Aperion Care Lakeshore

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow planned menus and diet extensions. These failures have the potential to affect all 243 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pest control for nine [R2, R15, R16, R17, R18, R19, R20, R21, R23] residents in a sample of 23. These failures have the potential to affect all 247 residents residing in the facility. Findings Include: Pest Control Invoice documents indicate the following:10/23/25-Exterminator sprayed for German Roaches and bed bugs on the third floor. 11/12/25- sprayed on second floor for German Roaches and in laundry rooms, pantry, kitchen, locker room, and basement. Fourth floor room was sprayed for bed bugs. Rodent traps were placed on the first, second, third, fourth nursing floors and basement. 12/23/25,12/29/25, 1/5/26, 1/16/26, 2/18/26, sprayed fourth floor for bed beds and German Roaches, nursing stations for bed bug activity, also nursing station chairs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable home-like environment for nine [R2, R15, R16, R17, R18, R19, R20, R21, R23] residents in a sample of 23. Findings Include:During the survey dates of 5/19/26-5/21/26, general observations of the facility were completed. Environment throughout the facility surveyor's shoes were sticking to the floors, due to sticky substances on the floors in spots. The facility hallways were not clean with visible small shreds of papers noted on the floors. Walking down the hallways noted residents' garbage cans were full of clutter and food contains covering the bedside tables and window seals. On 5/19/26 at 10:19AM, R1 stated, I been having mice (sic) in my room since December 2025. I still see roaches as well. The mice live in my dresser drawls (sic). Every day I clean out the mice droppings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care in a timely manner for 4 (R1, R10, R11, R13) of 7 residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label opened foods in the refrigerator, freezer, and cooler with an open, use by, and expiration date. This failure has the potential to affect all residents in the facility. Findings Include:On 3/2/2026 at 9:34 am, surveyors observed large ice cream bucket dated 10/20/2025, and the freezer thermometer is 0 degrees. Pickles in the refrigerator have a received date for 1/29/26 and no open or expiration date, and refrigerator has a temperature tracking log with last temperature logged as 36 degrees. Nine (9) salads on a plastic plate covered in clear plastic wrap were observed in the refrigerator without use by date or expiration dates in the refrigerator by the ice machine. The refrigerator temperature was 36 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the narcotic accountability sheets were completed per facility protocol for two floors of four floors reviewed for medication storage and labelling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the main entree for a pureed meal was the correct consistency. This failure had the potential to affect nine (R50, R90, R116, R150, R196, R200, R219, R274, R276) residents of nine residents reviewed for pureed diets in a sample of 72 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during dining for 4 residents (R152, R179, R214, R256) on the 4th floor, failed to ensure proper Doffing of PPE (Personal Protective Equipment) for one resident (R223), and failure to follow Droplet Precautions for one resident (R274) on the 3rd floor. This failure has the potential to affect all residents residing on the 3rd and 4th floors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were in place and failed to ensure a privacy curtain fully covered a resident's space. This deficient practice affected six residents (R132, R172, R183, R231, R255, R260) reviewed for privacy in a total sample of 72 residents. Findings Include: 1. R255 is [AGE] years old. R255's diagnosis includes but are not limited to atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, hyperlipidemia, essential hypertension, malignant neoplasm of rectosigmoid junction, and gastrointestinal hemorrhage, unspecified. R255's Brief Interview for Mental Status (BIMS), dated 02/11/2026, documents R255 has a BIMS score of 12, which indicates R255 has some moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified experience when performing incontinence care and failed to ensure a resident's confidential information was not displayed for two residents (R183, R255) reviewed for dignity in a total sample of 72 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) to one resident (R46). This failure affected one resident out of sample size of 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date oxygen equipment (tubing and humidifier bottle) and failed to contain suction tubing. These failures affected one resident (R59) reviewed for oxygen in a total sample of 72 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' personal refrigerator temperature logs were monitored. This failure affected three residents (R59, R167, and R197), reviewed for personal refrigerators in a sample of 72 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent elopement for one [R1] out of four [R1, R4, R5, R6] residents reviewed for elopement. This failure resulted in R1 eloping through the front entrance three times including on 10/12/26 sustaining open areas to both feet, and on 2/6/26 sustaining a fall with a close head injury and left lower lip laceration requiring sutures. Findings Include:This was identified as an Immediate Jeopardy which began on 10/12/25. On 2/27/26 at 1:52 pm, the administrator was notified of the Immediate Jeopardy. On 02/28/26 at 3:54PM, the facility abatement plan was approved. The Immediate Jeopardy was removed on 3/1/26. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain environment free of bedbugs for residents reviewed for a safe and comfortable environment. These failures affected 7 residents that were exposed to bed bugs and has the potential to affect 74 residents living on the same floor.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected one (R3) out of three residents reviewed for abuse. This failure resulted in R2 sustaining a closed fracture of orbital wall.

