Arbor View Nursing & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 2 residents (Resident #1 and #2) reviewed for care plans.1. The facility failed to ensure Resident #1's comprehensive care plan reflected that resident had a diagnosis of diabetes mellitus and was receiving insulin.2. The facility failed to ensure Resident #2's comprehensive care plan reflected that resident had a diagnosis of diabetes mellitus type 2 and was receiving insulin. These failures could place residents at risk for not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 of 4 showers (200 hall and 300 hall showers); and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 Residents (Resident #1) reviewed for accidents/hazards. The facility failed to secure razors in the 200 and 300 halls. The facility failed to ensure Resident #1 had a fall mat in place, as indicated by physician's order and care planning. These failures could lead to injury and decreased quality of life. and could result in residents' self-harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations of injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 4 residents (Resident #2) reviewed for neglect. The facility failed to ensure rib fractures from an unknown origin sustained by Resident #2 on or around 5/31/2026 were reported to the SSA. This failure could lead to lack of oversight and abuse, neglect, or exploitation of residents.

Inspectors wroteBased on interview and record review, the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, the have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 4 residents (Resident #2) reviewed for neglect. The facility failed to have evidence of an investigation regarding rib fractures from unknown origin sustained by Resident #2 on or around May 31, 2026. This failure could lead to lack of oversight and abuse/neglect of residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure other Environmental Conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 4 (300 hall shower room) shower rooms in that:The facility failed to ensure the 300-hall shower did not have black substance/mold on the tile walls of the shower. This could cause harm to residents and could cause respiratory illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent injury for 1 of 4 residents reviewed for accidents. (Resident #3)The facility did not provide adequate supervision for smoking to Resident #3, who was assessed to not be a safe smoker. This failure could place residents who smoked at risk for injury from burns. Findings Included: Face sheet dated 06/17/2026 indicated Resident #3 was admitted on [DATE], with diagnoses of raynaud's syndrome with gangrene (blood vessels squeeze shut due to cold or stress), chronic obstructive pulmonary disease (lung disease making hard to breathe), hypertension (high blood pressure). Care plan review showed, . has been assessed to require supervision when smoking and .will not smoke without supervision. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident were free of significant medication errors for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors and received medication as prescribed by a physician on 8/29/2025. LVN A administered Resident #2's medications to Resident #1. This resulted in administration of two schedule IV-controlled substances: non prescribed medications: Temazepam 22.5 mg, Phenobarbital 129.6 mg, levothyroxine 75 mcg, Tamsulosin 0.4 mg, Levetiracetam 1250 mg, Oxcarbazepine 300 mg, Mirtazapine 7.5 mg, Risperdal 1 mg and prescribed Quetiapine (Seroquel) 800 mg which was a dose 32 times greater than prescribed for Resident #1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure for accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #14) reviewed for medications and pharmacy services. The facility failed to ensure Resident #14 morning meds were disposed of appropriately when the resident refused the medications on 9/06/2025 by MA P. The facility failed to ensure Resident #1's hydrocodone was appropriately wasted and documented when it was removed from original container on 8/29/2025 by LVN A. These deficient practices could put residents at risk for medication errors.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 7 residents reviewed for medical records 1. The facility failed to ensure LVN A documented Resident #1s medication error, medications given, assessment, vitals, change of condition, contact with MD and RP, follow up orders, or transfer to the hospital by EMS on 8/29/2025. 2. The facility failed to upload Resident #1's hospital records from the 8/29/2025 hospital stay into the permanent medical record. 