Arcadia Care Center

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 1's) Responsible Party (RP) regarding Resident 1's increased heart rate and fever on 7/4/2026. This failure resulted in Resident 1's representatives not being informed of Resident 1's change in condition and not making an informed decision (decision based on facts, relevant information, and clear understanding of potential risks, benefits, and alternatives) regarding Resident 1's increased heart rate and fever.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician or the facility's Medical Director promptly provided medical care to one of three sampled residents (Resident 1) when Resident 1's attending physician did not respond to Resident 1's change of condition of increased heart rate and fever on 7/4/2026. This failure had the potential for Resident 1 not to receive timely care and treatment and worsen Resident 1's condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility reviewed, updated, and/or revised new interventions for one of three sampled residents (Resident 1) care plan (a document that outlines a person's health needs and the care they require) for falls that occurred on 6/19/2026, 6/20/2026, and 6/26/2026. This deficient practices caused subsequent falls to Resident 2, potentially placing Resident 2 at risk for great bodily injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards for one of three sampled residents (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 failed to follow Resident 1's doctor's order for oxycodone (a potent, semi-synthetic pain medication prescribed to treat moderate to severe pain) on 5/11/26 to 5/13/26 and on 5/23/26. 2. LVN 1 did not have the knowledge of medication parameters (specific rules, clinical limits, and measurable values that guide how a drug is given, adjusted, or stopped). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized care plan (a document that outlines a person's health needs and the care they require) was developed and implemented for one of four sampled residents (Resident 1) medical condition of constipation (fewer than three bowel movements per week or experiencing difficult, painful, and incomplete passages of stool). This deficient practice had the risk to negatively affected Resident 1's care and create an immediate risk to Resident 1's health, safety, and quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure:1. Two of four Certified Nurse Assistants (CNA) met the annual performance evaluation requirements (CNA 2 and CNA 4).2. One of four CNAs met the requirement of full background check before hiring (CNA 4). These deficient practices had the potential to result in lack of knowledge and training among the CNAs, leading to inadequate resident care and the risk for abuse, neglect, and/or exploitation from inadequate background check.

Inspectors wroteBased on interview and record review, the facility's interdisciplinary team (IDT- a group of health care professionals who work together toward the goals of their residents) failed to ensure that a resident would not be allowed to keep medication at the bedside without being assessed to determine the resident's capability to self-administer medications in accordance with the facility's policies and procedures (P&P) for Resident Rights, Administering Medications, Safety and Supervision of Residents and Self-Administration of Medications, for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk of self-medicating inaccurately and had the potential to result in adverse consequences for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights be kept within reach for two of five sampled residents (Resident 3 and Resident 5) in accordance with the facility's policy and procedure (P&P), titled, Call Lights. These deficient practices had the potential for Resident 3 and Resident 5 to receive delayed care and services necessary to meet the residents' needs.a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician ordered medication Nystatin (a medication used to treat fungal or yeast infections of the skin, such as diaper rash) not left at bedside for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled, Storage of Medications. This deficient practice resulted in Resident 1's medication was left at Resident 1's bedside and had the potential for Resident 1 not to receive appropriate medication administration following the physician's orders to meet the residents' needs. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure licensed nurses (in general) monitored the right thigh wound Jackson Pratt drain (JP, a soft, flexible, bulb-shaped suction device that gently draws fluid from a wound to help speed up healing time and reduce risk of an infection), and monitored and changed the right lower quadrant (RLQ) abdominal wound vacuum canister (a medical device that uses continuous or intermittent suction to accelerate healing of wounds) when it was full for one of three sampled residents (Resident 3). These deficient practices resulted in delayed interventions and services for monitoring the wound and JP drain and had the potential to delay Resident 3's wound healing. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 completed documentation of the physician's order to perform the bladder scan (a non-invasive, painless ultrasound procedure used to measure the volume of urine in the bladder) and insert a straight catheter (a flexible, single-use, or intermittent tube inserted to the bladder to drain the urine and empty the bladder) for one of three sampled residents (Resident 2) on 12/8/2025. This deficient practice resulted in inaccurate documentation in Resident 2's medical record and had the potential for delaying interventions and services for Resident 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 1, a resident with dementia (loss of thinking, memory, and social abilities), was safely escorted to an outside appointment at GACH 1 for one of five sampled residents. This deficient practice resulted in the resident's safety being put at risk. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in the brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt. This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three of three sampled residents (Residents 10,75 and 119) with dignity and respect, based on the facility's policy and procedure (P&P) titled, Resident Rights, by failing to:a. Ensure Resident 119, who was occasionally (less than seven episodes of incontinence [inability to control the bladder and bowels]) incontinent, was offered alternative means to go to the bathroom. As a result, Resident 119 was instructed by staff to go the bathroom in Resident 119's brief (disposable absorbent garment designed to contain urinary or fecal incontinence). Resident 119 felt pain when having to be turned to be changed and made Resident 119, Feel horrible.b. Ensure Staff do not address Resident 10 as a feeder. As a result, Resident 10 stated Resident 10 felt useless.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of four of four sampled residents (Residents 10, 29,114 and 118). These deficient practices had the potential to result in delayed provision of necessary care and services for Residents 10, 29,114 and 118.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice and facility protocol for oxygen therapy for four of four sampled residents (Residents 23, 39, 40, and 113) by failing to:a. Ensure Resident 39's nasal cannula ([NC] a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not touching the floor while in use.b. Ensure Resident 23's NC was safely stored without the nasal prongs touching the back of the oxygen concentrator.c. Ensure Resident 40 received two liters per minute (lpm) of oxygen via NC according to the physician's order.d. Ensure Resident 113's NC was not touching the floor while in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store boiled eggs in one of one facility kitchen. This failure had the potential to result in foodborne illness in the residents who ate the boiled eggs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control policy and procedure for two of five sampled residents (Residents 83 and 162).a. Certified Nursing Assistant 1 (CNA 1) did not wear the required Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses like disposable masks, gloves and gowns) and did not perform hand hygiene while taking care of Resident 162 who was on Enhanced Barrier Precaution (EBP- infection control measures implemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs- bacteria or other microorganisms that have become resistant to multiple antibiotics]).b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) fed one of one sampled resident (Resident 40) in a respectful manner by not standing over the resident while assisting with eating during a meal. This deficient practice had the potential for Resident 40 to have decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 11's target behavior and adverse side effects (unwanted or undesirable effect) was monitored for the use of Alprazolam (antianxiety medication to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) for one of five sampled residents (Resident 11) as indicated in the facility's policy Behavioral Assessment, Management, Psychoactive Medications and Monitoring and Resident 11's care plan. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized/person-centered care plan for one of one sampled resident (Resident 11). The facility did not address Resident 11's Post-Traumatic Stress Disorder (PTSD- when a person keeps feeling scared/anxious long after a traumatic event was over) in accordance with facility's Policy and Procedure (P&P) titled Comprehensive Person - Centered Care Planning. This deficient practice had the potential for Resident 11 to not receive necessary care and/or services to address Resident 11's specific needs.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 7) was provided a communication device with the language that the resident understood in accordance to facility's policy Communication with Persons with Limited English Proficiency. This deficient practice had the potential result in Resident 7 to not be able to express their needs and receive the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to minimize the risk for edema (a condition characterized by the swelling of body tissues due to an excessive buildup of fluid) to the legs and feet for one of one sampled resident (Resident 136), according to the facility's policy and procedure (P&P) titled, Applying Anti-Emboli (the blockage of a blood vessel by a substance [embolus] that has moved from another part of the body) Stockings (thrombo-embolic deterrent [TED- also known as anti-embolism stockings, are a type of medical compression stocking designed to prevent blood clots and swelling in the legs] Hose), by failing to: Ensure Resident 136's TED hose was applied nightly starting 7/17/2025 as ordered by Resident 136's physician. As a result of this failure, Resident 136 did not get TED hose applied to Resident 136's left leg and thigh for eight days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that opened medication tablets were not placed inside a metal box and left on Resident 64's bed unattended. The Metal box was not labeled with an identifier for Resident 64 such as name, room number or date of birth . The Medication tablets did not have a sealed cover (refers to a tamper-evident seal or packaging feature that provides a visible indicator if the product has been opened or compromised. It's designed to protect the integrity and safety of the medication until administered to the resident) and did not have name or dosage. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote bowel and bladder continence (ability to control the bladder and bowels) for one of one sampled resident (Resident 119) according to the facility's policy and procedure (P&P) titled, Urinary Continence and Incontinence (inability to control the bladder and bowels)- Management and Assessment, by failing to: Ensure Resident 119, who was occasionally (less than seven episodes of incontinence) incontinent of bowel and bladder, was offered an alternative means to go to the bathroom. As a result of this failure, Resident 119 was instructed to go to the bathroom in Resident 119's brief (disposable absorbent garment designed to contain urinary or fecal incontinence). This failure had the potential for Resident 119 to lose more function of bowel and bladder and become more incontinent.