Inspectors wroteBased on record review and interview, the facility failed to follow their abuse policy for two residents (R1, R2,) out of five residents reviewed abuse. This failure resulted in staff not intervening in a timely manner, thus allowing R2 to hit R1 in the face, causing an injury to R1's right eye and nose.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure one resident (R6) was free from abuse. This failure affects 1 resident (R6) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers; failed to ensure a resident's wound dressing is intact as ordered by the physician; and failed to complete skin assessments accurately. This failure caused 1 resident (R2) to develop a 25x10 cm unstageable pressure ulcer to the sacrum and sustain severe pain (7/10). This failure affects 1 resident (R2) in a sample of 4 residents reviewed for pressure ulcers. Findings Include: R2's Face sheet, dated 4/21/2025, documents a diagnosis of but is not limited to Failure to thrive, Dysphagia, Major Depressive Disorder. Review of R2's Weekly Skin Assessments documents, on 3/12/2025 R2's skin was intact with no concerns. On 3/19/25, documents an unstageable pressure ulcer to R2's coccyx. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent a fall of a resident (R1), who was assessed at risk for fall and has a history of falls. These failures affect 1 resident in a sample of 4 residents reviewed for falls. As a result, R1 fell and sustained a head injury with a laceration, requiring R1 to be sent to the hospital. R1 received sutures to close the laceration.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Fall Assessments for one resident (R1). This failure affects one resident (R1) in a sample of 4 residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a resident's (R1) care plan, who was assessed at risk for fall and has a history of falls. This affects 1 resident (R1) out of 4 residents reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to have one (R1) resident assessed by Physical Therapy in a timely manner. This affects 1 resident (R1) out of 4 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct diet was served in accordance to physician orders and Dietician recommendations. This failure affects 1 resident (R2) out of 4 residents reviewed for diet orders.

Inspectors wroteBased upon interview and record review, the facility failed to conduct a thorough investigation, and failed to determine the root cause of an altercation for two of four residents (R2, R3) reviewed for abuse. These failures have the potential to affect 241 residents.

Inspectors wroteBased upon interview and record review, the facility failed to ensure two of five residents (R2, R3) in the sample remained free from abuse. These failures resulted in a physical altercation between R2 and R3. R2 sustained a large bruise on the forehead, bump on the back of the head, and pain rated 2 out of 10.

Inspectors wroteBased upon interview and record review, the facility failed to revise comprehensive care plans for two of four residents (R2, R4) reviewed for abuse and community access.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing precautions were put into place and consistently maintained, and failed to ensure residents were in a safe position, for 1 residents (R2) of 3 residents reviewed for safety. These failures resulted in R2 falling out the bed, sustaining a right femur fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bedtime snacks to residents who want to eat outside of scheduled meal service times. This failure has the potential to affect all 235 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two medication carts were free of loose tablets; failed to ensure multi-dose insulin vials and inhalers were labeled with an open date; failed to ensure expired house stock medications, insulin vials, and nebulizers were removed from medication carts and discarded; failed to ensure medication requiring refrigeration was properly stored; failed to ensure and maintain appropriate temperature recording for medication fridge; and failed to ensure medication for a discharge resident was removed from medication cart. These failures affected ten (R3, R44, R64, R66, R133, R149, R174, R228, R739, R740) residents reviewed for medication storage and labeling, and has the potential to affect all 158 residents residing on first, second, and third floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five residents (R79, R141) did not have expired milk in their personal refrigerators; failed to ensure four of five residents (R51 R79, R141 and R216) personal refrigerators had both thermometers and temperature logs; and failed to ensure one of five residents (R61) personal refrigerator temperature log was completed daily. These failures has the potential to affect all residents with personal refrigerators in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff don appropriate PPE (Personal Protective Equipment) while providing high contact care for a resident (R80) with Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 69 residents on the second floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling catheter drainage bag was covered in a privacy bag. This failure affected two residents (R56 and R101) reviewed for privacy and dignity in the sample of 84 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two residents (R13, R41). This failure affects two residents (R13, R41) reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a doctor's order for an Advanced Directive, which affected two residents (R56 and R133) reviewed for Advanced Directives in the sample of 84 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's (R589) bed was free from old food, condiments, and a meal tray. This failure affects R589 in the sample reviewed for a safe, clean, home-like environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a new pre-admission screening and resident review (PASARR) when resident was admitted to the facility. This failure affects 1 resident (R137) out of a sample of 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one dependent resident (R74) received her scheduled showers. This failure affected one of three residents reviewed for ADL care (Activities of Daily Living).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for 1 resident (R13). This failure affected 1 resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 84. R13 has diagnoses of Cerebral Palsy, Contracture, Unspecified Hand, Gastrointestinal Hemorrhage, Peptic Ulcer, Gastro-Esophageal Reflux Disease Without Esophagitis, Type 2 Diabetes Mellitus, and Mild Intellectual Disabilities. R13 does not have a Brief Interview of Mental Status score, because R13 is rarely/never understood. R13's Minimum Data Sheet, section GG (12/12/2024), documents Functional Limitation in Range of Motion: Upper and lower extremities: Impairments on both sides, and dependent (Helper does all the effort) for all self-care and mobility performance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents at risk for falls were supervised while at the dining room. This failure affected 2 (R82 and R88) residents reviewed for fall prevention program in the total sample of 84 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change oxygen equipment (nebulizer mask) per the facility policy. Thia failure affected one resident (R68) reviewed for oxygen equipment, in a total sample of 84 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic count was recorded on each shift; failed to record accurate narcotic medication counts; and failed to have a shift change controlled substance inventory count sheet available to ensure accurate count and review of narcotic medications are recorded and signed each shift by a nurse. These failures affected one resident (R46) out of one resident reviewed for controlled drug administration.

