Arden Park Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to provide needed care or services to one of three sampled residents (Resident 1) when:Licensed Nurse (LN) 1 failed to assess Resident 1 per family requests when Resident 1 was unresponsive for approximately 5 hours,Facility failed to ensure Resident 1 was assessed for medications side effects,LN 1 failed to notify Resident 1's physician immediately when her condition changed and LN 1 administered blood pressure medication to Resident 1 outside physician's ordered parameters. These failures resulted in Resident 1's emergent transfer to the hospital after being found unresponsive with low blood pressure and required stabilization in the intensive care unit (ICU).1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Nurses (LNs) had the knowledge, competencies and skill sets to provide care to residents prior to caring for residents on their own for nine of 13 sampled staff members when: 9 LNs did not have a completed competency checklist on hire. This failure resulted in the facility being unable to confirm LNs were competent prior to caring for residents and had the potential for residents in the facility to receive substandard care. During a concurrent interview and record review on 6/12/26, at 10:37 a.m. with Director of Staff Development (DSD), LN 1's employee file was reviewed. LN 1's employee file indicated, LN 1 did not have a complete competency checklist on hire signed by a Registered Nurse (RN). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice, the facility's policy and procedure (P&P), and physician's orders when the facility did not consistently complete Resident 6's ordered skin care and wound management treatments. These failures had the potential to cause Resident 6's skin and wound conditions to worsen and for Resident 6 to not achieve the highest practicable well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 6) received care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 6's foley catheter (a tube inserted through the urethra into the bladder to drain urine) care, management, and monitoring were not consistently done. These failures had the potential for Resident 6 to develop foley catheter complications such as blockage or infection, and for Resident 6 to not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for four of 35 sampled residents (Resident 164, Resident 6, Resident 36, and Resident114) when:1. Staff did not notify the physician of abnormal high lab values for Resident 164;2. Staff did not notify the physician of abnormal low lab values for Resident 6;3. Resident 36 was administered 3LPM (liters per minute, flow rate of the oxygen) of oxygen instead of the ordered 2LPM; and 4. Resident 114 was given 2.5 LPM of oxygen instead of the ordered 3 LPM.These failures placed Resident 164 and Resident 6 at risk for unmet care needs and delayed treatment, and placed Resident 36 and Resident 114 at risk for not receiving appropriate oxygenation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Emergency Medications policy and procedure for a census of 152 residents when the Emergency Kit (E Kit), a storage box containing emergency medications, was not replaced upon the next routine medication delivery after being used. This failure increased the potential risk of not having essential emergency medications available when needed and increased the risk of drug diversion. During a medication storage inspection in the facility's east station medication room on 3/16/26 at 9:20 a.m. with Licensed Nurse 1 (LN 1), E Kit #082 was observed secured with a red plastic zip tie, indicating that the E Kit had been previously opened by the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly according to the facility's Policy and Procedure (P&P), when:1. An opened inhaler (used to administer medication by breathing in) in the medication cart was not correctly dated with an expiration date, and2. A labeled pharmaceutical bag was found behind the drawers in the back of a medication cart These failures placed the residents at risk for receiving expired or outdated medication and had the potential for medication error and drug diversion for the census of 152.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served under sanitary conditions for 149 residents who received meals from the kitchen in a census of 152 when:1. Multiple dishes were stored upright, exposed to dust and splatter, and 2. Two of five roasts were thawed improperly. These findings increased the potential for food born illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the rights for privacy and a dignified existence were respected for seven residents (Residents 31, 39, 66, 76, 130, 141, and 143) in a census of 152 when their curtains did not enclose their cubicles for privacy. This failure increased the potential for embarrassment during personal care and private visits for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 33 of 60 resident' rooms (Rooms 100, 102, 103, 104, 105, 106, 107, 108, 111, 204, 205, 206, 207, 208, 209, 210, 212, 300, 301, 302, 303, 304, 305, 306, 307, 310, 311, 408, 410, 411, 503, 505, and 517) met the minimum requirement of 80 square feet (sq. ft.) per resident. This failure had the potential to result in inadequate space for the provision of care for 100 residents.