Inspectors wroteBased on observation, interview and record review the facility failed to:a. Post nurse staffing data in a prominent location readily accessible to residents and visitors for viewingb. Post resident census at the beginning of the shift for which the data was posted on 7/24/2025.c. Maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. These deficient practices of posting inaccurate nurse staffing information had the potential to mislead the residents and visitors and affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to record and track a prescribed narcotic for one of one sampled resident (Resident 29). This failure had the potential to result in diversion (the illegal selling of prescribed medications) of a controlled substance.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review (MRR) reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 119) according to the facility's policy and procedure (P&P) titled, Medication Regimen Review, by failing to:Ensure Resident 119's consultant pharmacist recommendation to order laboratory test to monitor Resident 119's thyroid-stimulating hormone (TSH- blood test used to check how well the thyroid gland is working) while taking levothyroxine (also known as Synthroid- medication used to treat hypothyroidism [a condition where the thyroid gland does not produce enough thyroid hormone]) was acted upon. As a result of this failure, Resident 119 did not have an updated TSH level drawn since Resident 119's admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four dumpster containers were covered. This failure had the potential to attract and expose the facility to pests and other scavengers to the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by not notifying one of two sampled residents' (Resident 1's) Representative (R1) when Resident 1 was transferred to the General Acute Care Hospital (GACH 1). This failure resulted in the violation of Resident 1's and R1's right to be notified of any changes of condition/status of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Charting and Documentation, by failing to document notification to one of two sampled residents (Resident 1's) representative (R1) of Resident 1's transfer to the General Acute Care Hospital (GACH 1). This deficient practice had the potential to not provide complete information regarding Resident 1's transfer to GACH 1.

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/with little or no delay) notify one of three sample residents' (Resident 2) Responsible Party (RP 2) when Resident 2 experienced a change in condition (CIC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (PP) titled, Change of Condition Reporting, by failing to: Ensure RP 2 was notified when Resident 2's Primary Care Provider/Medical Doctor (MD) 1 discontinued Resident 2's Avycaz (brand name for ceftazidime/avibactam- an antibiotic [medicine that stops the growth of or destroys bacteria in the body] used to treat complicated urinary tract infections [UTI- an infection in any part of the urinary tract, the system of organs that makes urine]). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services for one of three residents (Resident 2), according to the facility's policy and procedures titled, Antibiotic Stewardship (the effort to measure and improve how antibiotics [medicine that stops the growth of or destroys bacteria in the body]) - Orders for Antibiotics, and Urinary Tract Infection (UTI- an infection in any part of the urinary tract, the system of organs that makes urine)/Bacteriuria (bacteria in urine), by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the laboratory (a room or building equipped for experimental study in science or for testing and analysis) services (laboratory services/laboratory tests included certain blood tests and urinalysis [UA- a medical test that examines a person's urine to detect and diagnose different health conditions], that helped healthcare professionals to detect and treat diseases) for one of three sampled residents (Resident 2) according to the facility's policy and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, by failing to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's dignity for six of six sampled residents (Residents 13, 15, 75, 86, 120, and 279) when: a. Facility staff failed to answer Residents 120 and 279's call light (a device used by a resident to signal his or her need for assistance from staff) in a timely manner. b. Facility staff stood next to Residents 13 and 15 while feeding lunch. c. Facility failed to ensure Residents 13, 75 and 86 were treated with dignity by protecting the residents' private space. LVN 2 and LVN 7 failed to knock multiple times prior to entering and/or opening the door of the residents' room. These failures resulted for the residents to feel frustrated and embarrassed and had the potential for the residents to experience a decline in psychosocial well-being. (Cross reference F689)

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's representative was provided education regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney [legal document that allows someone to act on your behalf in certain situations] for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the information was complete and accurate for two of eight sampled residents (Residents 4 and19). These deficient practices had the potential for the residents to receive life-sustaining care and/or treatment against their will.

