before the administration of the pain medication for Resident 28. In addition, the facility failed to ensure the pain medication was administered according to the physician's order for Resident 28. * The facility failed to ensure the pain medication was administered as ordered by the physician for Resident 18. These failures placed Residents 18 and 28 at risk for ineffective pain management.

Inspectors wroteBased on interview, facility document review, medical record review, and facility P&P review, the facility failed to ensure the proper monitoring and documentation of the ongoing assessments before, during, and after dialysis treatments were conducted for one of one final sampled resident (Resident 108) reviewed for dialysis services. * The facility failed to ensure Resident 108's Hemodialysis Communication Records were complete. In addition, the facility failed to ensure Resident 108's AV (arteriovenous) hemodialysis site assessments were consistent as per the physician's order. These failures had the potential to delay the identification and response to complications related to the hemodialysis site, and delay of care and treatment for Resident 108.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medication to one of one final sampled resident (Resident 28) and one nonsampled resident (Resident 97) observed for medication administration. * The facility failed to ensure the correct medication was administered to Resident 97. LVN 7 administered sodium bicarbonate (alkalinizing agent) 650 mg oral tablet instead of sodium chloride (electrolyte replenisher) oral tablet 1 gram as ordered by Resident 97's physician. * LVN 7 administered lactobacillus acidophilus (probiotic) oral capsule instead of lactobacillus rhamnosus GG (probiotic) oral capsule as ordered by Resident 97's physician. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medications for one of four medication carts (Medication Cart B) inspected. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Cart B. This failure had the potential to negatively impact the residents' well-being, and the potential for the medications to lose stability and effectiveness.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of the kitchen employees (Dietary Aide 1) was competent in the position related duties. * Dietary Aide 1 failed to intervene when the low dishwashing machine failed to reach 120 degrees Fahrenheit. This failure had the potential for food preparation equipment, dishware, and utensils not to be cleaned and sanitized correctly.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for one sampled resident (Resident 89) and one nonsampled resident (Resident 87) reviewed for meal observation. * The facility failed to ensure Resident 87 was served the pureed soup and dessert as per the menu. * The facility failed to ensure Resident 39 was served omelet, bread, jelly, and margarine for breakfast, as listed on the meal ticket. These failures posed the risk of negatively impacting the residents' satisfaction and dietary compliance.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for two of 114 residents (Residents 55 and 114) who received food prepared in the kitchen. * The facility failed to ensure Resident 114 was served with his juice of choice for his lunch meal. * The facility failed to ensure Resident 55 was served with the preferred beverage as per the meal ticket. These failures had the potential to affect the residents' overall meal intake and nutritional status.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food brought from the outside were handled safely. * The facility staff and residents' visitors were not educated on the safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to food borne illness in the residents who resided in the facility.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain an accurate medical record for two of 24 final sampled residents (Residents 6 and 10) and one of three residents (Resident 22) reviewed for closed records. * The facility failed to ensure the POLSTs were complete for Residents 6, 10 and 122. This failure had the potential for the residents' care needs to not be met as their medical information was inaccurate.