Inspectors wroteBased on interviews, and record review, the facility failed to protect one of 35 sampled residents' (Resident 77) right to be free from physical and verbal abuse by another resident when Resident 79 cursed at Resident 77 and threw a water pitcher at Resident 77's head. This failure had the potential to cause physical and mental harm to Resident 77.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse, for two of 35 sampled residents (Resident 77 and Resident 79), when an incident on 2/26/26 involving Resident 77 and Resident 79 was not reported to the Department. This failure had the potential to place Resident 77 at risk for continued abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an accurate medical record for one of 35 sampled residents (Resident 157) when PICC (peripherally inserted central catheter, a long thin flexible tube inserted through a vein in the upper arm and into a large vein just above the heart used to deliver medications directly into the bloodstream) dressing changes and an administration of IV (intravenous) medication were not recorded in the resident's medical record. These failures resulted in an inaccurate medical record and had the potential for miscommunication among healthcare professional which could lead to inadequate care for Resident 157.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain three resident wheelchairs (Resident 80, Resident 130 and Resident 143) in a census of 152 in safe operating order when the armrests were damaged and unable to be sanitized. This failure placed the residents at risk for discomfort, skin tears, abrasions and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for one of three sampled residents (Resident 3) when Resident 3 had ongoing oxygen therapy without a physician's order. This failure had the potential to put Resident 1's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse, when Certified Nursing Assistant 1 (CNA 1) hit Resident 1 in the face. This failure resulted in Resident 1 sustaining a cut on his nose bridge about half an inch in length, a bruise under his left eye, and expressing feeling like a piece of crap.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practice for two of seven sampled residents (Resident 1 and Resident 2), when Licensed Nurse 1 (LN 1) did not sanitize (to clean or disinfect) a shared glucometer (device used to measure blood sugar levels using a test strip and drop of blood) in between use. This failure had the potential to spread infection among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when the comprehensive centered care plan was not followed. This failure had the potential to result in Resident 1 ' s gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) to be displaced during Activities of Daily Living ( (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident(Resident 8) was provided with adequate supervision and safe environment, for a census of 154. This failure resulted in Resident 8's fall and transfer to the acute care hospital due to a bump and cut to the right forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store, serve, and distribute food in accordance with professional standards of food service safety when: 1. The ice machine was not clean; 2. Several various kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had food debris; 3. Various size of cooking pans, readily available for use, had dry and heavy black substance buildup and deep scratches on the cooking surfaces; 4. Improper dating for the opened packages of food items in dry storage, walk-in refrigerator, and walk-in freezer; 5. Improper storage and handling for the opened package food items in the walk-in refrigerator and walk-in freezer; 6. Produce that were not fresh and not discarded found in walk-in refrigerator; 7. Issues found in resident's food refrigeration unit located in east station: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain pharmacy services for a census of 154 when: 1. Expired glucagon [define] Emergency Medication [define] found in emergency supply kit (e-kit); 2. Twelve boxes of expired ear wax drops and 28 boxes of expired covid [define] test kits; 3. The medications for Random Resident (RR) was not discarded after discharge from the facility; and, 4. Narcotic medication [define] reconciliation did not match the electronic Medication Administration Record (eMAR) for Resident 81. This failure had the potential to cause inaccurate accountability of controlled medications and the potential to result in diversion of the residents' medication. 1. During medication storage observation and interview on 12/4/24 at 3:18 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%) when five medication errors occurred out of 31 opportunities during medication administration for two residents (Resident 3 and Resident 28) of six selected residents during medication pass, when: 1. Resident 28 did not receive insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician orders; 2. Resident 28 did not receive the correct bowel care medication and dose per physician's order; 3. Resident 28 did not receive respiratory medication per physician order; and, 4. Resident 3 did not receive Vitamin D supplement as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident 28 and Resident 56) were free of significant medication errors for a census of 154, when: 1. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered as ordered for Resident 28; and, 2. Resident 56 received five duplicate doses of Baclofen (a medication used to treat muscles spasms, cramping, and tightness in people with spinal cord injuries). These failures had the potential to compromise the health and safety of Resident 28 and Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service personnel had skill sets to safely and effectively carry out the functions of the food and nutrition services when Dietary Aide (DA) 2 was unable to verbalize or demonstrate the procedure for cleaning and sanitizing food contact surfaces and was unable to verify the sanitizer concentration to ensure effective sanitation (cross refer to F812, #9). These failures had the potential to result in ineffective sanitation with potential to cause food borne illness in a high-risk population of 153 residents who consumed food from the facility kitchen. The census was 154.