Alta View Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary behavioral health assessments, care, and services for the treatment of Resident 1's schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors) by failing to: 1. Identify, address, and provide Resident 1 with the necessary behavioral health care and services. 2. Develop a behavioral health care plan for Resident 1. These deficient practices denied Resident 1 behavioral health care and services needed to maintain mental well-being and resulted in Resident 1 being unnecessarily admitted to General Acute Care Hospital (GACH) 1 on 6/3/2026.

Inspectors wroteBased on observations, interview and record review, the facility failed to implement their policy and procedures (P&P), titled, Infection Prevention and Control Program, revised in April 2025, during an outbreak (the sudden occurrence of two or more residents (or staff) getting the same illness within a short period) of Invasive Group A Streptococcus (IGAS - refers to a surge in rare, dangerous infections caused by common bacteria [Strep A] invading blood, muscles, or lungs, rather than just the throat or skin) for two of two sampled residents, (Resident 1 and Resident 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the clinical records as indicated in the facility's Charting and Documentation policy and procedure for one of three sampled residents (Resident 1) by failing to ensure to document: -A significant care event on 3/6/2026, including Resident 1's refusal of shower care, aggressive behavior, staff interventions, and outcome. -The transfer of care from Certified Nursing Assistant 1 (CNA 1) to CNA 2 during the shower refusal on 3/6/2026. These failures resulted in an incomplete medical record of Resident 1 and had potential to affect Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed ensure its' policy and procedures (P&P) titled Transfer or Discharge, Preparing a Resident for, were implemented for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being discharged to a board and care ( without a post-discharge plan documented, and the potential to delay ordered home health services and missing the ordered follow-up doctor's appointment. During a review of Resident 1's admission Record , dated 3/6/26, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hypertension (HTN - high blood pressure), hyperlipidemia (HLD - high cholesterol, epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), and difficulty in walking. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident 1) to return to the facility following a hospitalization on 12/3/2025, Resident 1 was transferred to general acute care hospital (GACH) on 11/11/2025. This deficient practice delayed Resident 1's return to the facility and had the potential to result in psychosocial harm for Resident 1, and Resident 1's responsible party.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food was not stored in the kitchen for 76 of 84 residents who received food from the facility's kitchen. This deficient practice had the potential to cause food-borne illnesses to the residents related to ingestion of expired food and has a potential to lead to foodborne illnesses which can be life-threatening. During an initial kitchen tour observation on 8/18/2025 at 8:08 a.m. with the Dietary Manager (DM), it was observed to have undated and expired food items stored in the refrigerator: Undated prepared peanut butter and jellied sandwiches were stored in one of four refrigerators. Expired deli turkey slides were stored inside one of four refrigerators in a container with a label to use by 8/17/2025. During a concurrent observation and interview on 8/18/2025 at 8:08 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen freezer #1 and freezer #2 was maintained at 0-degree Fahrenheit (F-unit of measurement) temperature while hashbrowns, whipped topping, french fries, assorted vegetables, sweet potato fries were store. This deficient practice placed 76 of 84 residents residing in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During a concurrent initial kitchen tour observation on 8/18/2025 at 8:03 a.m. and interview with the Dietary Manager (DM), the following were observed. a. Freezer #1 is located outside the storeroom. The internal thermometer reads 12 degrees F. b. Freezer #2 located inside the storeroom, the internal thermometer reads 10 degrees F. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide a Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN, a document that the facility must provide to Medicare beneficiaries when the facility anticipates that Medicare might not pay for certain services) for two of three sampled residents (Resident 44 and Resident 95). This failure had the potential to result in Resident 44 and Resident 95 not being able to make an informed decision (a choice made after carefully gathering and assessing all relevant facts) regarding the care that may not be covered by Medicare (a federal system of health insurance for people over [AGE] years of age and for certain younger people with disabilities) program.