3. The facility failed to ensure LVN A documentation of medication administration accurately reflected any medications given on 8/29/2025. These failures placed residents at risk for delayed or inaccurate medical information which could result in a lack of continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for 7 of 7 residents (Residents #65, #19, #20, #44, #54, #23, and Unknown) reviewed for abuse. The facility failed to ensure Resident #65 was not injured after entering Resident #19's room on 6/23/2025, when Resident #19 had known aggressive behaviors related to other residents entering his room. The facility failed to ensure Resident #20 was protected from abuse after entering Resident #19's room on 7/5/2025. The facility failed to ensure Resident #44 was not injured after entering Resident #19's room on 7/5/2025. An IJ was identified on 7/24/2025 related to Resident #19 (items 1-3). The IJ template was provided to the facility on 7/24/2025 at 4:24 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #19 and #44) investigated for accidents. The facility failed to ensure Resident #19 received adequate supervision to prevent physical aggression towards other residents. The facility failed to ensure Resident #44's received adequate supervision to prevent falls with interventions to prevent further injury when the resident had falls at the facility on 05/12/2025, 05/19/2025, 05/23/2025, and on 07/23/2025 and unwitnessed injuries on 05/01/2025 and 07/05/2025. The falls on 05/12/2025 and 07/23/2025 both resulted in hip fractures. An Immediate Jeopardy was identified on 07/29/2025. The IJ template was provided to the facility on 7/29/2025 at 4:46 PM. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing. 1. The facility failed to have the services of an RN on 02/22/2025, 02/23/2025, 03/09/2025, 06/01/2025, and 06/14/2025. 2. The facility failed to have at least 8 consecutive hours of RN coverage on 03/22/2025, 03/23/2025, 04/19/2025, 04/20/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/12/2025, 05/13/2025, 05/17/2025, 05/31/2025, and 06/15/2025. These failures could have placed residents at risk of not having the critical skills of a RN.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 3 beverage carts and 1 of 1 ice machines. 1. The facility failed to properly label beverage pitchers with the date of preparation and contents on 3 of 3 beverage carts during the dinner meal service on 7/25/2025. 2. In one of the freezers there was raw ground beef stacked on top of raw chicken drumsticks, which was stacked on top of pasta. 3. In the freezer in the dry storage area, there were 2 products that were undated and unlabeled. 4. The facility failed to keep the ice machine clean. 5. The facility failed to ensure there was a fan that was clean that was blowing towards the 3-compartment sink for cleaning dishes. 6. The facility failed to not store sanitizing buckets near food products. 7. [...]

Inspectors wroteBased on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility, licensed for 179 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests for 1 of 1 facility reviewed for effective pest control. The facility failed to provide a resident environment that was free from pests, as flies, gnats, and a roach was observed in the facility. This failure could result in illness and/or psychosocial harm for residents living in areas with insects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 5 of 16 residents (Residents #5, #19, #23, #44, and #65) reviewed for abuse and neglect. 1. The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on [DATE] when Resident #65 suffered a scalp laceration requiring 12 staples from a resident-to-resident altercation with Resident #19 on [DATE].2. The facility failed to report an unwitnessed fall resulting in a femur fracture for Resident #5 on [DATE].3. The facility failed to report an incident of witnessed abuse from Resident #23 on [DATE].4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency and law enforcement entities for 5 of 16 residents (Residents #5, #19, #23, #44, and #65) reviewed for abuse and neglect. The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on [DATE] when Resident #65 suffered a scalp laceration requiring 12 staples from a resident-to-resident altercation with Resident #19 on [DATE]. The facility failed to report an unwitnessed fall resulting in a femur fracture for Resident #5 on [DATE]. The facility failed to report an incident of witnessed abuse from Resident #23 on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 3 (CNA AB, NA G, NA AH) of 24 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA AB, NA G, NA AH had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 2 residents (Residents #8 and #20) reviewed for unnecessary medications. The facility failed to ensure Resident #8 received a hypertension medication based on the physician's order for the specific medication. The facility failed to ensure Resident #20 received a hypertension medication based on the physician's order for parameters for the specific medication (metoprolol). These failures could result in unintended side effects or residents not receiving the intended therapeutic effects of the medication regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 2 of 4 medication carts (200 hall medication cart and 300 hall treatment cart) reviewed for medication storage. The facility failed to ensure 2 medications requiring refrigeration (promethazine suppositories and Latanoprost eye drops) were stored in the refrigerator. The facility failed to ensure the 300 hall medication cart was locked when not in use. These failures could lead to residents not receiving the intended therapeutic effects of medication or unintended access to medications and ingestion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #69) out of 8 residents reviewed for environmental concerns. Resident #69's window blind was broken, and it could not cover the window fully. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs without adequate indications for its use for 1 of 3 Resident (Resident #46) whose records were reviewed for unnecessary medications. Resident #46 had an order for a psychotropic medication (Buspirone HCl) without adequate indications for its use. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, have evidence that all allegations are thoroughly investigated and to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken, for 2 of 5 residents (Residents #23 and #44) investigated for abuse and neglect. The facility failed to investigate an incident of witnessed abuse from Resident #23 on 5/25/25. The facility failed to investigate an incident in which Resident #44 sustained an injury of unknown source on 7/23/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the residents' status for 2 of 18 residents (Residents #19, #46) reviewed for assessments. The facility failed to ensure Resident #19's MDS accurately reflected the known diagnosis of PTSD.The facility failed to ensure Resident #46's MDS assessment accurately reflected the known diagnoses of depression and anxiety. These failures could place residents at risk of improper or incorrect care and services as necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1of 16 Residents (Resident #70) reviewed for comprehensive person-centered care plans. The facility failed to revise Resident #70's comprehensive care plan to reflect the resident's ADL self-care performance. This failure placed all residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #79) reviewed for personal hygiene. Resident #79 received 1 shower from the time of his admission on [DATE] to 07/24/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that respiratory care was provided in accordance with professional standards of practice, the comprehensive care plan, or the residents' goals and preferences for one of one resident reviewed (Resident #69) reviewed for respiratory care. RT P failed to listen to all lobes in Resident #69's lungs prior to the administration of a respiratory medication (albuterol inhaler). This failure placed residents at risk of improper assessment, inaccurate identification of concerns with the respiratory system, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 6 residents (Residents #44 and #79) reviewed for clinical documentation and medical records accuracy. 1. The facility failed to ensure Resident #44's skin assessment accurately reflected staples to the resident's forehead 3 days after they were placed. 2. The Electronic Health Record for Resident #79 did not reflect any medical diagnoses. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they established and maintained an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 out of 6 (Residents #46 and #33), reviewed for infection control, in that: 1. LVN N put a pill back in Resident #46's pill cup after it fell into her bare hand and gave them to the resident. 2. CNA O cleaned/wiped Resident #33's penis towards the urinary opening (from dirty to clean) during peri care. These failures placed residents at risk of transmission of communicable diseases and infections, a decline in overall health, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 3 of 4 residents (Resident #1, Resident #3, and Resident #5) reviewed for snacks. The facility failed to ensure Resident #1, Resident #3, and Resident #5 were offered snacks at bedtime as prescribed by the physician. This failure could affect residents who received meals/snacks served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and inadequate nutrition status.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 3 residents (Residents #1, #3 and #5) reviewed for accuracy of medical records: 1. The facility failed to ensure Resident #1's prescribed high protein snack order was documented on the TAR as ordered by the physician. 2. The facility failed to ensure Resident #3's prescribed health shake snack order was documented on the TAR as ordered by the physician. 3. The facility failed to ensure Resident #5s prescribed snack order and health shake was documented on the TAR as ordered by the physician. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents reviewed for dignity. The facility failed to ensure Medication Aide A did not enter Resident #1's room in the 300 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 10 residents (Resident #2) reviewed for accidents and hazards: The facility failed to ensure Resident #2 did not have disposable razors in his room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for qualified dietary staff. 1. The facility failed to ensure the DM had the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. These deficient practices could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 10 kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. The facility failed to ensure the Dietary Aide E met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: 1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. 2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. These deficient practices could result in in errors in care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for 3 of 3 (Resident #1, #2 and #3) residents reviewed for privacy and confidentiality, in that: The facility failed to prevent LVN A from having access and reviewing electronic medical records for Resident #1, #2, and #3's on [DATE] after she was removed from working from the facility on [DATE]. These failures placed residents at risk for having personal medical information disclosed and placed them at risk for misuse of the information.