Inspectors wroteBased on interviews and record review, the facility failed to notify the responsible party of two of three sampled residents (Residents 178 & 179) in writing regarding the Medicare Advance Beneficiary Notice (ABN, written notice that informs Medicare beneficiaries of certain items or services that Medicare may not pay for prior to receiving the items or services). This failure had the potential to negatively affect Residents 178 and 179's physical and psychosocial well-being due to responsible party's lack of information, including the resident's right to appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall safety intervention for two of three sampled residents (Residents 55 and 279) in accordance with the facility's Policy and Procedure (P&P) titled, Falls - Clinical Protocol,, by failing to: a. Ensure the facility staff provided supervision when Resident 279 ambulated in her room and/or while ambulating to the bathroom. b. Ensure the bed for Resident 55 who was assessed as high risk for fall and had a history of falling, was at the lowest position and floor mats were in place. These failures had the potential to result in falls/injury for Residents 55 and 279. (Cross reference F550)

Inspectors wroteBased interview and record review, the facility failed to monitor fluid restriction on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 for one of one sampled resident (Resident 49) in accordance with the physician's orders. These failures had the potential to lead to fluid overload (too much fluid volume in the body) and overall decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of infections in the facility in accordance with the facility's policies and procedures and national health guidelines. A. One of one Certified Nursing Assistant (CNA 1) did not don (wear) the required protective personal equipment (PPE, equipment worn to minimize exposure to a variety of hazards) prior to entering the room of one of one sampled resident (Resident 55), who was on contact isolation precautions (type of transmission-based precaution requiring the use of gown and gloves to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment). B. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician of one of one sampled resident's (Resident 14) blood sugar value of 420 milligram/deciliter (mg/dL - unit of measurement) on 7/1/2024 as indicated in Resident 14's Medication Administration Record (MAR). This failure had the potential for Resident 14 to experience undesired effects of high blood sugar.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 75) was provided with a home-like environment by not allowing Resident 75 to use the [NAME] and [NAME] restroom (a restroom that has two doors and is usually accessible from two bedrooms to share) of other residents. This failure had the potential to result in invasion of privacy for Resident 75 and other residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow the food preferences of one of four sampled residents (Resident 27) during lunch tray line (system of food preparation in which meal trays are moved along an assembly line). This failure had the potential to cause inadequate nutrition related to decreased appetite, refused meal, or meal replacement with less healthier options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its facility's Policies and Procedures (P&Ps) on dishwashing and standard precautions for one of one dishwasher (DW 1) observed in the facility's kitchen. This failure had the potential to for foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents related to food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP 85), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) for one of three sampled residents (Resident 85) understood the BAA prior to signing. This failure had a potential to result in a decline in Resident 85's physical and/or psychosocial condition due to possible hardships related to arbitration proceedings.

Inspectors wroteBased on interview and record review, the facility failed to notify one of one sampled resident (Resident 14)'s representative of the facility's policy for bed hold. This failure had the potential for Resident 14's representative to be uninformed of their rights to return to the facility after discharge or transfer.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of nine sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side to change the resident ' s adult brief (disposable underwear) on the bed as indicated in Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/2023. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a personalized care plan for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s care plan indicated how many staff were needed to provide care to Resident 1. This failure had the potential to result in Resident 1 not receiving necessary and appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) had the competency to provide care to residents who were on a low air loss (LAL) mattress (a kind of mattress used for residents who are at risk of developing pressure sores or already have pressure sores) when CNA 1 did not notify a licensed nurse to set Resident 1 ' s low air loss mattress on static mode (firm surface set in place and unlikely to move) before providing care to Resident 1. As a result, on 1/2/2024 at 11:20 AM, Resident 1 fell from her bed to the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control practices (a set of practices that prevent or stop the spread the of infection and/or diseases in the healthcare setting) in accordance with the facility ' s policy and procedure and Centers for Disease Control and Prevention (CDC, a federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) guidelines by failing to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the needs for eight out of 28 sampled residents were met (Resident 54, 65, 95, 103, 106, and 177) by failing to: 1. Ensure call lights were answered in a timely manner to address the residents needs for Residents 54, 65, 95, 103, 106, and 177. This deficient practice had the potential to affect residents' quality of care and quality of life due to nursing services were not provided to the residents in timely manner. 