Inspectors wroteBased on interview and record review, the facility failed to provide nonpharmacological interventions (behavioral interventions that do not involve medications) prior to administering Resident 4 Lorazepam (a medication that helps reduce anxiety) PRN (as needed) for one of five residents sampled for unnecessary medications (Resident 4). This deficient practice increased the risk of Resident 4 experiencing adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy (medications that affect brain activities associated with mental processes and behavior), such as drowsiness, low blood pressure, constipation, or increased risk of fall; possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to accurately set the settings of the Low Air Loss mattresses (LAL - medical-grade mattress designed to prevent and treat pressure injuries [PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin] by reducing moisture and heat buildup) for two of three sampled residents (Resident 56 and Resident 90) according with the residents' weights per the physician's orders. This failure had the potential to prevent the promotion of skin wound healing for Resident 56 and Resident 90.

Inspectors wroteBased on record review and interview the facility failed to ensure that one of six sample residents (Resident 46) who was assessed at risk for weight loss, and were provided with timely nutritional intervention to prevent continuous significant weight loss, including: 1. Failure to follow Registered Dietitian (RD) interventions for Resident 46 to have dental evaluation. 2. Failure to have interdisciplinary (IDT-team-a coordinated group of experts from several different fields) meeting to strive to prevent, monitor, and intervene Resident 46's undesirable weight loss as indicated in the facility's policy and procedure on Nutrition (Impaired) Unplanned Weight Loss-Clinical Protocol revised on July 2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures by failing to wear appropriate personal protective equipment (PPE) while feeding residents on enhanced barrier precautions (EBP- infection control measures that require targeted use of gowns and gloves during high-contact resident care activities along with strict hand hygiene) for three of four sampled residents (Resident 39, Resident 44, and Resident 81)This failure had the potential to spread disease and infection among residents and staff. 1. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] with diagnoses including Candidiasis (C. auris- a multidrug resistant fungus that causes life-threatening infections) and cerebral infarction (stroke- loss of blood flow to part of the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to offer COVID-19 vaccines for three of three residents sampled for immunizations (Resident 4, resident 62, and Resident 96). This deficient practice had the potential to result in Resident 4, Resident 62, and Resident 96 contracting, transmitting, and experiencing complications related to COVID-19 such as acute respiratory distress syndrome (ARDS- life-threatening lung injury), pneumonia (an infection/inflammation in the lungs), respiratory failure requiring oxygen, and sepsis (overwhelming infection spreading throughout the body).1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of 20 sampled residents (Resident 15) by not ensuring Resident 15's call light (a device used by residents to call for assistance) was within reach. This deficient practice had the potential to cause a delay in staff meeting Resident 15's needs for assistance further resulting in falls and accidents. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to a part of the brain) and needing assistance with personal care. [...]