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had a right to a dignified existence in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 Residents (Resident #1) reviewed for dignity, in that: The facility failed to ensure a visitor, not related to Resident #1, did not record, and publish a video to social media, that could be taken out of context and in a manner than was distressing for family. This deficient practice could affect dependent residents and their families and contribute to feelings of shame and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. NA I failed to ask for assistance on 04/28/2024 when leaving Resident #1 unattended, that resulted in a fall with injury. This failure could place residents at risk of accidents and potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation, in that: The kitchen was dirty and un-sanitary. This failure could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters, in that: The drain plug was missing from Dumpsters #1 and #2. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that: Mice and rats were seen in the facility's kitchen in the past. This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observations, interviews, and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 1 (Resident #1) resident with PASARR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. The Failures could affect residents with PASSR services and could result in residents not receiving the PASSR recommended services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. An Immediate Jeopardy (IJ) situation was identified on 01/17/24. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that: Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 2 of 2 HVAC Heating Units reviewed for safe operating equipment: 1. The HVAC Heating Unit for Hall 100 (Male Secured Unit) was not functioning during cold winter weather 2. The HVAC Heating Unit for Hall 200 was not functioning during cold winter weather This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia).

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 (Residents #6, 7, and 8) residents reviewed for accidents. 1. Resident #6 had one unauthorized, unchaperoned elopement event on 07/21/2023. 2. Resident #7 had one unauthorized, unchaperoned elopement event on 07/30/2023. 3. Resident #8 had one unauthorized, unchaperoned elopement event on 10/26/2023. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 10/26/2023 and ended on 10/30/2023. The facility had corrected the noncompliance before survey began. This failure could place residents at risk for harm, injury, or death due to elopement.

Inspectors wroteBased on interview and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 73 days out of 110 (9/1/23 - 9/13/23, 9/19/23 - 9/23/23, 9/27/23 - 10/6/23, 10/10/2023 - 10/12/23, 10/21/23 - 10/30/2023, 11/2/23 - 11/5/23, 11/9/2023 - 11/12/23, 11/17/23 - 11/19/2023, and 11/23/23 - 12/10/23) reviewed for nursing services, in that: The facility did have a registered nurse for at least eight consecutive hours per day, seven days per week on the following dates: 9/1/23 - 9/13/23, 9/19/23 - 9/23/23, 9/27/23 - 10/6/23, 10/10/2023 - 10/12/23, 10/21/23 - 10/30/2023, 11/2/23 - 11/5/23, 11/9/2023 - 11/12/23, 11/17/23 - 11/19/2023, and 11/23/23 - 12/10/23. This deficient practice could place residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 2 out of 9 LVNS (LVN G and LVN H) reviewed for the administration of medications via and caring for a central line. As of 12/08/2023, 2 LVNs (LVN G and LVN H) operated outside their scope of practice by administering medications via Resident #1's PICC. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 4 out of 4 (Resident #13, Resident #14, Resident #15, and Resident #16) resident records reviewed in that: The facility failed to ensure the administration and count of controlled substances were reconciled. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments in 3 medication carts of 6 medication carts (Nurse's Cart 300-hallway, Treatment Cart 300-hallway, and Treatment Cart 200-hallway) reviewed for medication storage, in that: The facility failed to ensure the Nurse's Cart 300-hallway, Treatment Cart 300-hallway, and Treatment Cart 200-hallway were locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to provide the required abuse training for all employees for 3 of 3 abuse incidents reviewed for abuse training, in that: The facility failed to address allegations of abuse for Resident #s 4, 5, and 3 by in servicing all staff on abuse definition and reporting. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident had the right to be free from abuse for 3 of 3 (Resident #3, Resident #4, Resident #5) residents reviewed for abuse. 1. The facility failed to address allegations of abuse for Resident #4 and Resident #5 by in servicing all staff on abuse definition and reporting. 2. Resident #3 was verbally and mentally abused by LVN J. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 (Resident #57, #66, and #138) residents reviewed for Medicare/Medicaid services. 1. Resident #57 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There were two reach-in freezers in the conference room that did not have temperature tracking logs and one freezer did not have a thermometer. 2. There was an opened 5 lb. container of cottage cheese that was past its use by date in the walk-in cooler. 