Antelope Valley Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one person towards another) when on 7/8/2026, at 8:30 a.m., while Resident 1 was seated in a wheelchair, Resident 1 used his (Resident 1) left palm and struck Resident 2's forehead while Resident 2 was also seated in a wheelchair in the hallway. As a result, on 7/8/2026, at 8:30 a.m., Resident 2 was subjected to physical abuse while under the care of the facility. Resident 2 sustained a reddened forehead with a bump (any raised area or swelling) measuring approximately one inch long and one inch wide and Resident 2 had facial grimace, yelled and had guarding behavior of covering her (Resident 2) forehead due to pain (pain level not specified). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for two of four sampled residents (Resident 1 and Resident 2) by failing to: Ensure Certified Nursing Assistant (CNA) 2 reported Resident 1's unwitnessed fall on 6/4/2026 to the licensed nurses. Ensure CNA 2 did not move Resident 1 until the licensed nurses had assessed the resident following Resident 1's unwitnessed fall. Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC - when there is a sudden change in a resident's condition) on 6/4/2026 related to the resident's fall. Ensure licensed nurses appropriately assessed and monitored Resident 2's medical status following the resident's Change of Condition (COC) on 6/9/2026 related to the alleged physical abuse against CNA 4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to report the allegation of an employee-to-resident physical abuse (any intentional act causing injury or trauma to another person through bodily contact) to the State Survey Agency (SSA) for one of four sampled residents (Resident 2). On 6/9/2026, an allegation that Certified Nursing Assistant (CNA) 4 pushed and punched Resident 2 on the face was reported to Licensed Vocational Nurse (LVN) 3, LVN 4, and the Director of Nursing (DON). The SSA did not receive the report from the Abuse Coordinator for the allegation of abuse. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteDuring an interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a moderate risk for falls (as indicated in Resident 1's Fall Risk Observation and Assessment), was free from falls and injury by failing to ensure Resident 1 was supervised and assisted while taking a shower in the shower room. As a result, on 6/4/2026 between 9 a.m. to 10 a.m., Resident 1 fell to the ground while taking a shower in the shower room. Resident 1's fall was not reported to the licensed nurses until 6/6/2026, two days following the fall, when Resident 1 complained of right lower back and right buttock pain. Resident 1's fall resulted in a bluish discoloration with diffused yellow edges on the right iliac crest (the curved top ridge of the hip bone) and right buttock.

Inspectors wroteBased on interview and record review, the facility failed to revise and update the comprehensive care plan to reflect current wound orders for left and right arm gangrenous (tissue in a living body that is dead, decaying, or rotting, usually caused by a severe lack of blood supply) wound and intervention for one of three sampled resident (Resident 1). This deficient practice had the potential to delay care and services that were specific to the Resident 1's needs.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Background Screening Investigations, for one of seven sampled staff (Certified Nursing Assistant [CNA] 1) when the facility failed to run a background (a screening process that verifies a person's history [employment, education, credit] to confirm accuracy) and criminal check (a specific type of background check, searches public records for convictions or felony/misdemeanor arrests) prior to staff employment. This deficient practice had the potential to affect the residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) maintained acceptable parameter of nutritional status when the facility failed to follow up with the Medical Doctor when Registered Dietitian (RD- a credentialed food and nutrition expert who uses evidence-based science to help people improve their health, manage diseases, and create personalized meal plans) made recommendations on 2/17/2026 and 3/18/2026. This deficient practice had the potential for Resident 1 to have an unintentional weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the intravenous catheter (IV-a flexible plastic tube that is inserted into a vein to deliver fluids and medications) care consistent with professional standards of practice for three of four sampled residents (Resident 1, 2 and 3), by failing to: 1. Ensure Resident 1's IV was assessed and monitored for potential complications.2. Ensure peripherally inserted IV was labeled and dated for Resident 2 and Resident 3. These failures had the potential to delay the provision of necessary care and services for Residents 1,2, and 3 and to negatively affect the residents' well-being. Cross reference F842.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of the peripheral intravenous catheter (peripheral IV-a flexible plastic tube that is inserted into a vein to deliver fluids and medications) insertion for four of four sampled residents (Residents 1, 2, 3, and 4). This deficient practice had the potential for inaccurate medical interventions for Residents 1, 2, 3, and 4. Cross reference F694.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a person-centered care (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of four sampled residents (Resident 1) by failing to develop a care plan to address Resident 1's Intravenous Gamma-Globulin (IVGG- a therapy used to treat immune-related disorders by strengthening the immune system) infusion for cervical disc disorder at cervical vertebra (C)5-C6 level with myelopathy (a severe, often progressive condition involving spinal cord dysfunction). This failure had the potential to delay care and negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen tubing (a long, flexible plastic tube designed to safely deliver oxygen from a source directly to a patient through a nasal cannula or mask) and the humidifier solution container (a bottle container filled with water that connects to the oxygen supply system to add moisture to the dry medical oxygen) were changed according to the facility's policy and procedures (P&P) for one of three sampled residents (Resident 3). This deficient practice had the potential to result in bacterial and mold growth which could result in Resident 3 developing a respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to develop a care plan to address Resident 1's nutrition related to early dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) schedule. This failure had the potential for delays in the delivery of necessary care, services and could potentially result in hypoglycemia (low blood sugar) to Resident 1. Cross reference F684.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Resident 1 was fed, had breakfast and was provided with a sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten) before getting picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026. This failure had the potential to place Resident 1 at risk of hypoglycemia (low blood sugar). Cross reference F656.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to ensure Registered Nurse 1 (RN 1) documented interventions provided to Resident 1 when Resident 1 was picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026, without breakfast and without sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten). This failure had the potential to result in confusion in Resident 1's care and Resident 1's medical records containing inaccurate documentation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was discharged in a safe and orderly manner for one of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's post-discharge destination could meet Resident 1's needs prior to the discharge on [DATE].2. Involve Resident 1's Representative in the development of the discharge plan and informed of the final discharge plan. These deficient practices had the potential for Resident 1 not to receive necessary care and services and negatively affecting Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1 and 2) by failing: To follow physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) metoprolol (medication used to treat hypertension [HTN-high blood pressure]) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110/60 millimeters of mercury (mmHg-a standard unit of pressure). On 1/9/2026, at 9 a.m., Licensed Vocational Nurse 4 (LVN 4) administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was given pain medication as per physician's order. This failure had the potential to result in Resident 3's increased risk for drowsiness (sleepiness) and sedation (the use of medication to make a person calm, relaxed, or sleepy during a procedure).