Inspectors wroteBased on interview, and record review, the facility failed to inform and consult with resident's physician when there was a significant change in the resident's physical status for one of six sample residents (Resident 46) regarding 7.2 pounds weight loss in 14 days. This deficient practice delayed the Medical Doctor (MD) being notified and the resident not being reassessed for the 7.2 pounds weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean environment for one of six sample residents (Resident 31). This deficient practice had the potential for an unsafe and unclean resident's environment with the potential for the spread of infection and to place the resident at risk for physical discomfort. During a record review of Resident 31's admission Record dated 6/27/2025, the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to Gastrostomy-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), Delayed Milestone in Childhood (a situation where a child does not reach a particular developmental milestone at the expected age). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessment for entry and discharge from the facility were completed within the required time frame for one of three sampled residents (Resident 94). This failure had the potential to result in Resident 94 receiving a delay in care and services at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entry on the Minimum Data Set (MDS- an assessment and care screening tool) related to weight loss was accurately coded to reflect the resident's weight loss of five percent in a month for one of six sampled residents (Resident 46). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and services for Resident 46. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a plan of care for one of six sample residents (Resident 46), who had lost 7.2 pounds (5.9 percent) in 14 days after admission. This deficient practice had the potential for delayed provision of necessary care and services. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified-Calorie Malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). dysphagia (difficulty swallowing), pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to explain medications that were administered to one of nine sampled residents (Resident 35) observed during medication pass, as indicated in the facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 10/2017 and Charge Nurse/Nurse Supervisor Competency Assessment, dated 10/2020. This deficient practice failed to provide information to Resident 35 regarding his medications before Licensed Vocational Nurse 1 (LVN1) administered the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure to inform the facility nursing staff (in general) to maintain the medication refrigerator's temperature with the correct reference range of 36-to-46 degrees Fahrenheit ([ F] is a unit of temperature) (2-to-8 degrees Celsius ([ C] is a unit of temperature) in accordance with the regulatory standards, manufacturer's specifications and the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 1/2025, for the storage and monitoring of refrigerated medications for one of one inspected medication room (Medication Room). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic (medicine that kill or stop the growth of bacteria) Stewardship for one of three sampled residents (Resident 62) by failing to complete an Infection Surveillance Outcome form (a tool used in healthcare to document and analyze infections and monitor antibiotic use in a facility) for Resident 62. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification for Resident 62. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (PVC 20) was administered to one of three residents sampled for immunizations (Resident 62) after Resident 62 consented to receive the vaccine. This failure had the potential to result in Resident 62 contracting, transmitting, and experiencing complications related to pneumococcal diseases such as pneumonia (an infection in the lungs), meningitis (inflammation of brain and spinal cord membranes), and sepsis (a life-threatening blood infection). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 12 hours required in-service training for one of two sampled Restorative Nursing Assistant (RNA). This deficient practice has a potential to compromise residents safety due to RNA training was insufficient.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his personal belongings after discharge as indicated in the facility's policy and procedures titled Resident's Personal Belongings. This failure resulted in Resident 1 feeling angry, belittled, and disgusted. A review of Resident 1's admission sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including muscle weakness (lack of physical or muscle strength), and essential hypertension (high blood pressure). A review of Resident 1's History and Physical dated 2/26/25, indicated Resident 1 was a great historian. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for Resident 2 ' s Central Venous Catheter (CVC-is a thin, flexible tube that's inserted into a vein to give fluids, blood, and/or medications). This failure had the potential to negatively affect the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2 ' s Central Venous Catheter (CVC, a thin, flexible tube that's inserted into a vein to give fluids, blood, and/or medications) care was documented, indicating it was done in the Intravenous (IV, inside the vein) Administration Record (IVAR). This failure resulted in the documentation not being complete and therefore unable to tell if the care was completed.

Inspectors wroteBased on interview and record review the facility failed to notify the physician and the next of kin (NOK) when resident had a change in condition for one of three sampled residents (Resident 1). For Resident 1 whose weight was 126 pounds (lbs., unit of measurement) on 10/8/24 and on 11/4/24 Resident 1 weighed 118 lbs., the facility identified Resident 1 had a significant weight loss of eight lbs. in one month. The facility failed to notify Resident 1 ' s physician and Resident 1 ' s NOK in a timely manner. This deficient practice had the potential for delay in providing Resident 1 interventions to prevent further weight loss and the NOK not updated with Resident 1 ' s condition.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate record for one of three sampled residents (Resident 1). For Resident 1, who had a physician order to collect urine sample for urinalysis (UA, test of urine for the presence of infection and other problems), culture and sensitivity (C&S, determine the causative agent of the infection and the best way to treat it) on 10/25/24, the facility failed to ensure the Resident 1 ' s record reflected that the urine sample was not collected and the notification of Resident 1 ' s primary physician. These deficient practices resulted in inaccurate representation of Resident 1 ' s medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Dishware were not sanitized with adequate amount of sanitizer per manufacture guidelines. Sanitizers and disinfectants are used on food contact surfaces such as pots, pans and dished helps to prevent the growth and spread of germs and the risk of food borne illness. 2. The ice machine was not maintained in a clean manner and the inside compartment of ice machine was dirty. 3. Individual juice cartons with manufactures instruction if frozen, thaw, refrigerate and use within 10 days, were not monitored for the date they were thawed to ensure expired juice were discarded. One large bowl holding 15 individual cartons of orange pineapple flavored juice were stored in the reach in refrigerator with no thaw date. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment and screening tool) for the section relating to Restorative Nursing Program (nursing aide program that helps residents maintain their function and joint mobility) use for one out of the four sampled residents (Resident 34). This deficient practice had the potential to incorrectly reflect Resident 34's plan of care and care and services received by the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide chest physiotherapy on 8/10/2024 and 8/12/2024 according to the physician order for one out of the two sampled residents (Resident 42). This deficient practice had the potential to result in Resident 42 becoming short of breath and could negatively impact the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 28 in one of two inspected medication carts (Medication Cart 1.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and that Resident 28 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up the requested dental services for dentures for one of four sampled resident (Resident 25). This deficient practice resulted in a delay of Resident 25 being evaluated for dentures and increased Resident 25's risk for weight loss and loss of muscle mass.