Inspectors wroteBased on interview and record review, the facility failed to have fall interventions in place to prevent a resident from serious injury. This failure affects one (R1) of three residents reviewed for falls in a total sample of four residents. The failure resulted in R1 sustaining two cervical (neck) fractures and be subjected to excruciating pain while awaiting surgery to fix the injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure no pests were in resident's rooms. This failure has affected three residents (R3, R4, and R5), with the potential to affect 242 residents that currently are residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop safety precautions to address resident risk and environmental hazards to minimize the likelihood of accidents related to residents smoking inside their rooms/bathrooms/lounge in the facility for two (R3, R5) of six residents reviewed for safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents participated in care planning conferences for 3 (R1, R6, R7) out of 3 residents reviewed. Findings Include: R1's clinical records show an original admission date of 3/29/24. R1's Quarterly MDS assessment, dated 6/30/24, shows R1 is cognitively intact. R1's clinical records lacked documentation of a care conference for R1. On 8/11/24 at 9:13 AM, R1 stated the facility has not conducted any care plan meeting since R1's admission. R1 stated, They have not given me a care plan meeting. I'm leaving at the end of the month and they still have not done any meeting. I told [V1 Administrator], and V1 said that V1 would schedule one, but there is no point anymore since I'm leaving end of the month. R6's clinical records show an original admission date of 3/6/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate and sufficient services to ensure comprehensive bladder function assessment was completed and comprehensive care plan was developed for 2 (R39 and R145) residents reviewed for indwelling urinary catheter, and failed to address R52's urinalysis results in a sample of 35. This resulted in R52 experiencing burning with urination, which was left untreated.