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet during lunch on 12/3/24 and 12/4/24 when: A. During a dining observation on 12/3/24: 1. Five residents (Resident 3, 13, 42, 114, and 126) with CCHO (consistent or controlled carbohydrate) diets (a diet for people who need to control their blood sugar or to manage diabetes) received one slice of bread instead of a 1/2 slice of bread. 2. Resident (RES) 42 with CCHO and Renal diet (diet to manage chronic kidney disease) received white rice instead of brown rice. B. During a meal service distribution on 12/4/24: 1. Four residents (Resident 82, 105, 129, and 142) with fortified diets (added calories and/or protein) did not get the fortified foods with their meals. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control was provided for eight residents (Resident 129, Resident 13, Resident 361, Resident 14, Resident 41, Resident 96, Resident 28, and Resident 16) for a census of 154 when: 1. Resident 129's nebulizer (a machine that delivers droplet medication into the lungs) mask and tubing were on the floor and the tubing was not labeled or dated; 2. Resident 13's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was undated and not properly stored when not in use; 3. Resident 361's BIPAP (bilevel positive airway pressure, a type of device that helps with breathing) machine was observed on the floor and BIPAP mask was not properly stored when not in use; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 45 resident rooms (104 to 109, 111, 203 to 210, 212, 214, 300 to 309, 400 to 409, 500, 503, 505, 507, 509, 511, 515, 517) met the required 80 square feet (sq ft) per resident. This failure had the potential to result in inadequate space for provision of care and a decrease in the quality of life for residents residing in these rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were fully informed of the risks and benefits of medications for two of 33 sampled residents (Resident 147 and Resident 142) when: 1. The informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought) did not indicate the correct indication and target behavior for Resident 147; and, 2. There was no informed consent for the increase in the dose of Buspirone (medication used to treat anxiety) for Resident 142. These failures increased the potential for Resident 147 and Resident 142 to not be informed of the medications' risks and benefits and alternative options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for two of 33 sampled residents (Resident 142 and Resident 109) when: 1. Resident 142's bathroom was in disrepair; and 2. Resident 109's bedside table was chipped and peeled on the sides. These failures increased the potential to negatively impact Resident 142 and Resident 109's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 33 sampled residents (Resident 311) from verbal abuse when Resident 312 expressed racial slurs to Resident 311. This failure resulted in Resident 311 feeling unsafe in his room and experiencing emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to develop person-centered care plans timely, specific to medical, nursing, physical, mental, and psychosocial needs for two of 33 sampled residents (Resident 147 and Resident 361) when: 1. Care plan for Resident 147's use of antipsychotic (medication used to treat psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was not developed timely upon starting Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought); and, 2. There was no care plan developed for Resident 361's hard of hearing and use of hearing aid (a device worn in or behind ear designed to amplify sound for individuals who have difficulty hearing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet professional standards of quality for two residents (Resident 28 and Resident 116), for a census of 154, when: 1. Resident 28's insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) order was marked as given prior to administration; 2. The licensed staff did not dispose used lancets (small sharp objects used to take blood samples for blood sugar) in biohazard sharps containers; and 3. Resident 116's medication was left at bedside. These failures had the potential to put residents' health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 107) received vision services as ordered in a timely manner. This failure increased the potential for Resident 107 to experience further loss of vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) consistent with facility policy and professional standards for two of thirty-three sampled residents (Resident 311 and Resident 318), when: 1. Resident 311 developed pressure injury to sacrum (base of the spine) after admission to the facility; and 2. Resident 318 did not have an accurate skin assessment upon admission to the facility. These failures placed Resident 311 and 318 at increased risk for infection and health status decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 27) received services to maintain mobility of fingers and prevent further contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). This failure increased the potential for Resident 27 to experience total loss of mobility on fingers and to negatively impact psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of 33 sampled residents (Resident 147 and Resident 30) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 147's Clozapine (medication used to treat Schizophrenia - a mental illness that is characterized by disturbances in thought) was given without appropriate target behavior and side effects monitoring; and, 2. Resident 30 did not have adequate indication for the use of antipsychotic medication. These failures decreased the facility's potential to monitor Resident 147 for appropriate target behaviors and had the potential to result in increased risk and exposure to side effects associated with psychotropic medications for Resident 147 and Resident 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services furnished by outside resources had written agreements when two out of 33 sampled residents' (Resident 41 and Resident 50) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinics. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 41 and 50.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process when Resident 1 was discharged home without proper arrangements for home health services to manage the wound and therapy services. This failure resulted in Resident 1 ' s not having wound care for over 8 days which had the risk potential for the wound to get infected and deteriorate in functional status due to therapy services not provided.