Inspectors wroteBased on interview, and record review, the facility failed to develop individualized person-centered care plans (a set of instructions for providing individualized care to a resident for an identified area of concern) to meet the residents need for three of ten sampled residents (Residents 12, 275, and 40). -For Resident 12, the facility failed to develop a care plan with goals and interventions for doxycycline (an antibiotic [medicines that fight infections] used to treat infections). -For Resident 275, the facility failed to create a care plan for the problematic behaviors of angry outbursts and agitation related to the diagnosis of psychosis (a severe mental condition in which thoughts and emotions were so affected that contact was lost with external reality). [...]

Inspectors wroteBased on interview and record review, the facility failed to: -Ensure lorazepam (a medication used to treat mental illness) was used for a medical condition as diagnosed and documented in the resident's clinical record between 3/8 and 3/20/2024, for one of five residents sampled for unnecessary medications (Resident 275). -Define resident-specific target behaviors regarding the use of lorazepam for one of five residents sampled for unnecessary medications (Resident 275). -Monitor Lorazepam for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and effectiveness between 3/8 and 3/20/2024, for one of five residents sampled for unnecessary medications (Resident 275). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills for the following: -Two of two staff were not following the manufacturer's guidelines of the test strip, when checking the concentration of the Quat Sanitizer (a chemical use for disinfection) solution used in the two compartment sinks and sanitation of food preparation surfaces. -One of two staff were unable to demonstrate and verbalize proper dish machine temperature checks. -Two of two staff were not following the manufacturer's guidelines of the test strip when checking the concentration of the chlorine (a chemical used for disinfection) solution used in the low temperature dish machine. [...]