Inspectors wroteBased on interview and record review, the facility failed to provide mail services to residents on Saturdays. This has the potential to affect all 213 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was adequate staffing to provide care for the residents. This failure has the potential to affect all 213 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled and dated, failed to properly store scoops when not in use, failed to store food based on manufacturer's guidelines, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 209 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 213 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled when opened, and failed to ensure discontinued medications were removed from the medication cart in 4 of 5 medication carts reviewed for medication storage and labeling. This affects 9 residents (R3, R47, R82, F195, R35, R52, R74, R136, and R76) reviewed for medication storage. Findings Include: On 04/30/24 at 10:39 AM, the 3 Southwest medication cart was reviewed with V12 (Licensed Practical Nurse). R3's Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (Microgram)/Dose 1 inhalation inhale orally every 12 hours was observed in the medication cart opened and undated. The Advair label reads (Discard 1 month after opening). V12 stated, After opening it they are supposed to date it. R47's Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the multi-use blood pressure device and glucometer was properly cleaned and disinfected between resident use for 5 (R97, R120, R176, R183, R271) residents; failed to ensure signage on the door or wall outside of the resident room indicating Enhanced Barrier Precaution (EBP) was posted for 1 (R145) resident; and failed to ensure PPE (Personal Protective Equipment) was readily accessible and worn when providing care for 3 (R23, R39, R47) of 10 residents on Enhanced Barrier Precautions. These failures have the potential for cross contamination for 9 (R23, R39, R47, R97, R120, R145, R176, R183, R271) residents reviewed for infection control in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure the residents medical records includes documentation if influenza and pneumococcal immunizations were received or did not received for 3 residents (R208, R205, R139); failed to ensure the residents medical records includes documentation education was provided to eligible residents and/or resident representatives regarding the benefits and potential side effects of all available pneumococcal and influenza immunizations for 5 residents (R208, R205, R58, R77, R139); failed to assess eligibility and offer influenza immunization to 1 resident (R208); and failed to assess eligibility and offer pneumococcal immunization to 1 (R208) out of 5 residents reviewed for pneumococcal and influenza immunizations in the final sample of 35. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure the residents medical records includes documentation if COVID-19 immunizations were received or not received for 3 residents (R208, R205, R139), and failed to ensure the residents medical records includes documentation education was provided to residents and/or resident representatives regarding the benefits and potential side effects of COVID-19 immunization for 5 (R208, R205, R58, R77, R139) out of 5 residents reviewed for COVID-19 immunization in the final sample of 35. Findings Include: R208's face sheet shows R208 was admitted on [DATE] and is [AGE] years of age with diagnoses not limited to Dementia and Type 2 Diabetes Mellitus. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy and promote dignity for one resident [R38] reviewed for urinary catheters in the sample of 35. R38's clinical record indicates the following medical diagnoses of neuromuscular dysfunction of bladder, acute kidney failure, hematuria, essential (primary) hypertension, chronic obstructive pulmonary disease with (acute) exacerbation, and schizoaffective disorder. On 4/30/24, at 11:15 AM, R38 was lying in bed with his urinary bag half filled, with urine noted from the hallway. On 4/30/24 at 11:18 AM, R38 stated, I have a urinary catheter, due to my bladder not working. I am not sure when the nurse aide emptied my urine bag. I do not want anyone seeing my urine or urinary bag. On 4/30/24, at 11:22AM, V6 [Licensed Practical Nurse] stated, I see (R38's) urinary bag from the hallway half filled with urine. [...]

Inspectors wroteBased on observation, interview, and record review the facility, failed to ensure the call light was within reach for 3 (R39, R82, R114) of 5 residents reviewed for accommodation of needs in a sample of 35. Findings Include: 1. R82 has diagnoses not limited to Cognitive Communication Deficit, Essential (Primary) Hypertension, History of Falling, Hypothyroidism, Obesity, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Hyperlipidemia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Asthma with (Acute) Exacerbation, Dysphagia, Oropharyngeal Phase, Chronic Kidney Disease, Hypokalemia, Dementia, Major Depressive Disorder, Diabetes Mellitus Abnormalities of Gait And Mobility, Thyrotoxicosis, Osteoarthritis of Knee, and Chronic Diastolic (Congestive) Heart Failure. R82's Care plan documents: Focus: [...]