Inspectors wroteBased on interview and record review, the facility failed to notify the Physician of resident's refusal of buspirone hydrochloride (medication used to treat generalized anxiety disorder [GAD - excessive, persistent worry that interferes with daily life, not just normal stress]) for one of three sampled residents (Resident 1). This failure had potential for Resident 1's delays in the delivery of necessary care and services and had the potential to increase Resident 1's level of anxiety.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's refusal of medication. This failure had potential for Resident 1's delays in the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for three of five sampled residents (Resident 1, Resident 2, and Resident 3) by failing to: 1. Ensure licensed nurses monitored Resident 1's respiratory (organs that are involved in breathing) status after the resident's change of condition (COC) on 11/12/2025.2. Ensure licensed nurses monitored Resident 3's respiratory status after the resident's change of condition (COC) on 11/20/2025.3. Ensure licensed nurses monitored Resident 2's gastrointestinal (stomach and intestines) status after the resident's change of condition (COC) on 11/21/2025. These deficient practices had the potential to place Resident 1, Resident 2, and Resident 3 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 3 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use. These deficient practices had the potential for Resident 3 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure two antidepressant medications, Celexa and Wellbutrin, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 8.) 2. Ensure two antipsychotic medications, Seroquel and Abilify, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 6.) 3. Monitor the use of Wellbutrin for adverse effects (unwanted or dangerous medication-related side effects) in the Medication Administration Record (MAR - a record of medications administered, and regular monitoring completed for a resident) for one of five residents sampled for unnecessary medications (Resident 8.) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) by failing to: 1. Develop and implement a comprehensive care plan on the use of bilateral cushion boots (are padded, boot-like medical devices worn on both feet (bilateral) to protect and support them) per the physician's order for one of two sampled residents (Resident 93) reviewed for pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had potential to result in a delay in the delivery of the necessary care and services and development of a pressure injury on Resident 93's heels. 2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) for two of five sampled residents (Residents 16 and 10) needs by: 1. Failing to follow up with the physician timely when Resident 16 was complaining of pain on urination for one of two sampled residents (Resident 16) reviewed for change of condition (COC- significant change in a patient's health or functional abilities which requires medical attention or change in their care plan). This failure had the potential to result in the resident's pain on urination to be untreated timely and worsening of the pain which may lead to development of infection. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Resident 93, 189, and 36) by failing to: 1. Keep Resident 93's bilateral cushion boots (is a medical device worn on both feet and ankles to provide cushioning, support, and protection for various foot-related issues) on the resident while in bed per physician's order. The deficient practice had the potential for delay of necessary care and services and worsening of the resident`s pressure injury. 2. Obtain a physician order prior to applying wound dressing on Resident 189's right heel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 93, 199, 33, and 19) reviewed for accidents by failing to ensure: 1. Residents 93, 199, and 33's floor/fall mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. 2. Conduct an interdisciplinary team (IDT-a collaborative group of healthcare professionals and staff, including the resident and their family, who work together to develop and implement a person-centered care plan) root cause analysis after Resident 19 fell on 6/25/2025. The deficient practices increased the risk of accidents such as falls with injuries on residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to: 1. Ensure a change of condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) regarding significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) was reported to the physician, resident representative, and Registered Dietician (RD) per facility policy and procedure (P&P) on 8/1/2025. 2. Ensure the physician was notified of, and followed up on, Registered Dietician (RD) 1's recommendation for an appetite stimulant (medications that increase appetite) on 8/7/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of five sampled residents (Resident 134 and 51) reviewed under the Pain care area and one resident present during the Resident Council task (Resident 89) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four errors out of 32 opportunities contributed to an overall error rate of 12.5 % affecting three of six residents observed for medication administration (Resident 67, 99, and 187). The errors noted were as follows: 1. Incorrect preparation of Lokelma (a medication used for kidney failure) for Resident 187. 2. Incorrect time of administration for sevelamer (a medication used for kidney failure) for Resident 187. 3. Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 99. 4. Failure to administer potassium chloride (a potassium supplement) with food per the physician order for Resident 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (when the observed or identified preparation or administration of medications or biologicals are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for: 1. Three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. An aerosol can of whipped cream was without a cover with the nozzle or tip exposed remained on the top shelf of the walk-in refrigerator. 2. A metal container of turkey and cheese sandwiches in the walk-in refrigerator did not indicate a preparation date. 3. One can of sliced apples with dent remained at the bottom shelf in the dry storage room with the non-dented cans. 4. Six plastic containers of food were stacked wet in the drying rack in the dishwashing room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's policy regarding use and storage of foods brought to residents by family and other visitors was followed for one of one sampled resident refrigerator by failing to ensure the facility's resident refrigerator was within acceptable temperature range per facility's policy and procedure for refrigerator at equal or less than (=/< - a unit of measurement) 41 degrees Fahrenheit (F, a scale for measuring temperature). This deficient practice had the potential to result in food-borne illnesses (food poisoning) of residents and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical records for two of three sampled residents (Resident 197 and 14) reviewed for documentation by: 1. Failing to ensure Licensed Vocational Nurse 3 (LVN 3)'s code status documentation on Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) matches the Physicians Order on [DATE] for Resident 197. 2. Failing to ensure LVN 4 documented her observation and intervention when Resident 197 was unresponsive on [DATE]. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices for three of 10 sampled residents (Residents 121, 26, and 12) by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 11 wore personal protective equipment (PPE- gown, gloves, face shield), gown, while conducting a gastrostomy tube (G-tube-a medical device that delivers nutrition, fluids, and medications directly into the stomach through a small opening in the abdomen) assessment on Resident 121`s who was under Enhanced Barrier Precautions (EBP- an infection control intervention to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies for Infection Prevention and Control Program, and Antibiotic (medication used to treat infection) Stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) Program for two of two sampled residents (Resident 106 and 202) reviewed under infection control facility task and five of five sampled residents (resident 93, 10, 12, 155, and 16) reviewed for antibiotic use by: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position by failing to implement the antibiotic (medication used to treat infection) stewardship program (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) and the infection prevention and control program for three of five sampled residents (Residents 10, 106 and 202) by: 1. Failing to ensure Residents 106 and 202 were monitored for antibiotic adverse effects (undesired or harmful effects). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administration of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) was evaluated and considered safe by the interdisciplinary team (IDT-a multidiscipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) for one of five sampled residents (Resident 51) reviewed during pain management. This deficient practice had the potential to result in increased risk of Resident 51 administering lidocaine patches to the wrong location due to lack of technique resulting in medical complications such as uncontrolled pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of one (1) sampled resident (Resident 42) reviewed under the call devices in reach care area. This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 42 when the resident was unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) was respected for one of eight sampled residents (Resident 134) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the resident's right to have their wishes honored regarding health care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the primary physician, responsible party (RP), and Registered Dietician (RD) of a significant change in condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to notify per the facility policy and procedure (P&P) when the resident had significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) on 8/1/2025. This deficient practice had the potential to result in further weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients) in Resident 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of two sampled residents (Resident 201 and 157) reviewed under environment facility task by: 1. Failing to ensure the resident`s bilateral floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have tears and were in disrepair for Resident 201. This deficient practice had the potential to negatively affect Resident 201's psychosocial well-being and make the resident feel uncomfortable in their living space. 2. Failing to ensure the resident's floor was not sticky with yellowish stains on the floor where the urinal bottle (is a portable container used to collect urine, often by people who cannot easily access a toilet) was placed for Resident 157. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan (is an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) on the use of urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) with appropriate indication for one of three sampled residents (Resident 199) reviewed for urinary catheter. The deficient practice had a potential for delays in the delivery of necessary care and services and development of urinary tract infection (UTI, an infection in the bladder/urinary tract) in Resident 199.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) is reviewed and revised by the interdisciplinary team (IDT, is a group of people from different fields of expertise who work together and coordinate their efforts to solve a complex problem or reach a common goal) for one of two sampled residents (Resident 93) by failing to resolve the care plan on stage three (3) sacral coccyx pressure injury (a deep wound affecting the skin and fatty tissue below it, where the fat layer is visible but the bone, tendon, or muscle is not exposed). This deficient practice had the potential to negatively affect the provision of care and services for Resident 93.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services necessary to maintain safe and good nutrition for one (1) of three (3) sampled resident (Resident 101) reviewed for activities of daily living (ADLs - routine/tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care area by failing to ensure Certified Nursing Assistant (CNA) 3 provided assistance to Resident 101 with meals as indicated in the meal ticket. This deficient practice placed Resident 101 at risk for weight loss, dehydration (a condition that occurs when the body loses more fluids than it takes in), or nutritional problems, and accidents such as choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder (a loss of control over when urinating, causing urine to leak out accidentally) received services and assistance for two of three sampled residents (Residents 157 and 188) reviewed for bladder and bowel incontinence by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) of the residents with the name and room number. The deficient practices had the potential to cause cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to to another) and increase the risk of urinary tract infection (UTI, an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra) due to the switching of urinals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for one (1) of two (2) sampled resident (Resident 18) reviewed for tube feeding by failing to ensure the EF was started timely as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one (1) of one (1) sampled resident (Resident 177) reviewed during a random observation by failing to ensure Registered Nurse (RN) 1 labeled the intravenous (IV - thru the vein) antibiotic (medication used to treat infection) bag with the date and time it was administered. This deficient practice placed Resident 177 at risk for developing complications such as inflammation of the vein and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Residents 173 and 52) reviewed for respiratory care by failing to ensure: 1. Resident 173's suction canister (is a container used with a medical suction machine to collect and store fluids removed from a patient's body) was changed every seven (7) days and labeled with the date it was last changed. 