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: a. Staff was wearing wristwatches and gold bracelet during food preparation and dishwashing. b. Refrigerator gasket was dusty. c. Freezer had ice crystals, tape residue, and food debris on the bottom shelves. d. Storage racks were not six inches (in., unit of measurement) from the floor. e. Dirt debris on the dry storage floor. f. Three dented cans in the storage area. g. Domes were not air dried before storage. h. Sheet pan storage racks were dusty. i. Two staff were not wearing beard guard in the kitchen. j. Staff did monitor food temperature during food pick up from Facility 2 on the first day the kitchen was closed. k. Sticky dirt build-up in two of the plate lowerators (kitchen equipment to warm and hold plates). l. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when cockroaches (a type of insect) were observed in the kitchen. This deficient practice resulted in multiple cockroaches (eleven cockroaches), observed hiding in the cracks at the base of the steam table (assembly area for resident's food), crawling in the kitchen on the sheet pan's storage rack. This deficient practice caused an increased risk in 68 of 73 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced the resident's dignity and respect for one of six sampled residents (Resident 51). The Certified Nursing Assistant stood over Resident 51 while assisting him during a meal. This deficient practice had the potential to affect Resident 51's sense of self-worth, self-esteem, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set assessment (MDS - a comprehensive resident assessment and care planning tool), Section I (active diagnoses) on 3/12/2024, for one of five residents sampled (Resident 275) for unnecessary medications by: -Including a diagnosis of anxiety (feeling of fear, dread, and uneasiness that may occur as a reaction to stress) without evidence to support this as an established diagnoses in the clinical record. -Omitting a diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) despite evidence to support this as an established diagnosis in the clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 28) was provided a communication device with the language that the resident was able to understand. On 3/18/2024 Resident 28 repeatedly stated comida in Spanish (food). Sitter 1 stated he did not understand what Resident 28 was saying and ingnored the resident. As a result, Resident 28 appeared distressed and prevented Resident 28 from communicating with the staff, delaying appropriate care / treatment the resident requested.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (has a high potential for abuse) affecting Resident 69 in one of two inspected medication carts (Medication Cart 3). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Resident 69 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a recommendation from the facility consultant pharmacist, concerning adding instructions for how to treat moderate pain, in one of five sampled residents for unnecessary medications (Resident 46). This deficient practice increased the risk that Resident 46 could have experienced pain that was not adequately treated with medications available, causing a decline in Resident 46's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate transmission-based precaution (TBP, the second tier of basic infection control that is used in addition to Standard Precautions [the minimum infection prevention practices that apply to all patient care] for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) signage was posted for one of six sampled residents (Resident 40). This deficient practice had the potential to cause the spread of infection to staff, other residents, and the community.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from misappropriation of the resident's property (the willful misplacement or wrongful temporary or permanent use of a resident's belongings or money) by the staff. The Certified Nursing Assistant (CNA) received money from Resident 1. This deficient practice resulted in the misappropriation of Resident 1's money while under the care of the facility.

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) for two of five sampled residents (Resident 1 and 2) when on 10/22/2023, at 3:45 p.m., Resident 1 and Resident 2 punched each other. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility and resulted in Resident 1 having facial bruises, a facial cut, and he was feeling anxious and not safe in this facility. Resident 2 had a skin tear on his forehead and a skin tear on his upper left cheek.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment and supervision for one of three sampled residents (Resident 1), who was at risk for elopement (leaving facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave), at risk for wandering (occurs when a person with loss of memory, thinking or reasoning roams around and becomes lost or confused about their location), and had diagnoses of epilepsy (a brain disorder that can cause people to suddenly have a seizure), to address the resident's attempt of elopement on 11/11/2023 at 1:05 PM. The facility failed to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that was free of accident hazards for two of seven residents (Resident 24 and Resident 33) by failing to: 1. Ensure Certified Nurse Assistant 9 and 10 (CNA 9 and CNA 10) checked the integrity of the Hoyer lift (an equipment used by caregivers to safely transfer patients) sling and if the size was appropriate prior using it to transfer Resident 24 from a wheelchair (WC) to a bed on 10/5/2023 in accordance with the facility's policies and procedures (P&P) titled, Lifting Machine, Using a Mechanical, revised 9/2023, and the manufacturer's undated instruction manual on Hoyer lift sling. Resident 24 weighed 426 pounds at the facility. On 10/5/2023, the Hoyer lift sling snapped (break suddenly and completely) when CNA 9 and CNA 10 were transferring Resident 24 from WC to a bed. [...]

Inspectors wroteRepeat Deficiency from the Recertification Survey 10/2023. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles for two of two medication carts. An open bottle of Morphine Sulfate and an open bottle of Ondansetron were open without labeled dates of opening. This deficient practice caused an increased risk of residents to receive potentially ineffective or toxic medication due to improper storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure for infection control to prevent an infectious disease outbreak (a sudden rise in the number of cases of an infectious disease) by staff failing to perform hand hygiene when entering and exiting resident rooms, and after touching residents' surroundings in 21 of 36 rooms. This failure had the potential to cause or prolong an infectious disease outbreak, affecting all residents and staff in the facility.