2. Ensure residents (Residents 95 and 103) were assisted with incontinent care, bathroom use, and with maintaining wellbeing to the extent possible in accordance with their own needs. This deficient practice had the potential for residents' lack of care and not maintaining their well-being in accordance with their own needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan timely for three of 28 sampled residents (Residents 20, 24, and 25) by failing to: 1. Resident 25 who was on a restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) for both lower extremities (hips, knee, ankle, foot) passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises did not have a care plan for RNA. 2. Resident 20 who had sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) did not have a care plan to address her sleep apnea and the use of a Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two out of five sampled residents (Residents 25 and 76) who had limited joint range of motion received restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) treatments and services; a. Resident 76 was not provided an RNA program to put on and take off left and right knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for both knee contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). b. For Resident 25, 1. the RNA order dated 5/12/2021 did not specify site and location to perform RNA exercises to both lower extremities. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to two residents (Residents 67 and 77) whose insulin was found to be expired during the inspection of one of two medication carts (Medication Cart 1.) As a result, Residents 67 and 77 received a combined total of eight doses of expired insulin between [DATE] and [DATE]. This deficient practice had the potential to cause Residents 67 and 77 to experience serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one single-use vial of injectable haloperidol (a medication used to treat hallucinations - seeing or hearing things that are not there) was discarded for one resident (Resident 35) in one of two inspected medication carts (Medication Cart 1.) 2. Ensure expired insulin (a medication used to treat high blood sugar) was discarded for five residents (Residents 27, 51, 67, 77, and 374) in one of two inspected medication carts (Medication Cart 1) and one of two inspected Medication Rooms (Medication room [ROOM NUMBER].) 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report laboratory (Lab) work in a timely manner to the resident's oncologist (doctor that specializes in treatment of cancer) for one of five sampled residents (Resident 60.) This deficient practice resulted in a delay in Resident 60's oncology care and Resident 60 did not receive Sprycel (a medication used to treat CML) medication between 5/5/21 and 5/21/21 (17 days). This deficient practice could have resulted in a negative impact to his overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to opt in to certain medication therapy or treatments once they are educated about the risks and benefits) prior to prescribing psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 116.) This deficient practice could have denied Resident 116 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to accommodate resident's preference for 1 of 2 sampled residents (Resident 4), to go back inside his room to keep warm rather than stay in the facility hallway without clothes and wrapped in a thin blanket while waiting for his turn to use the facility's common shower room. This failure resulted in not meeting the right to make a choice by the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide Resident 323's representative access to residents' medical records when requested. This deficient practice resulted in Resident 323's representative not receiving documents on a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to complete an advance directives (a written instruction, such as a living will or durable power of attorney for health care recognized under state law) to four of six sampled residents (Resident 35,48, 223 and 224). This deficient practice had the potential to delay emergency treatment or had the potential to execute emergency, life sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an orderly (uncluttered physical environment that is neat and well kept), sanitary (preventing the spread of disease causing organisms by keeping care equipment clean and properly stored), and home-like environment for Resident 14. This deficient practice had the potential to result in an environmental hazard (danger or threat), increased the risk for falls or injury, and increase the spread of infectious disease and illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Nursing Assistant (NA) 1, NA 2, and Certified Nursing Assistant (CNA) 2 reported an alleged injury of unknown origin/source was reported immediately, but not later than two (2) hours to the local, state and federal agencies and thoroughly investigated by facility management for one of one sampled residents (Resident 76). Resident 76 informed FM 2 that someone pinched her to the arm. Resident 76's family member (FM 2) asked NA 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. FM 2 did not notify NA 1 about Resident 76's allegation of someone pinching her. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the plan of care for one of seven sampled residents (Resident 76 and 116): 1. Resident 76's family member (FM 2) asked Nursing Assistant (NA) 1 and another unidentified staff on 5/14/21 about new bruises found in the resident's bilateral arms. NA 1 did not inform the charge nurse of the resident's bruises (from unknown source), to initiate an investigation immediately and revise the plan of care. 2. Resident 76 who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and treatment for 2 of 28 sampled residents (Resident 76 and 95) in accordance with the plan of care and the facility's policy and procedures by failing to: 1. Ensure facility staff assessed and monitored Resident 76's bilateral arms bruises/discoloration in a timely manner. This deficient practice had the potential to result in a delay in providing the necessary care and treatment to Resident 76. 