3. There were two boxes of pasta and one box of thickened water on the floor in the dry storage room. 4. [NAME] B had facial hair and was not wearing a facial hair restraint while engaged in food preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters (Dumpster #1 and Dumpster #2), in that: Dumpsters #1 and #2 did not have drain plugs for 4 of 4 days, and Dumpster #2 had trash pulled through the drain hole. This could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 1 of 7 residents (Resident #289) reviewed for dignity in that: Resident #289 was observed in their resident room wearing nothing but a disposable brief. The door to the resident's room was open, and the privacy curtain in front of the resident's bed was open. These failures could affect residents by contributing to poor self-esteem and decreased self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences involving the call light; in 1 of 81 residents reviewed for call light , Resident # 288 . Resident #288 had no access to his call light, as he was lying in bed, and the call light was on the floor. This deficient practice could affect 15 residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 38 residents (Residents #8, #57) whose assessments were reviewed, in that: 1. Resident #8's Annual MDS dated [DATE] incorrectly documented the resident was on an anticoagulant. 2. Resident #57 Quarterly MDS did not have depression listed under active diagnoses. This failure could place residents at-risk for inadequate care due to inaccurate assessments. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 2 of 38 Residents (Resident #55 and #57) reviewed for care plans, in that: 1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #55 to address hospice information, details of hospice care provided and coordination of services. 2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #57 to address the resident's diagnosis of depression and use of psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, the physicians' orders, and the residents' choices for 1 of 7 residents (Resident #7) reviewed for quality of care in that: The facility failed to provide Resident #7 with adequate and timely wound care to treat a wound to the resident's stomach. This failure could place residents at risk for not receiving appropriate care and treatment resulting in infection, delayed healing, and diminished quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for that 1 of 7 residents (Resident #14) reviewed for hearing in that: The facility failed to ensure Resident #14 received appropriate services to assess for maintaining or improving hearing abilities. This failure could affect residents by placing them at risk for unmet needs and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 out of 36 residents reviewed reviewed for indwelling catheters , (Resident # 12 and 41) The facility failed to ensure Resident # 12 and Resident # 41 indwelling catheter was attached to prevent pulling or tugging to the urethra. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents who use psychotropic drugs, PRN orders for psychotropic drugs are limited to 14 days for 1 of 20 Residents , Resident (# 41) reviewed for unnecessary psychotropic medications. The Facility failed to address as needed order for Alprazolam that exceeded the 14-day limit for as-needed psychotropic medications. This deficient practice could affect 1 resident who receives Alprazolam in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents are free of any significant medication errors and that accepted professional standards and principles which apply to administration were followed for 2 (Resident #288 and Resident # 4) of 15 Residents observed and reviewed for medication administration in that: 1. Resident # 288's medications were in a medicine cup in the top drawer of the medication cart. 2. Resident #4's medications were in the medicine cup in the top drawer of the medication cart. This deficient practice could affect residents who receive medications, resulting in needed medications not being taken and documented as taken.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 7 residents (Resident #14) reviewed for dental services in that: The facility failed to assist Resident #14 in obtaining dental services after assessments indicated the resident had mouth or facial pain, discomfort, or difficulty with chewing. These failures could lead to pain, and dental/gum problems.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 of 38 (Residents #55, #57, and #289) residents reviewed for complete and accurate medication administration records, in that: 1. Resident #55 had an order to be in isolation however she came off isolation over 2 months ago. 2. The facility documented Resident #289s admission note in Resident #57's electronic health record. These failures could place residents at risk for not receiving care and services necessary to achieve and maintain desired health outcomes and honor their advance directive preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 7 staff (LVN D) reviewed for infection control, in that: LVN D did not sanitizer the scissors prior to cutting medical tape during wound care for Resident #7. LVN D did not change gloves, or sanitize her hands after touching her face mask, and continued wound care for Resident #7. These deficient practices could place residents who receive wound care at-risk for infections.