2. Resident 173's suction tubing (a flexible tube, typically for medical or industrial use, that connects a vacuum source to a device or catheter to remove fluids, secretions, or debris from a specific area) dated 3/18/2025 was discarded and changed every (7) days. 3. Resident 52's oxygen tubing had a label including the date and time of when it was last changed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) treatment, received services consistent with professional standards of practice for one (1) out of one (1) sampled resident (Resident 16) reviewed under the dialysis care area by failing to ensure the post dialysis assessment was completed on 8/23/2025. This deficient practice placed the resident at risk for unmonitored development of complications related to renal disease (a condition when the kidneys get damaged and unable to properly filter waste and extra fluid from the blood) like swelling, high blood pressure and shortness of breath.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (a framework for understanding and responding to the effects of trauma in individuals, families, and communities) for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area by: 1. Failing to ensure appropriate referrals were provided to Resident 42 when the resident had a history of trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) in the past. 2. Failing to complete a timely trauma-informed care assessment. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary behavioral health care and services for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area when the facility failed to conduct a behavioral interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting on the use of Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions) and escitalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]). This deficient practice had the potential to negatively affect the delivery of care and services the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Accurately account for one dose of oxycodone/APAP (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 7 in one of five inspected medication carts (Station 2 Cart C.) 2. Administer one dose of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) four percent (% - one part in every hundred) for one of five sampled resident (Resident 51) reviewed during pain management care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one opened Humulin 70/30 (a medication used to control high blood sugar) insulin pen was labeled with an open date as required by the manufacturer's specifications affecting Resident 172 in one of five inspected medication carts (Station 3 Cart A.) The deficient practice of failing to label open insulin pens with an open date increased the risk that Resident 172 may have insulin that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) to two of five sampled residents (Residents 106 and 202) after the two residents had provided their consent to receiving the vaccine and the physician ordered the vaccine administration. These failures placed Resident 106 and Resident 202 at a higher risk of acquiring and transmitting pneumonia (an infection/inflammation in the lungs) to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer Coronavirus Disease 2019 (COVID-19 - an infectious disease that most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment) vaccine to one of five sampled residents (Resident 106) after the residents had provided their consent to receiving the vaccine. This failure placed Residents 106 at a higher risk of acquiring and transmitting COVID-19 to other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) received medication as prescribed by failing to:1. Ensure Resident 3 received Eliquis (a prescription that prevents blood clots from forming and stops existing clots from getting bigger).2. Ensure Resident 3 received Femara (a medication that helps treat certain types of breast cancer)3. Ensure Licensed Vocational Nurse (LVN) 1 signed off the Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering Resident 3's medications. These deficient practices had the potential for Resident 3 to be negatively affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a topical cream for pain (Diclofenac Sodium- medicated gel to treat pain) was not left at the resident's bedside drawer for one of three sampled residents (Resident 2) and that and Resident 2 was assessed for self-administration of Diclofenac Sodium. This deficient practice had the potential to place other residents at risk to have access to Diclofenac Sodium and misuse the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light of one of three sampled residents (Resident 1) was within reach. This deficient practice had the potential for Resident 1's needs to be not met when Resident 1 calls for help.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of six sampled residents (Resident 6) by failing to: 1. Ensure Resident 6's pain medication, morphine sulfate extended release (medication to manage moderate to severe pain) scheduled every 12 hours for pain management, was administered according to the physician order. 2. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage severe pain) 10-325 milligrams (mg - unit of measurement), scheduled every four hours as needed, was administered according to the physician order. 3. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage moderate pain) 5-325 mg, scheduled every four hours as needed, was administered according to the physician order. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented by failing to: 1. Ensure Resident 1 had a care plan that addressed the resident's possession of a vaping device (a battery-powered device that simulates smoking). 2. Ensure Resident 1's care plans were accurately and completely documented. These deficient practices had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's respiratory diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident was found in possession of a vaping device (a battery-powered device that simulates smoking). This deficient practice resulted in incomplete information on Resident 1's medical records and had the potential for delayed medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for three of four sampled residents (Resident 2, Resident 3, Resident 4), when the facility failed to inform Resident 2, Resident 3, and Resident 4 verbally and in writing of the findings of the investigations and the actions that were taken to correct the identified problems. This deficient practice had the potential to violate the rights of Resident 2, Resident 3, and Resident 4.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary treatment and services for one of four residents (Resident 1) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow its Policy and Procedures (P&P) titled, Pressure Injury Risk Assessment, that indicated to do weekly skin assessments for the first four weeks. This deficient practice had the potential for Resident 1's wounds to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4 ' s oxygen tubings were dated when it was changed. 2. Ensure Resident 4 ' s oxygen tubings were kept inside an oxygen supplies bag when not in use. 3. Ensure Resident 4 ' s oxygen tubings were not touching unclean surfaces. These deficient practices had the potential for Resident 4 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control precautions when two Licensed Vocational Nurses (LVN 1 and LVN 2 ) were inside an enhanced barrier precaution (interventions designed to reduce the transmission of infections) room changing a gastrostomy tube (a flexible tube inserted through the abdominal wall into the stomach) feeding, without personal protective equipment (equipment worn to minimize exposure to hazards that cause illness) for one of five resident samples (Resident 1). This deficient practice could have resulted in the spread of infections to staff, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to notify the attending Medical Doctor (MD) 1 of one of three sampled residents (Resident 1) who had a significant change of condition (COC - a major decline in a resident's health status) when Resident 1's last recorded urine output (refers to the amount of urine produced and excreted by the body over a specific period of time) was on 3/10/2025 at 7:39 p.m. in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, which indicated the facility will notify the resident's attending physician when there was a significant change in the resident's condition, or when there was a need to transfer the resident to a general acute care hospital (GACH). This deficient practice resulted to a delay in transferring Resident 1 to GACH 1 on 3/12/2025 at 3:08 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor one of three sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - an infection in the bladder/urinary tract), who had no urinary output (refers to the amount of urine produced and excreted by the body over a specific period of time). This deficient practice resulted to Resident 1 being transferred to General Acute Care Hospital (GACH) 1 on 3/12/2025 at 3:08 a.m. and was diagnosed with acute urinary retention (the inability to fully empty your bladder, meaning urine stays inside instead of being passed out) and urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). 2. Ensure an ADM was present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT)/Operations Manager (OM) was performing administrative tasks without the presence of the ADM at the facility. These deficient practices resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility ' s functions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was assessed as high risk for falls was free from falls and injury in accordance with the resident's care plan by failing to: 1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and to physical activities) 1 (PT 1) during a physical therapy (is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) session on 1/5/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1. Ensure Resident 1's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. 2. Ensure Resident 1 had the correct number of bed linen layers between the resident and the LALM. 3. Ensure Resident 1's oxygen nasal cannula (a device used to deliver supplemental oxygen) was not pressing on the resident's face. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to: 1. Ensure Resident 1's urine output was monitored for presence of sediments. 2. Ensure Resident 1's urinary catheter stoma (a surgically created opening on the abdomen that allows waste to be diverted from the body to the outside) had a wound dressing (a material placed directly on a wound to protect it and help it heal). 3. Ensure Resident 1's urinary catheter drainage bag was not touching the floor. These deficient practices resulted to Resident 1's urinary catheter drainage bag with yellow, cloudy urine with visible sediments during an observation on 1/14/2025 at 11:58 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document blood pressure before holding (not administering) amlodipine (medication used to treat high blood pressure) per physician order. This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 4) who had a urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by failing to ensure the physician's order was followed when Resident 1 had a change in condition. This deficient practice had the potential to result in uncontrolled pain and may cause a delay in wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who was prescribed Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days. This deficient practice had the potential for Resident 2's infection to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free of any significant medication error when the facility failed to administer Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days. This deficient practice had the potential for Resident 2's infection to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 4) received proper assistive devices to maintain hearing abilities by failing to ensure Resident 4 was wearing hearing aids as prescribed by the physician. This deficient practice had the potential to affect Resident 4 psychosocially when Resident 4 is unable to hear.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services for one of four residents (Resident 2) at risk for developing pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow the manufacturer guideline for low air loss mattress. This deficient practice had the potential for Resident 2's wounds to worsen.