Inspectors wroteBased on record review and interview, the facility failed to make a referral for re-evaluation after a change in mental health status for 1 (R2) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR) in a sample of 35. Findings Include: R2 was admitted to the facility on [DATE], with diagnoses not limited to Cocaine Abuse, Abnormal Posture, Seizures, Bipolar Disorder, and Essential (Primary) Hypertension. R2's Care plan documents: Focus: (R2) has a mood problem r/t (related/to) Bipolar Date Initiated: 10/28/22. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. R2's Interagency Certification of Screening Results for Long Term Care documents: Date client received screening: 03/13/1998. Screening is valid for 90 days from date of screening. Screening indicated nursing facility services are appropriate. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for residents with known mental illness for one (R59) of two residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to include Advance Directives in the resident's plan of care. This failure affected three (R12, R91, R186) residents reviewed for Advanced Directives and comprehensive care plans in a total sample of 35 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure resident will have a comprehensive care plan that is current with the medical regimen for 1 (R81) resident reviewed for individualized revision of care plan in a total sample of 35. Findings Include: R81's Minimum Data Set (MDS), dated [DATE], shows R81 is not cognitively intact. According to the admission Record, R81 was admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses of, but not limited to Paranoid Personality Disorder, Dementia, Parkinson's disease, and Chronic Obstructive Pulmonary Disease. R81's Physician Order Sheet (POS) shows R81 has an active order as of 5/1/24 for Do Not Resuscitate (DNR). Practitioner Orders for Life Sustaining Treatment (POLST), dated 6/16/23, documented: Do Not Resuscitate (DNR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care for one (R169) dependent resident in a total sample of 35 residents reviewed for ADL/Activities of Daily Living care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate oxygenation, failed to ensure head of bed was elevated, and failed to change and properly store oxygen tubing for 1 [R18] resident reviewed for oxygen in the sample of 35. R18's clinical record indicates R18' s following medical diagnoses include but no limited to chronic obstructive pulmonary disease with exacerbation, muscle wasting, hypertensive disease, and schizophrenia. R18's Care plan, dated 11/9/21, indicates: R18 have to chronic obstructive pulmonary disease and should be free of signs. Interventions: -Elevated head of bed to prevent shortness of breath while lying flat -Oxygen settings: Oxygen at 3liters per nasal canula for chronic obstructive pulmonary disease R18's Minimum Data Set section [J], dated 3/4/24,- shortness of breath, R18 have trouble breathing when lying flat. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for respiratory equipment by not ensuring handheld nebulizer was changed weekly and not providing a clean plastic bag with a zip loc or draw string for each set up for 1 (R133) resident reviewed for respiratory care in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk versus benefits of using bed rails and review them with the resident or the resident's representative prior using them; failed to obtain informed consent prior to using the bed rails; and railed to implement person-centered comprehensive care plan addressing the use of the bed rails. These failures have the potential to affect 2 (R32, R158) out of 2 residents reviewed for bed rails in a final sample of 35. Findings Include: 1. R158's clinical records show R158 has diagnoses not limited to Dementia, Cognitive Communication Deficit, Restlessness and Agitation, and Altered Mental Status. R158's Minimum Data Set (MDS), dated [DATE], shows R158 is cognitively impaired and requires staff assistance with bed mobility. R158's comprehensive care plan does not address the use of the bed rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure consent was obtained prior to administering psychotropic medication to 1 (R122) out 5 residents reviewed for psychotropic medications in a final sample of 35. Findings Include: R122's Order Summary Report, printed on 5/2/24, shows R122 is on antipsychotic medication Quetiapine 25 mg by mouth at bedtime related to diagnosis of Dementia with behavioral disturbance ordered on 12/11/23 and Mirtazapine 15 mg by mouth at bedtime related to diagnosis of major depressive disorder ordered on 3/15/23. R122 had an order for Seroquel 50 mg by mouth two times a day on 3/15/23. R122's Medication Administration Record (MAR) for March 2023 showed R122 started receiving the Seroquel 50 mg twice a day and Mirtazapine 15 mg at bedtime on 3/15/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for 3 (R39, R82, R114) of 5 residents, and failed to ensure resident's room call lights were functioning for the residents to call for staff assistance when needed for 2 (R2, R82) of 3 residents reviewed for accommodation of needs in a sample of 35. Findings Include: 1. [...]

Inspectors wroteBased upon observation, interviews, and record review, the facility failed to follow the housekeeping cleaning schedule, and failed to ensure that adequate staff are available to ensure the building is maintained in a clean sanitary condition. These failures have the potential to affect 218 residents residing in the facility.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure staff are aware of the smoking safety policy, failed to follow policy procedures, failed to implement care plan interventions, failed to ensure (R8, R9) smoking materials were confiscated, and failed to ensure smoking did not occur inside the facility. These failures have the potential to affect 218 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R5) who depends on staff's assistance for their ADL (Activities of Daily Living) care received incontinence care. This failure affected one out of four residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a resident's food preference based on religious beliefs, which affected one resident (R3) in a sample of four residents (R3, R4, R6 and R8) reviewed for menus and meal variety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R1) who developed pressure ulcer at the facility did not develop sepsis from the wound; failed to have low air loss mattress (LALM) connected to power(R12); and failed to have LALM at the correct weight settings(R13 and R14), for residents with current pressure ulcers(R13) and for residents with recently healed pressure ulcers(R12 and R14) who are at risk for further pressure ulcers. These failures affected four residents, R1, R12, R13, and R14, reviewed for pressure ulcers and pressure ulcer prevention interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety and supervision of a resident at risk for falls who had repeated falls, and failed to prevent the resident (R10), with a documented history of alcohol abuse and alcohol intoxication, from obtaining and using alcohol.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared at a safe and appetizing temperature. This failure has the potential to affect 80 residents living on the 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a lock per the resident's preference to aid in securing personal valuables for one (R3) resident out of three residents reviewed for resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to keep two residents (R2, R6) free from abuse resulting in R6 receiving minor injuries.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate misappropriation of property for one (R3) of three residents reviewed for misappropriation of resident property.

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure medications were administered prior to a resident's appointment. This failure affected R9 whose blood pressure registered at 180/93 while at the clinic, which put R9 at an increased risk for stroke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of <5% for 2 (R10 and R11) of 3 (R9, R10, and R11) residents observed for medication administration. There were 36 opportunities and 8 errors resulting in 22.2% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff properly documented on the medication administration record (MAR). This failure affected one resident (R6) in the sample of 82 residents residing on the third floor. Findings Include: [...]