Inspectors wroteBased on interviews and record reviews the facility failed to establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship program, in that: The facility did not perform antibiotic stewardship for 4 consecutive months (October, November, December 2022, and January 2023. This deficient practice placed residents at risk for infections and ineffective antibiotic therapies.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests for 1 of 124 residents (Resident #25), in that: There were gnats too numerous to count flying around Resident #25's head and body, and also gnats too numerous to count on the resident's mattress, pillows, water pitcher, bed frame, light fixture, and cord attached to the light fixture. This deficient practice could lead to the spread of diseases and have an adverse effect on the resident's mental health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 Resident (#72) reviewed for medication storage, in that: RN H left Resident #72's medication unattended and unsecured at Resident #72's bedside. This deficient practice placed residents at risk for not receiving therapeutic effects of the medications as prescribed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the menu was followed for 1 of 1 kitchen reviewed for menus in that: The facility failed to ensure protion sizes were served according to the menu and recipe: 1. Residents who received a pureed diet were served ½ cup portion of Pureed Spaghetti with Pureed Meat Sauce instead of a 1 cup portion at the noon meal; and 2. Residents who received a regular diet were served one ½ cup portion of Caesar Salad instead of two ½ cup portions at the noon meal. These deficient practices could place residents at risk of dissatisfaction, poor meal intake, and/or unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Employee A did not have a beard guard on to cover his facial hair during food preparation. 2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position. 3. Two and ½ cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor. These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that: 1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall. a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, or if the events that caused the allegation did not involve abuse or result in bodily injury not later than 24 hours, to the State Agency for 2 of 7 residents (#26 and #84) reviewed for abuse in that: The facility did not report to the State Survey Agency that Resident #26 reported she was going to give Resident #84 a blow job (oral stimulation of his penis) when the residents were found alone in the TV area. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 Resident (Resident #38) reviewed for coordination with the State Agency, in that; The facility did not submit the Nursing Facility Specialized Services (NFSS) form to the State Agency. This deficient practice placed the resident at risk for not receiving specialized services provided by the State Agency.

Inspectors wroteBased on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide quality laboratory services to meet the needs of its residents, for 1 of 1 glucometer reviewed for calibration, in that: The facility did not record the serial number of the glucometer being calibrated, the calibration solutions were not labeled with the opened date, and the glucometer was not calibrated daily. These deficient practices placed residents at risk for their blood sugar levels not being accurately assessed.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 2 of 2 CNAs (CNA C and CNA D) records reviewed for staff training. The facility failed to provide CNAs C and D with 12 hours in-service training per year. This failure could affect the residents by allowing them to be care for by untrained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing data was posted in a prominent place readily accessible to residents and visitors for 1 of 1 facility reviewed for staff posting for 2 of 4 days, in that: The facility failed to post the nursing staffing information daily at the start of the shift. This failure could place residents at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters for 3 of 4 days, in that: All 3 dumpsters (Dumpster #1, #2 and #3) did not have drain plugs for 3 of 3 days; and Dumpster #3 had lids ajar with trash bags bulging out for 2 of 3 days. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.