Inspectors wroteBased on interviews, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (intentional bodily injury) by a resident for one of three (Resident 1) sampled residents when on 9/17/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 hit Resident 1 on the shin with a closed fist. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on abuse reporting by failing to report immediately, but no later than two hours after the allegation is made, an allegation of resident to resident abuse, to the State Survey Agency (SSA), the Ombudsman and the local law enforcement agency for two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in a delay of notifying the necessary agencies and may have placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of five sampled residents (Residents 90, 118, and 49) investigated during review of physical restraints care area by failing to obtain a consent for use of bed rails (bars or boards that are attached to the side of a bed to help people move around and reduce the risk of falling) and perform quarterly bedrail assessment for entrapment. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (reflect shared decisions made with patients, caregivers and families about tests, interventions, treatments, and other activities needed to achieve the goals of care) for four (Resident 63, 171, 107, and 170) out of 36 sampled residents by: 1. Failing to ensure Resident 63 had a care plan (CP) addressing the resident's urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system) and the use of ceftriaxone (a type of antibiotic used to treat bacterial infection and can be administered into one of the muscles or through a needle placed in one of the veins). This deficient practice had the potential to result in staff not knowing about the resident's change of condition and treatment. 2. [...]

Inspectors wrote1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 7/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that causes high blood sugar levels because the body doesn't produce enough insulin or doesn't use it properly), dysphagia (difficulty swallowing), and generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed). During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for four of five sampled residents (Resident 63, 49, 52, and 55) investigated during review of pressure injury by failing to: 1. Ensure Resident 63's weekly Comprehensive Skin Evaluation/Assessment was done for the week of 8/25/2024 to 8/31/2024. 2. Set Resident 49 and 52's Low Air Loss Mattress (LALM, a type of air mattress that helps prevent and treat pressure wounds by regulating temperature and moisture levels of a patient's skin) according to the resident's weight. 3. Ensure Resident 55 were not placed on multiple layers of bed linens while on a low air loss mattress. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for five of nine sampled residents (Resident 79, 15, 161, 50, and 111) reviewed under the Accidents care area, by failing to: 1. Ensure Resident 79's albuterol inhaler (medication that is breathed in to relieve shortness of breath) was not left at bedside and readily available for use by residents. 2. Ensure Resident 15 was identified as a smoker, had a smoking evaluation completed including a smoking risk assessment with interventions, and that the resident did not have smoking items readily available at bedside. 3. Ensure Resident 161's sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) in bed was properly functioning for one (1) out of seven (7) sampled residents during a random observation. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for three of seven sampled residents (Resident 16, 32, and 34) investigated during review of respiratory care area by failing to: 1. Ensure Resident 16 was administered oxygen (O2) per physician's order, oxygen was documented when administered, and oxygen was monitored while in use. 2. Ensure Resident 32 and 34 were administered oxygen per physician's order. These deficient practices had the potential to place residents at risk for respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents 50 and 55 in two of five inspected medication carts (Station 1 Cart A and Station 3 Cart C.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Residents 50 and 55 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wrote2. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 50's H&P, dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. During a review of Resident 50's Order Summary Report, dated 8/23/2024, the Order Summary Report indicated a physician's order to give Ativan oral tablet 0.5 mg my mouth two times a day for anxiety. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for five (5) out of 5 sampled residents (Residents 36, 165, 5, 90 and 118 ) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) the insulin administration sites investigated under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wrote6. During a concurrent observation and interview on 9/14/2024 at 4:50 p.m., with the Infection Preventionist (IP), observe at nurse's station 1, medication cart 1 was unlocked, The IP stated medication carts must be locked at all times when not in use so residents and unauthorized staff will not have access to the medications in the cart. During an interview on 9/16/2024 at 12:44 p.m., with Registered Nurse 1 (RN 1), RN 1 stated medication carts must be locked at all the times when not in use to prevent residents from having access to medications which may result in residents experiencing adverse (unwanted) reactions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services when the Registered Dietitian (RD) did not have oversight in the kitchen and Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS) did not carry out function of food services by failing to ensure: a. Staff reported the out-of-range temperatures of the reach-in refrigerator from 9/11/2024-9/14/2024. b. Recipe for creamed corned was available for staff and ensuring staff followed recipes for creamed corn for mechanical soft diets (diet consisted of food that are chopped half inches ([in] a unit of measurement) and puree cold cereal for puree diets (diet consisted of food with smooth, pudding-like consistency) producing inconsistent, watery, and lumpy foods. c. Staff followed spreadsheet portion sizes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a .Failed to report out of range temperatures on 9/11/2024-9/13/2024 of the reach-in refrigerator and failed to verbalize safe refrigerator temperatures. b. Failed to serve 5 residents creamed corn for mechanical soft diet (diet consisted of food that are chopped half inches ([in] a unit of measurement). c. Failed to follow recipes for creamed corn and puree cold cereals. d. Failed to followed spreadsheet portion sizes for Salisbury steak. Residents were given two (2) to three (3) ounces ([oz], unit of measurement) instead of 4 oz. e. Failed to thaw ham in the sink safely. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 81 of 81 residents on regular texture (diet with no texture restriction) and 5 of 62 residents on mechanical soft (diet consisted of food that are chopped half inches ([in] a unit of measurement) or less and restrict food that are difficult to chew or swallow) when: a. Staff served 5 residents on soft mechanical diet confetti corn instead of creamed corn. b. Staff served two (2) to three (3) ounces ([oz], unit of measurement) instead of four (4) oz Salisbury steak to regular and large portions diet. c. [NAME] did not follow recipe for confetti corn. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. There was no recipe for creamed corn cereal and cook did not follow puree cold cereal recipe resulting to watery and lumpy cold cereal. b. Cooks did not follow the recipe for confetti corn and its was missing green bell peppers affecting color contrast presentation. c. Staff did not use parsley as garnish indicated on the menu spreadsheet. d. Puree eggs were bland and lacking in flavor. This deficient practice placed 169 of 179 facility residents on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (diet with consisting with soft, pudding like consistency foods) received watery, lumpy cold cereals as cook did not follow the recipe for puree cold cereal. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 14 of 169 residents on puree diets.