Inspectors wroteBased on observation and interview, the facility failed to maintain the essential equipment in a safe operating condition for one of three facility water heaters (Water Heater 1). * Water Heater 1 was observed leaking water from the check valve. This failure had the potential to cause water heater component damage, which posed the risk for the residents' water heater to malfunction.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR level 1 contained accurate information for one of two final sampled residents (Resident 3) reviewed for PASRR. * Resident 3 had the diagnosis of major depressive disorder (mood disorder characterized by persistent sadness, hopelessness, and loss of interest in activities lasting at least two weeks) and was prescribed quetiapine (antipsychotic medication). However, the PASRR level 1 showed Resident 3 had no diagnosed mental illness and was not prescribed the psychotropic medication. This failure posed the risk for Resident 3 inappropriate placement in a long-term care nursing home when a PASRR level 2 evaluation was not done.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the plan of care was revised for one of 24 final sampled residents (Resident 25). * The facility failed to ensure Resident 25's plan of care was revised to address the resident's fall on 1/4/26. This failure posed the risk for Resident 25 to not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 79) reviewed for respiratory services was provided with the appropriate respiratory care. * The facility failed to ensure Resident 79's nebulizer mask and tubing were labeled with the date and properly stored in a bag when not in use. This failure had the potential to affect Resident 79's respiratory health and well-being.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for six of six final sampled residents (Residents 60, 83, 110, 716, 816, and 818) reviewed for IV care. * The facility failed to ensure the initial PICC line external catheter measurements were documented in the medical record and confirmed the baseline measurements of the PICC line external catheters and arm circumferences prior to the administration of IV antibiotics for Resident 83. In addition, the facility failed to ensure Resident 83's PICC dressing was labeled with the date and a care plan was developed for the use of Resident 83's right upper arm PICC. * The facility failed to ensure accurate documentation of the monitoring and documentation of Resident 60's right arm midline. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * Residents were served the yellow cake instead of the carrot cake with cream cheese frosting as shown on the posted menu. * Residents 97 and 466 were not served the chocolate ice cream as per the menu. * Resident 66 who was on a renal diet was not provided a renal diet per the menu. In addition, Resident 66 was not served a double portion of the protein per the diet order. These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accident hazards for one of three final sampled residents (Resident 4) reviewed for accident hazards. * The facility failed to implement the bilateral floor mats as per the plan of care for Resident 4. This failure had the potential risk for injury to Resident 4.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services related to the use of the GT for three of three final sampled residents (Residents 55, 58, and 74) reviewed for the GT management. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 55. CNA 14 had resumed the GT feeding after providing incontinent care to Resident 55. In addition, the facility failed to ensure Resident 55's enteral feeding formula was labeled with the time and the Kangaroo (enteral feeding pump machine) water bag was labeled with the time and name of contents inside the bag. * The facility failed to ensure LVN 2 auscultated the resident to check the GT placement prior to the administration of the GT medication for Resident 58. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to the meet the needs for two of two final sampled residents (Residents 55 and 816) reviewed for respiratory care. * The facility failed to administer the oxygen as per the physician's order to Resident 816. * The facility failed to ensure Resident 55's sterile water for the humidifier was labeled with an opened date. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of two final sampled residents (Resident 818) reviewed for pain management. The facility failed to ensure Resident 818 was administered pain medication as per the physician's order. Additionally, the facility failed to consistently provide the NPI for pain prior to the administration of a narcotic pain medication to Resident 818. These failures had the potential for not effectively managing the resident's pain.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 21) reviewed for dialysis care. * The facility failed to ensure Resident 21's scheduled medications on the dialysis days were held as per the physician's order. In addition, the facility failed to ensure Resident 21's AV shunt was assessed after the dialysis treatment and fluid restriction was monitored . These failures had the potential to negatively affect Resident 21's physical well-being, which potentially would result in the resident having an excess of fluid which could lead to negative health consequences.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of two final sampled residents (Residents 50 and 58). * The facility failed to ensure the physician's orders for Resident 58 were accurate. The medication route was ordered to be oral instead of GT. This failure had the potential for the medications to be administered in error. * One of five licensed nurses (LVN 2) who was observed during the medication administration was found to have an error. LVN 2 failed to administer the complete dose of one of Resident 58's medications when significant residual of the multivitamin (supplement) medication was observed in the medication cup after administering the medication via GT to Resident 58. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 60 and 110) reviewed for unnecessary medication were properly monitored for the signs and symptoms of bleeding related to the use anticoagulant (prevents blood clots) medication. * The facility failed to ensure Resident 110 was monitored for the signs and symptoms of bleeding for the use of enoxaparin (anticoagulant medication) medication. * The facility failed to monitor for signs and symptoms of bleeding related to Resident 60's use of the apixaban (anticoagulant medication) medication. These failures had the potential for the residents to develop significant side effect of bleeding and negatively affect the resident's health condition and well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the monitoring for the use of the antipsychotic medications (medications that affect brain activities associated with mental process and behavior) for three of five sampled residents (Residents 4, 41, and 60) reviewed for unnecessary medications were completed when: * The facility failed to ensure Resident 41 was monitored accurately for orthostatic hypotension as ordered by the physician for the use of Seroquel (antipsychotic medication). In addition, the facility failed to ensure Resident 41's informed consent for the use of the Seroquel medication included the indication for its use and the date for the Seroquel medication to be stopped. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 11.54%. Three of five licensed nurses (LVNs 1, 2, and 10) were found to have made errors during the medication administration observations. * Resident 50 had a physician's order for zinc (supplement) for wound healing. LVN 1 failed to administer the zinc medication as ordered due to the unavailability of the medication. * LVN 2 failed to check Resident 58's last bowel movement and if Resident 58 had loose stool prior to administering the polyethylene glycol 3350 (laxative medication) medication. * LVN 10 failed to check whether Resident 109 had a bowel movement in the last 72 hours prior to administering the polyethylene glycol medication. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aide 1 was unable to correctly demonstrate how to test the chemical concentration of the sanitizing solution used to sanitize the food contact surfaces. * Dietary Aides 1 and 2 were unable to correctly describe how to manually wash the dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of the residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure the labeling and dating of the food items in the freezer used for the residents food. * The facility failed to ensure the maintenance tools were stored properly. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure the education was provided to the staff on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food brought from the outside sources.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented as evidenced by: * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. The facility only documented on the surveillance log the residents who were prescribed with antibiotics were identified as having infection. * The facility failed to ensure the staff used proper PPE upon entering the resident's room for one nonsampled resident (Resident 88) who had Covid. * The facility failed to ensure LVN 7 donned the proper PPE during high-contact care for Resident 616 who was on enhanced barrier precautions. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and/or maintain copies of the advance directives in the medical records for two of eight final sampled residents (Residents 18 and 60) reviewed for advance directives. These failures had the potential for the residents' decisions regarding their healthcare and treatment not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the written information regarding the facility's bed hold policy was provided to the resident/resident's representative at the time of transfer to the acute care hospital for one of three sampled resident (Residents 47) reviewed for hospitalization. This failure had the potential for the resident and/or representative to be unaware of their rights to request a bed hold upon transfer.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the expired medications were removed for one of four Medication Carts (Medication Cart B). This failure had the potential for the medication to lose the stability and effectiveness.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of six garbage dumpsters. This failure had the potential to attract pests/rodents that carried diseases.