Inspectors wroteBased on interview and record review, the facility failed to provide dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) services, consistent with professional standards of practice, to meet the needs of one of three sampled residents (Resident 1), when: 1. Resident 1 missed scheduled dialysis appointments due to transportation issues, and 2. Resident 1's responsible party (RP) and physician were not informed about missed dialysis appointments. These failures increased Resident 1's risk of developing medical complications, including hospitalization and death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure professional standards of quality were followed for one of three sampled residents (Resident 1), when the fluid restriction physician order was not followed. This failure had the potential to increase Resident 1's difficulties in breathing resulting in hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to protect the five out of eight sampled residents' (Resident 1, Resident 3, Resident 4, Resident 5, and Resident 7) right to be free from mental and physical abuse by a resident (Resident 2) when: 1. The facility failed to reasonably investigate residents' complaints regarding Resident 2 to ensure their well-being and safety; and, 2. Resident 2 (with known history of wandering) went inside Resident 1 and Resident 4's room on 7/2/24, unsupervised, masturbated, and pooped on the floor. These failures resulted in Resident 1, Resident 3, Resident 5, and Resident 7 being scared, feeling unsafe, fearful, and experiencing emotional distress, and had the potential for Resident 1, Resident 3, Resident 4, Resident 5, and Resident 7 and all residents in the facility to experience physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of eight sampled residents (Resident 1) when: 1. Resident 1 reported to nursing staff that she was slapped by Resident 2 on 4/9/24; and, 2. Resident 1 reported to the Assistant Director of Nursing (ADON) that Resident 2 (with known history of wandering) went inside Resident 1's room on 7/2/24, unsupervised, masturbated, and pooped on the floor. This failure had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy for four of seven sampled residents (Resident 1, Resident 3, Resident 5, and Resident 7) when the facility failed to ensure one of Resident 1's allegation of abuse and mistreatment was timely and thoroughly investigated. This failure to protect, investigate, and provide a safe environment caused Resident 1, Resident 3, Resident 5 and Resident 7 to feel emotionally unsafe, violated, and helpless. Not investigating and interviewing these other residents allowed the perpetrator (Resident 2) to have access to Resident 1, Resident 3, Resident 5 and Resident 7 and other vulnerable residents and allowed further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable access to a telephone for one resident (Resident 1). This failure prevented Resident 1 from calling her significant other and from being contacted by the State Agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate documentation of Activities of Daily Living (ADL) services provided for one of three sampled residents (Resident 1), when Resident 1's clinical record did not reflect Resident 1 was offered bathing services according to facility's protocol. This failure had the potential for Resident 1 to not receive bathing services per facility protocol resulting in missed skin change evaluations and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 2) was provided with adequate supervision and safe environment, for a census of 145. This failure resulted in Resident 2's fall and transfer to the acute care hospital for further evaluation. Resident 2 sustained multiple fractures (break) of the bones of the neck requiring surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with respect and dignity when facility staff was on the phone while providing care, for a census of 145. This failure had the potential for Resident 1 not to receive care based on her needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective pain management was provided for one of three sampled residents (Resident 1) who was admitted to Hospice (specialized care that provides physical comfort, and quality of life for patients with a terminal illness and approaching the end of life) when the facility's licensed staff did not administer the right dose of pain medication as ordered by the physician. This failure had the potential for Resident 1 to endure pain and suffering as a result of poor pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) for one of three sampled residents (Resident 1) accurately reflected Resident 1's Physician's Order for Life Sustaining Treatment (POLST) when her MDS Section S RESIDENT ASSESSMENT AND CARE SCREENING was not accurately documented. This failure had the potential to result in Resident 1 receiving interventions that were contrary to her own choices.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a detailed approach outlining resident's concerns and needs) for one of three sampled residents (Resident 1), when she fell, and no actual fall care plan was developed or prior care plans revised to include new interventions to prevent further falls. This failure increased the risks for Resident 1 to have recurrent falls and injuries when preventative interventions were not revised.