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. The thermometers inside the walk-in refrigerator and reach-in refrigerator were broken. b. There was an expired tuna salad dated 9/13/2024. c. Two (2) sliced turkey packs were at 44.4 degrees Fahrenheit ([°F] a degree of temperature) and 42.3°F inside the walk-in refrigerator and sliced cheese was at 47°F was in the reach-in refrigerator. The reach-in refrigerator roof had dirt buildup. d. Shelves in the walk-in freezer and dishwashing area were rusty and not smooth. e. Six (6) chopping boards had scratches and chopping board racks had grease buildup. f. Cook was wearing two (2) gold bracelets during food preparation. g. [...]

Inspectors wrote6. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 50's H&P, dated [DATE], the H&P indicated that resident has fluctuating capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the kitchen reach-refrigerator by the trayline area (an area where food was assembled) in a safe operating condition. This deficient practice had the potential to result in food stored in the danger zone temperatures (a temperature range in which disease-causing bacteria grow best) that could lead to foodborne illness in 169 of 179 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor the resident's right to a dignified existence for one of two sampled residents (Resident 165) investigated during review of dignity care area by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not stand over Resident 165 while assisting the resident during a meal. The deficient practice had the potential to affect the resident's self-esteem and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess if a resident was capable and trained to perform self-administration of medication safely before leaving a nasal spray (a liquid medicine that is sprayed into the nose to deliver medication) at bedside for one of 61 sampled residents (Resident 50) who were observed during resident screening. This deficient practice had the potential to violate the resident's right to be assessed for capacity and to be informed of their ability to self-administer medications and had the potential to result in unsafe medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of two residents (Resident 55) investigated during review of environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident representative when the physician ordered to transfer the resident to general acute care hospital 1 for one of three sampled residents (Resident 49) investigated under hospitalizations. This deficient practice had violated the resident's responsible party's right to be inform of the care services provided.

Inspectors wroteBased on interview and record review, the facility failed to provide the notification of transfer or discharge to the resident or resident representative and send a copy of the notification to the ombudsman (a long-term care resident advocate) for one of one sampled resident (Resident 51) investigated during review of hospitalization care area. This deficient practice had the potential for Resident 51 to have an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure all residents to a nursing facility are evaluated for serious mental disorder [clinically significant disturbance in an individual's cognition, emotional regulation, or behavior] and receive the services they need) Level I pre-screen that was negative and were later identified with a serious mental disorder were referred for a Level II evaluation (provides a determination of an individual's mental health needs) for two of two sampled residents (Residents 55 and 26) reviewed under the PASSAR care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services, care, and equipment for residents with limited range of motion (ROM, a full movement of a joint) for one of one sampled resident (Resident 170) by failing to: 1. Provide Resident 170 with controlled ankle motion (CAM, an orthopedic device prescribed for the treatment and stabilization of severe sprains) as evaluated by the resident's physical therapist. 2. Develop care plan interventions addressing the resident's mobility with the use of CAM boot. This deficient practice had the potential to result in a decline in the resident's mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, a condition that happens when bacteria overcome the body's defenses in the urinary system) for one out of one sampled resident (Resident 51) investigated during a random observation by: 1. Failing to ensure the resident's indwelling urinary catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body) drainage bag was hanging on the side of the bed below the resident's bladder. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. 2. Failing to ensure indwelling urinary catheter tubing was secured with a securement device per facility policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for one (1) out of 1 sampled resident (Resident 52) investigated under the tube feeding care area when Resident 52's medication piston syringe (a type of syringe used to administer medication and irrigate the feeding tube) was not rinsed properly after use. This deficient practice had the potential for the resident to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of four sampled residents (Resident 68) reviewed under the dialysis care area by failing to ensure licensed nurses performed and documented assessments before and after Resident 68's hemodialysis sessions. This deficient practice placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD.