Inspectors wroteBased on observation and interview, the facility failed to ensure the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of infectionswere maintained in the facility's laundry room area. This failure had the potential risk for the transmission of communicable diseases to the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 2) was provided a floor mat as per the resident's care plan to prevent or minimize the injury in case of a fall. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * Residents were served the canned sliced peaches instead of peach shortcake as shown on the posted menu. These failures had the potential for the 91 residents receiving food prepared in the kitchen to not meet their nutritional needs which might lead to nutritional related health complications.

Inspectors wroteBased on observation and interview, the facility failed to follow the proper sanitation and food storage practices. * The facility failed to ensure the prepared food items were properly dated and labeled. *The facility failed to ensure the resident and staff's personal food items were not stored in the walk-in refrigerator. * The facility failed to ensure the personal belongings were stored away from the kitchen preparation area. * The facility failed to ensure the food items in the resident's refrigerator were properly labeled and dated. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the dignity was maintained for one of 22 final sampled residents (Resident 89). * The facility's staff was standing over Resident 89 when assisting the resident with the house supplement. This failure created the potential to affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to assess two of 22 final sampled residents (Residents 55 and 745) for their ability to self-administer the medications. * Resident 745 had a bottle of over-the-counter analgesic cream at the bedside and LVN 6 took it out from the drawer and gave to the resident to self-administer. Resident 745 did not have the assessment and physician's order for the self-administration of medications. * Resident 55 had a packet of A&D ointment (skin protective barrier) at bedside which was provided to self-administer by a facility staff member. Resident 55 did not have the assessment and physician's order to self-administer the A&D ointment. These failures had the potential for poor health outcomes to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT were provied to one of 22 final sampled residents (Resident 46) and one of 11 nonsampled residents (Resident 91). * Resident 91's enteral water bag was unlabeled and undated. * The facility failed to ensure Resident 46's GT syringe was rinsed and dried prior to storing as per the facility's P&P. These failures posed the risk for complications related to the GT for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 22 final sampled residents (Residents 693 and 743). * The facility failed to ensure a physician's order for supplemental oxygen therapy was obtained prior to the oxygen administration for Resident 693. This failure had the potential for Resident 693 receiving unnecessary oxygen. * The facility failed to ensure Resident 743's nasal cannula tubing was dated as per the facility's P&P. This had the potential for increased risks of infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 11 nonsampled residents (Resident 78) was administered the medication at the correct time as ordered. * LVN 1 was observed administering the medication to Resident 78 after a meal instead of before meals as ordered. Failure to administer the medication at the right time posed the risk of poor health outcome for this resident.

Inspectors wrote2. Review of the facility's P&P titled LTC Facility's Pharmacy Services and Procedures Manual - Storage and Expiration Dating of Medications, Biologicals revised 7/21/22, showed the facility should ensure the medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. a. On 9/15/22 at 1200 hours, an observation and concurrent interview was conducted with the Central Supply Clerk in the Central Supply Room. Medications were observed in the locked cabinets including three eight ounce bottles of pink bismuth regular strength. The expiration date on the three bottles was 6/22. The bottles were observed in the same area as the non-expired medications. The Central Supply Clerk stated he must have missed those expired medications when he last checked the medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, LVN 1 failed to follow the facility's P&P on hand hygiene practices and infection prevention during contact with two residents (Residents 46 and 78). * LVN 1 did not perform hand hygiene during Resident 78's medication administration. * LVN 1 did not perform hand hygiene before GT medication administration for Resident 46. These failures had the potential to spread infectious organisms to the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the patient care equipment was maintained in a safe operating condition when two of five glucometers were not checked for quality control. This failure put the residents at risk for inaccurate blood sugar readings.