Inspectors wroteThe facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal medical information when meal tray tickets were thrown into the general trash and dumpsters. This had the potential of compromising resident privacy for the 150 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two out of 33 sampled residents (Resident 96 and Resident 52) when: 1. Resident 96's Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) care plan was not developed; and, 2. Resident 52's care plan intervention did not accurately reflect Resident 52's physician's order for oxygen therapy. These failures placed Resident 96 and Resident 52 at risk to not meet their medical, physical, and psychosocial needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care consistent with the facility policy and procedure for three of 33 sampled residents when: 1. Resident 14 received oxygen therapy without humidifier and the resident's BiPAP (a device supplies pressurized air into the lungs through a mask or nasal plugs) was placed on the bedside table unbagged and undated, and 2. Resident 52 and Resident 107's physician's orders for oxygen therapy were not followed. These failures placed Resident 14 at risk for respiratory infection and increased potential for ineffective respiratory therapy for Resident 52 and Resident 107.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet food storage and service practices that meet professional standards for food service safety when: 1) Kitchen staff did not consistently use hair and beard guards while in the kitchen, 2) Dry storage did not have a thermometer and temperature monitoring system, 3) Dry storage floors found with black markings, rust stains and holes in the linoleum, 4) Food not consistently closed and covered after opening, 5) Ice build-up found on freezer ceiling and floor as well as thick condensation making visibility poor, 6) Wet pans and bowls in ready to use area, 7) Equipment not replaced when no longer meeting safe standards, 8) Food particles and debris found on kitchen equipment, 9) Dumpsters found with lids left open, overflowing, and trash around base, 10) Resident refrigerator without freezer log system for [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 151 residents when: 1. Two facility staff entered a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) without using all the required personal protective equipment (PPE); 2. Resident 3's incentive spirometer (a hand-held exercise equipment for the lungs that helps people to take slow, deep breath) was left on top of Resident 3's bedside drawer with no cover, and was not labeled with a resident identifier and the date it was initially used; 3. Resident 52's incentive spirometer was not stored properly; 4. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that 44 resident rooms (104-109, 111, 203-210, 212, 214, 300-309, 400-409, 500, 503, 505, 507, 509, 511, 515, and 517) met the required 80 square feet (sq ft) per resident when the following rooms were measured as: room [ROOM NUMBER] at 70.5 sq ft per resident room [ROOM NUMBER] at 73 sq ft per resident room [ROOM NUMBER] at 71.9 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 74.1 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 73.5 sq ft per resident room [ROOM NUMBER] at 73.4 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 73.2 sq ft per resident room [ROOM NUMBER] at 72.8 sq ft per resident room [ROOM NUMBER] at 70 sq ft per resident room [ROOM NUMBER] at 73. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of 33 sampled residents (Resident 121's) dignity when the resident's urinary catheter drainage bag with an indwelling urinary catheter was not covered with a privacy bag. This failure resulted in Resident 121's urinary bag to be exposed and visible from the hallway and placed the resident at risk for feeling an involuntary loss of his dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for one of 33 sampled residents (Resident 30) when Resident 30's bed and bedside drawer was re-arranged without Resident 30's permission. This failure resulted in Resident 30 experiencing emotional distress, irritation, and hindered Resident 30's ability to transfer from his wheelchair to his bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 33 sampled residents (Resident 96 and Resident 52) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 96 and Resident 52 had fingernails that were long and with blackish substance underneath the fingernails. These failures had the potential for Resident 96 and Resident 52 to sustain injury and/or for the residents to acquire an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 33 sampled residents (Resident 80 and Resident 103) received enteral feeding (tube feeding) consistent with the facility's policy and procedure and the resident's care plan when: 1. Resident 80's medical record had no documented evidence for enteral tube feeding assessments prior to nutrition formula and/or medication administration, and 2. Resident 103 had no I&O (Intake & Output) summary and evaluation in the medical records. These failures placed Resident 80 at risk for complications related to tube feeding such as aspiration pneumonia and increased the potential for Resident 103's fluid imbalance to go unnoted. 1. Resident 80 was admitted to the facility in the Summer of 2023 with diagnoses that included cognitive impairment and had PEG tube (percutaneous endoscopic gastronomy tube; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented clinical records for one out of 33 sampled residents (Resident 96) when Resident 96's clinical record did not accurately reflect Resident 96's advance directive (legal documents that provide instructions for medical care, recognized under State law, relating to the provision of health care when the individual is incapacitated or in the event of a medical emergency). This failure placed Resident 96's advance medical related wishes and directives at risk to not be followed in an emergency.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Resident 1's temperature and blood glucose level were not assessed upon Resident 1's change in condition. This failure had the potential to delay interventions for Resident 1's life-threatening symptoms when the Resident was hypoglycemic (low blood glucose) and hypothermic (low temperature) upon arrival to the Emergency Department (ED).