Inspectors wrote2. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2022, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and hypothyroidism (when the thyroid {a large cartilage of the larynx [area of the throat containing the vocal cords]} gland doesn't make enough thyroid hormone). During a review of Resident 111's History & Physical (H&P), dated 9/14/2023, the H &P indicated the resident has the capacity to make decisions. During a review of Resident 111's MDS, dated [DATE], the MDS indicated that resident needs partial/moderate assistance during oral hygiene, upper body dressing, personal hygiene, and substantial/maximal assistance during toileting hygiene, lower body dressing, putting on/taking off footwear, and dependent assistant during shower. [...]

Inspectors wrote2. During a review of Resident 129's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 8/12/2024, with diagnosis of Wernicke's encephalopathy (an acute neurological condition characterized by a clinical triad of ophthalmoplegia (weakness in the muscles that control eye movement), ataxia (poor muscle control that causes clumsy movements), and confusion). During a review of Resident 129's History & Physical (H&P), dated 8/23/2024, indicated that resident has the capacity to understand and make decisions. During a review of Resident 129's Change of Condition Evaluation dated on 9/10/2024, the change of condition evaluation indicated Resident 129 had abdominal pain and urinary retention. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC, a written document that informs beneficiaries when Medicare-covered services are ending) was given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A (helps cover inpatient hospital care, skilled nursing facility care, and some home health care) or when all of Part B (an optional insurance plan that covers some medical services and supplies) therapies were ending per their policy and procedures to one of three sampled residents (Resident 87) investigated under beneficiary notification task by providing Resident 87 the notice of Medicare Non-Coverage on 4/8/2024, the last day covered day of Part A Service. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was complete and not missing information for 16 of 16 sampled days reviewed (between 9/1/2024 to 9/16/2024) when the census was not indicated in the Nursing Staff posting. This deficient practice had the potential for facility staff, residents, and facility visitors to be unaware of whether the facility was adequately staffed to take care of residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures that provides coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) vaccines to all residents and staff that chooses to receive them by failing: 1. To complete the COVID-19 Consent Form for one of three sampled residents (Resident 1) whose responsible party consented for Resident 1 to receive it (COVID-19 vaccine). 2. To maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status for four of four sampled staff (LVN 1, LVN 2, CNA 1, and CNA 2). This deficient practice had the potential to result in increased risk of infection and placed Resident 1 and other residents at risk for severe illness, hospitalization, or complications from the virus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of one sample resident (Resident 4) by failing to administer ketoconazole (medication used to treat infections caused by a fungus or yeast) as ordered. This deficient practice had the potential to result in decreased efficacy and potential for the infection to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control program by failing to implement staff coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) screening and antigen testing policy and procedure including appropriate timing, documentation, and submission of the staff ' s COVID-19 antigen test results. These deficient practices had the potential to result in increased of transmission of COVID-19 infections among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility ' s governing body established and implemented policies and procedure from 6/15/2023 to 8/29/2024 for the use or non-use of video surveillance cameras installed in the facility. This deficient practice placed the residents at risk for privacy concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for one of two sampled residents (Resident 2) by failing to ensure Resident 3 ' s television volume level was not at maximum level, particularly during sleeping hours/quiet time per facility ' s policy. This deficient practice had the potential to affect the comfort of Resident 2 and placed the Resident 2 at risk for difficulty sleeping, irritability, and at risk for conflict among roommates.

Inspectors wroteBased on interview and record review, the facility failed to provide prompt resolution of grievances for one of two sampled residents (Resident 2) by failing to take the appropriate interventions to resolve Resident 2 ' s grievance related to his roommate ' s television volume at maximum level, particularly during sleeping hours. This deficient practice had the potential for Resident 2 ' s grievances to go unnoticed causing frustration and distress to the resident; and had the potential to result in a delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to maintain hearing abilities by not assisting in arranging provision for one of one sampled resident (Resident 3) by failing to follow through Resident 3 ' s hearing test appointment as ordered. This deficient practice had the potential to result in worsening of Resident 3 ' s condition and could affect the resident's daily activities and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice to one of two sampled residents (Resident 5) by failing to obtain a physician order for Resident 5 ' s breathing treatment (involve inhaling medications using a nebulizer/humidifier device [a small machine that turns liquid medicine into a mist that can be easily inhaled]) when a resident had a change in condition. This deficient practice had the potential to place Resident 5 at risk for receiving unnecessary breathing treatment not indicated for the resident's current medical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when on 8/20/2024 in Resident 1 ' s room observed red stains on ceiling above Resident 1 ' s bed. This deficient practice had the potential to negatively impact the psychosocial wellbeing of Resident 1 by not providing a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy to one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore a gown while providing perineal care (also known as peri-care, washing the genitals and anal area) to Resident 2, who was placed on Enhanced Barrier Precautions (EBP- an infection control method that uses personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents, such as antibiotics] between residents in skilled nursing facilities). This deficient practice had the potential to result in an increased risk for MDRO transmission.