2. Ensure facility staff addressed Resident 95's complaint of constipation and administered medication as needed for constipation as ordered by the physician. This deficient practice had the potential to result in abdominal discomfort, fecal impaction, and lead to complication such as bowel obstruction and lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that interventions were implemented for a resident who had an existing Stage IV pressure ulcer [full thickness tissue loss with exposed bone, tendon or muscle with or without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft and stringy in texture) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like)] on the coccyx (tailbone) by failing to: 1. Reposition Resident 76 while up in the wheelchair to reduce the pressure in the coccyx area. 2. Provide a gel cushion (pressure reducing device) while up in the wheelchair as indicated in the resident's physician order. This deficient practice had the potential to delay Resident 76's wound healing and placed the resident at risk for further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an unobstructed urine flow and secure the catheter for two of two sampled residents (Resident 14 and 67). This deficient practice had the potential to increase tension to the catheter and cause urethral tear or potential dislodgment, and decrease the urine flow by increasing kinks in the catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment consistent with professional standards of practice for two of three sampled residents (Resident 6 and 20) who required oxygen administration by failing to: 1. Ensure facility staff provided Resident 20 with a working Bilevel Positive Airway Pressure (BiPAP; a device that helps push air into the lungs) machine at bedtime for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) as ordered by the physician. 2. Ensure facility staff monitored Resident 20's oxygen saturation (refers to the amount of oxygen in the bloodstream) every shift to titrate (adjust based on oxygen need) the oxygen flow rate from 2 liters per minute (L/min) to 5 L/min via nasal cannula (NC; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the attending physician responded to two recommendations made by the consultant pharmacist (CP) regarding medication therapy for two of five sampled residents (Residents 13 and 116) between 2/24/21 and 4/28/21. 1. For Resident 13's, the clinical record did not indicate documented evidence of the attending physician's response to the consultant pharmacist's recommendation to justify continued use of Protonix on 2/24/21. 2. For Resident 116, the facility failed to obtain a response from the physician regarding the pharmacist's recommendation to add a 14-day stop date to Ambien or limit the PRN Ambien to 14 days. This deficient practice increased the risk that medication therapy for Residents 13 and 116 may not have been optimized for the best possible health outcomes. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Ambien (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 116.) 2. Monitor for adverse effects (unwanted or dangerous medication side effects) of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of five sampled residents (Resident 116.) 3. Monitor for behaviors tied to psychotropic medication use in one of five sampled residents (Resident 116.) These deficient practices increased the risk that Resident 116 to experience adverse effects of psychotropic medication therapy leading to an overall negative impact on her physical, mental, and psychosocial well-being.

Inspectors wrote1. A Review of Resident 39's admission Record, Resident 39 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of the spine, obesity (over weight) anxiety disorder and history of falling, and allergies to sulfa antibiotics. A Review of Resident 39's MDS dated [DATE] indicated the resident was cognitively intact and had no impairments with communication. A review of Resident 39's dietary preference list - a list attached to the resident's Nutritional Screen-Food Preferences dated 3/16/21, indicated Resident 39 was on mechanical soft diet with no added salt, dislike turkey, turkey salad, corn, salad and red sauce. A review of Resident 39's care plan dated 3/15/21 indicated the dietary staff would inquire and provide resident food preferences (like & dislike). [...]

Inspectors wroteb. A review of Resident 20's admission Record, indicated the facility admitted the resident on 2/17/21, with diagnoses including acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), diabetes mellitus (high blood sugar), and chronic kidney disease. A review of Resident 20's physician's order, dated 2/17/21, indicated BiPAP settings with respiratory rate = 4, fraction of inspired oxygen (FiO2; the concentration of oxygen in the gas mixture) = 30%, and expiratory positive airway pressure (EPAP; set to maintain upper airway patency) = 4 centimeters of water (cmH2O) at bedtime. BiPAP on at 9 p.m. and off at 6 a.m. for sleep apnea and remove per schedule. The order indicated may or may not need heated humidification (uses heat to warm water in the humidifier chamber to produce moisture which is carried by the breathed air). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated and existing infection preventionist (IP-responsible for the facility's Infection Prevention and Control Plan) completed the required initial specialized training in infection prevention and control no later than 1/1/2021 that meets the minimum set of requirements (14 hours) indicated by the Centers for Disease Control and Prevention (CDC). This deficient practice had the potential to result in the IP not having current knowledge and/ or training on surveilling and monitoring infection control practices and had the potential to further increase the development and transmission of communicable disease and infection in the facility.