Inspectors wroteBased on interview, and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) and injury for one of three sampled residents (Resident 1), who was identified as high fall risk by failing to: 1. Provide Resident 1 with bilateral (both sides of the body or two of something) bedside mats (Bedside mats, also known as a padded bedside fall mat or a bed mat, is a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) as indicated in the resident ' s physician ' s orders. 2. Update Resident 1 ' s care plan to include an intervention of placing bilateral bedside mats at Resident 1 ' s bedside to prevent injuries to resident who was at high risk for falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of six sampled residents (Residents 1, 2, and 3) by: 1. Failing to ensure staff held furosemide (medication used to treat fluid retention) on 6/9/2024 at 9 a.m., metoprolol ( medication used to treat high blood pressure) on 6/9/2024 at 9 a.m., and 6/22/2024 at 9 p.m., and midodrine (medication used to treat low blood pressure) on 6/17/2024 at 10 p.m., 6/19/2024 at 6 a.m. and 6/25/2024 at 10 p.m., per Resident 1's Physician's Order, dated 5/22/2024, to hold furosemide and metoprolol for systolic blood pressure (sbp - pressure in the arteries when the heart beats) below 110 and hold midodrine for sbp more than 120. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) during a Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) by: 1. Failing to ensure Resident 1 was monitored for signs and symptoms of COVID-19 twice per shift (eight-hour work schedule) as per facility's policy and procedure. 2. Failing to ensure Physical Therapist 1 (PT 1) wore protective mask inside the facility while talking to Certified Occupational Therapist Assistant 1 (COTA 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free from abuse by Resident 7. On 6/26/2024 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) and CNA 2 heard Resident 6 and Resident 7 screaming at each other and on 6/26/2024 at around at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 7 punched Resident 6's chest. This deficient practice resulted to Resident 6 being subjected to physical abuse by Resident 7 while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate a resident-to-resident physical abuse for two of three sampled residents (Resident 6 and Resident 7) by: 1. Failing to interview and obtain a written witness statement from Licensed Vocational Nurse 1 (LVN 1). 2. Failing to document attempts to interview Resident 8, who was Resident 6 and Resident 7's roommate. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to safely discharge on e of three sampled residents (Resident 1) who was intellectually disabled (a condition that limits intelligence and disrupts abilities necessary for living independently) and with history of schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) by: 1. Failing to ensure Resident 1 was discharged to a setting that would meet the resident ' s needs on 5/30/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 2) by failing to ensure the resident ' s urinary collection bag (collects urine) was covered with privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were appropriate number of linens and pads between the resident and the air mattress per manufacturer ' s guidelines for one of three sampled residents (Resident 3). This deficient practice had placed Resident 3 at risk for development of pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by: 1. Failing to ensure intervention was documented when Resident 1 had an 87 percent (%-unit of measurement) oxygen saturation (percentage of oxygen in the blood) on 5/30/2024 as per physician ' s order. 2. Failing to ensure Social Service staff documented late entry (documentation which is not made as soon as possible after an event has occurred) notes as per facility ' s policy on documentation. These deficient practices had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into the resident's medical record.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled, Change of Condition (COC - a major decline in a resident ' s status), which indicated the facility will notify the resident ' s attending physician (MD) when there was a significant change in the resident ' s condition, or when there was a need to transfer the resident to a general acute care hospital (GACH) for one of six sampled residents (Resident 1) who had a COC that started on 5/27/2024 at 9 a.m. As a result, Resident 1 was not transferred to the GACH until 5/28/2024 at 5:48 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to review and revised care plan for one of six sampled residents (Resident 5). This deficient practice had the potential for the resident to not receive appropriate care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was dependent on staff for transfers and was a fall risk, was free from accidents by ensuring Resident 2 was provided a two-person assistance. On 4/16/2024 at 4:45 p.m., Certified Nursing Assistant 1 (CNA 1) transferred Resident 2 alone from the bed to the wheelchair using a Hoyer lift (brand name of an assistive medical device used to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back). As a result, Resident 2 fell from the Hoyer lift and in the process of the fall the metal sling bar of the Hoyer lift that held the sling straps spun around hitting Resident 2 on his head. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled facility employees, Certified Nursing Assistant 1 (CNA 1), was competent to provide nursing services, by failing to evaluate competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skills necessary to care for the residents' needs. This deficient practice had the potential to negatively impact the residents ' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 3), who was placed on contact isolation precautions (intended to prevent transmission of infectious agents by direct or indirect contact with the patient or the patient ' s environment), by failing to ensure items inside an isolation room were not taken out and brought to other areas of the facility. Certified Nursing Assistant 2 (CNA 2) took Resident 3 ' s used pitcher to nurse station 3 and touched areas in the unit while refilling the resident ' s used pitcher. This deficient practice placed other residents at risk for exposure and contracting infections.

Inspectors wroteBased on observation, interview, and record review, the facility licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for three of three sampled residents (Resident 1, 2, and 3) during review of dialysis care. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive care consistent with professional standards and receive services to promote wound healing by: 1. Failing to provide wound care treatment on 10/13/2023 despite doctor's order on 10/12/2023. Wound care treatment was provided on 10/16/2023, three days after the doctor's order. 2. Failing to provide wound care treatment on 10/22/2023, 12/3/2023 and 12/24/2023 as per doctor's order. 3. Failing to ensure weekly wound assessment was done and documented as per facility's policy. The Skin and Wound Evaluation was documented on 10/19/2023 followed by 10/31/2023, missing one week in between. These deficient practices had the potential to place Resident 1 at risk for worsening of wound and had the potential to develop a wound infection.

Inspectors wroteBased on interview and record review, the facility failed to follow the comprehensive care plan on at risk for fall for one of three sampled residents (Resident 1) who needed two-person assistance from staff for locomotion (movement) and required assistive device (wheelchair and front wheeled walker (FWW-device used for walking) during ambulation when Family Member 1 (FM 1) walked with Resident 1 in the facility's parking lot. This deficient practice resulted to Resident 1's fall in the facility's parking lot on 5/26/2023.

Inspectors wroteBased on observation, interview and record review the facility failed to provide services that were patient centered for one of four sampled residents (Resident 7) who was ordered Restorative Nursing Assistant (RNA - provides rehabilitative care to individuals recovering from illnesses or injuries) to walk with a front-wheeled walker (FWW- an assistive device with two front wheels used for stability when walking) with two-person assist but refused for about three months and no longer could walk; however, no further evaluation was made and was not provided with range of motion (ROM - full movement potential of a joint [where two bones meet]) exercises. This deficient practice had the potential for the resident for contracture (a fixed tightening of muscle, tendons, ligaments, or skin) and further decline.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order for two of five sampled residents (Residents 1 and 2) as indicated in Medication Administration Record (MAR) by: 1. Giving Resident 1 spironolactone (medication used to high blood pressure) despite physician order to hold the medication if systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) was below 110 millimeters mercury (mmHg-measurement of pressure) on 10/1/2023 and 10/15/2023. 2. Giving Resident 1lisinopril (medication used to high blood pressure) on 10/11/2023 at 9 a.m. and hydralazine (medication used to treat high blood pressure) on 10/11/2023 at 2 p.m., despite physician's order to hold the medication for sbp less than 110 mmHg. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for two of five sampled residents (Resident 1 and Resident 5) by not: 1. Ensuring licensed nurses document administration of spironolactone (medication used to treat high blood pressure) accurately and per physician's order for Resident 1 on 10/2/2023, 10/6/2023 and 10/8/2023 at 9 a.m. 2. Ensuring licensed nurses document administration of lisinopril (medication used to treat high blood pressure) accurately and per physician's order for Resident 5 on 10/6/2023 and 10/12/2023 at 9 a.m. These deficient practices had the potential to result in inadequate management of resident's high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical and verbal abuse for two of five sampled residents (Resident 4 and Resident 5) when on 9/15/2023 at 5:30 p.m.: 1. Resident 5 used racial slur against Resident 4. 2. Resident 4, in response to the racial slur, punched Resident 5. These deficient practices resulted in Resident 4 and Resident 5 experiencing verbal and physical abuse.

Inspectors wroteBased on interview and record review the facility failed to provide a comfortable, sanitary and odor free environment to a resident who was eating lunch in the room for one of three (Resident 1) sampled residents. The deficient practice had the potential for Resident 1 to lose appetite and violated her right to have a sanitary and odor free environment while eating.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for two (Resident 9 and Resident 10) of four sampled residents when: 1. Resident 9 slapped Resident 10 on her left upper thigh. 2. Resident 10 grabbed Resident 9 ' s purse and pulled Resident 9 ' s hair. These deficient practices resulted in Resident 9 and Resident 10 experiencing physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged abuse to the State Survey Agency no later than 2 hours after the allegation occurred for two of four sample residents (Resident 9 and Resident 10). This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of a resident by failing to administer morphine (an opioid medicine prescribed for severe pain when other pain-relief medicines are not effective or cannot be used) medication as ordered by the physician for one of two sampled residents (Resident 13). This deficient practice had the potential to result in an increased pain and can lead to a decreased quality of life, increased distress, and potential complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection control and prevention program for nine out of nine sampled residents (Residents 2, 3, 7, 8, 9, 10, 11, 12, and 15) by: failing to ensure: 1. Failing to ensure Resident 3's oxygen tubing was labeled with the date of when it was last changed. 2. Failing to ensure Residents 2, 3, 11, and 12 wore a face mask during a Coronavirus-19 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) outbreak. 3. Failing to ensure Residents 7, 8, 9 and 10 maintained six feet distance from each other in the Activity Room. 4. Failing to ensure the Activity Room had no more than 24 persons as indicated on the maximum occupancy sign posted by the Activity Room entrance door. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan addressing the primary diagnosis of coronavirus disease 2019 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) for one of five sampled residents (Resident 4). This deficient practice had the potential for delayed provision of necessary care and services related to COVID-19 for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards to four out of five sampled residents (Residents 1, 16, 17 and 18) by: 1. Failing to ensure Resident 1's low bed (a bed that can go 9 to 10 inches off the floor to help prevent injuries due to falls) were left in the lowest possible position. 2. Failing to ensure Residents 16, 17, and 18's room was free from water spills on the floor. These deficient practices place the residents at risk for falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential personal information for one of nine sampled residents (Resident 9) was protected. The clinical records of Resident 9 were left unattended on the medication cart computer. The computer with visible clinical records of ten residents were unattended on the hallway in Station 1. This deficient practice had the potential to violate residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the results of the investigation on a resident-to-resident physical abuse allegation was reported to the State Survey Agency (SSA) within five working days of the incident for two of nine sampled residents (Resident 7 and Resident 8). The facility failed to provide the SSA with the five-day investigation report. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of nine sampled residents (Resident 9) by failing to ensure the medication carts were locked and medications were not left unattended. These deficient practices had the potential for medication contamination and non-authorized access to the resident's medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management regimen were provided as ordered for two of two sampled residents (Resident 7 and Resident 18), by failing to ensure: 1. Documentation of the pre and post pain assessments for one of four sampled residents (Resident 7) 2. Administration of pain medication for the appropriate pain scale as indicated by the physician's orders for one of four sampled residents (Resident 7). 3. Resident 18's Percocet (pain medication) and Tylenol (pain medication) medications were administered in accordance with the physician's orders. These deficient practices had the potential to result in confusion on the delivery of care and services rendered and may lead to inaccurate assessment and inadequate management of residents' pain.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Narcotic and Hypnotic Record (NHR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of three sampled residents (Resident 7, Resident 349, and Resident 350). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of eight residents (Resident 27 and 37) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to: 1. Ensure Resident 37's physician order for Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) had a duration (length of time). 2. Ensure Resident 37's physician order for Xanax had a specific behavior. 3. Ensure Resident 27's physician order for venlafaxine (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest)] had a specific behavior. 4. Ensure the correct behavior was being monitored for the use of venlafaxine for Resident 27. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for four of four sampled residents (Resident 126, Resident 21, Resident 26, and Resident 121) by failing to: 1. Ensure Resident 126's and Resident 26's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubings were labeled with the date they were last changed. 2. Ensure Registered Nurse 3 (RN 3) performed hand hygiene (alcohol-based hand rub) after handling soiled dressings during Resident 21's wound treatment. 3. Ensure the indwelling catheter drainage collection bag (catheter, a tube inserted into the abdomen or urethra [duct to conduct urine out of the body] that empties into a collection bag that collects the urine) and tubing were not touching the floor for Resident 121. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident rights by not feeding three of three sampled residents (Residents 5, 21, and 32) at eye-level. This deficient practice had the potential to affect the resident's self-worth.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of 32 sampled residents (Resident 37). This deficient practice had the potential for Resident 37 to not receive the proper and necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 7 and 21) care plans were reviewed and revised to reflect the current status and interventions being provided to the resident. This deficient practice placed the resident at risk of unrecognized change of condition and delay necessary intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of pressure ulcers (PU, damage to tissue caused by prolonged pressure over a bony prominence) by failing to ensure air mattress (mattress t o prevent pressure ulcers) setting was set to resident's weight, for one of one sampled resident (Resident 21). This deficient practice had the potential to cause worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral nutrition (delivery of nutrients directly into the stomach) were provided care and nutrition as assessed and ordered by the residents' physician for (Resident 51 and 344), by failing to ensure: 1. The nursing staff hung the prescribed feeding formula as ordered for Resident 51. This deficient practice had the potential to result in Resident 51 not receiving the prescribed amount of caloric intake. 2. The head of the bed was elevated while the Resident 344 was receiving enteral nutrition via gastrostomy tube (g-tube, a surgically placed device that passes through the abdominal wall into the stomach). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the correct flow rate (refers to the amount of oxygen gas being delivered to the body, measured in liters per minute) of oxygen as ordered by the physician, for one of three sampled resident (Resident 89). This deficient practice placed Resident 89 at risk for receiving more oxygen than required which may lead to side effects such as headaches, lethargy, and confusion.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from unnecessary medications by failing to document a specific indication for the use of Xarelto (brand name for rivaroxaban, an anticoagulant medication used to treat or prevent blood clots). This deficient practice placed Resident 347 at risk for receiving an anticoagulant without an adequate indication and had the potential to lead to side effects including bleeding and bruising easily.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 345) was free from significant medication error by administering as needed (PRN) morphine (medication used to help relieve moderate to severe pain) oral solution sublingually (under the tongue) to Resident 345 for whom the medication was not ordered. This deficient practice had the potential to result in adverse side effects (any unexpected or dangerous reaction to a drug) from Resident 345 receiving morphine that includes drowsiness and difficulty breathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the glucometer (portable device that measures the blood glucose [sugar] levels) test strips were labeled with the open date for one of six medication carts (Medication Cart A). This deficient practice had the potential for glucometer test strips to be used beyond its discard date, resulting in inaccurate glucose test results.